We're trying to see if we can help each patient first see themselves as an athlete in training, not a patient in rehab.

So if you start with that premise, then you can look around you and say, okay, what are the resources surrounding me that I have as an athlete in training?

And almost everybody has a gym somewhere nearby them in America today, certainly, and even around the world.

And all of us have the outdoor environment to use as our gym and get creative in how we use it.

So it starts on day one with how you visualize yourself.

Hello and welcome to the December 13.

2024 edition of the Tridock Podcast.

I'm your host Jeff Sankoff, the tridoc.

An emergency physician, triathlon coach and multiple Ironman finisher coming to you from beautiful sunny Denver, Colorado.

When this program is released, I will be firmly ensconced in my vacation rental in Taupo or Topa, New Zealand, just a few short hours away from the start of the Ironman 70.3 World Championships.

I'm confident that it is going to be an incredible event and one that I've been looking forward to for over a year.

My training hasn't been ideal in the lead up to this race, what with a week of vacation and now several days of illness making for a less than perfect race build.

But whatever comes to pass, I know that I will enjoy the event and give it my all.

You can look forward to some video clips that I will post to my Instagram and Facebook sites in the days to come from my experiences down under.

And I hope that if you were participating in the race that you will leave your comments about how it went in the private Facebook group for the podcast.

Before getting to the meat of the program, I do want to acknowledge the recent news of the retirement of Alistair Brownlee from professional triathlon.

Alistair Brownlee is one of the most decorated triathletes in history, renowned for his dominance in the Olympic and long distance formats of the sport.

Brownlee's most significant achievements came in the Olympic Games, where he won gold medals both in London in 2012 and Rio in 2016, becoming the first man to successfully defend the Olympic triathlon title.

His aggressive racing style, particularly on the bike and run, set him apart from competitors.

His 2012 victory in front of a home crowd was especially iconic, cementing his status as a national hero in the United Kingdom.

In addition to his Olympic success, Brownlee captured the ITU World Triathlon championship titles in 2009 and 2011, dominating the series with a combination of tactical intelligence and raw athleticism.

He also claimed multiple European Championships and Commonwealth Games titles, including a gold medal at the 2014 Games in Glasgow.

Once he transitioned to the longer course forms of triathlon racing, Brownlee continued to find success, including finishing second at the 70.3 World Championships in South Africa in 2018 and winning the first full distance Ironman that he raced in Western Australia in 2019.

Add to that a lengthy list of 70.3 wins and podiums, as well as the bronze that he captured at his final T100 race, and you have the makings of a really incredible career.

But for reasons that are beyond me, there are some out there who have been somewhat perpetual haters on Brownlee and after his retirement chose to cast aspersions.

I saw one Instagram post, for example, make the claim that since he had only won two Olympic gold medals, he should not be considered that great.

To which I found myself wondering how many gold medals the poster himself was in possession of.

Another person who is a prolific poster of YouTube videos related to triathlon put up a video lamenting the retirement of Brownlee and of triathlon tearing from his space as a somewhat unserious triathlete.

As though those two things could ever be considered comparable in their gravity worthy of being put in the same video.

Look, I was as disappointed as anyone that Brownlee could not have the kind of successful run at races like Kona or anywhere else on the Ironman circuit, but that in no way diminishes the man's accomplishments or his greatness.

Brownlee has been a star and a force to be reckoned with since he came onto the scene more than 10 years ago, and I know that I won't be the only one who misses his presence on the show.

Today, the Medical Mailbag answers a listener question related to a supplement derived from a very special fungus.

Specifically, that fungus is a variety of cordyceps.

Now, if you're a fan, like I am, of the HBO series of the Last of Us, then you will undoubtedly recognize the name Cordyceps.

But the question sent to us was not related to the end of Times, but rather whether or not this mushroom can somehow boost endurance performance.

Coach Juliet Hockman joins me shortly for our look at the evidence on this question.

Later, I'm pleased to bring to you a conversation that I had with renowned orthopedic surgeon, researcher and author Dr.

Kevin Stone.

Dr.

Stone has written a book titled Play how to Recover from Injury and Thrive, and our discussion was broad and very encouraging as to how progress is continuing to be made in the field of orthopedics and how this has had real world results on the ability of athletes to continue to do the things they love long after injuries that not long ago might have been considered career shortening or altering.

And that conversation is coming up in a little while.

Before we get to all of that, I want to take a moment to thank once again all of my Patreon supporters of this podcast who have decided that for about the price of a cup of coffee per month they could sign up to support this program and in doing so get access to bonus interviews and other segments that come out about every month or so.

The most recent of those episodes was released a couple of weeks ago now and featured an interview with professional triathlete and member of the Athletes board of the pto, Laura Siddle.

Laura helped me look forward to this weekend's 70.3 World Championship in New Zealand and gave her picks for the win on the men and women side.

That bonus episode and others like it are available on a private feed for all my subscribers.

Plus for North American subscribers who sign up at the $10 per month, they receive a special thank you gift in the form of a BOCO Tridoc Podcast running hat that I am proudly showing on the YouTube video that is being released the same time as the podcast.

So if you're interested in learning more about how to become a Patreon supporter, I hope that you will go over to my Patreon website, which is found at www.patreon.com tridocpodcast so that you could see the different levels of support and maybe get access to this cool gift.

As always, I thank you in advance just for considering before we get to the Medical Mailbag, I wanted to play a clip from the HBO series the Last of Us that I mentioned a short bit ago.

As I said before, when this episode's question about cordyceps was brought up, that was the first thing I thought of.

So I could not think of a better way to introduce this medical mailbag.

And Dr.

Newman, you're also an epidemiologist.

I presume the prospect of a viral pandemic keeps you up at night as well.

No.

No, no.

All right, well, that's our show.

No.

Mankind has been at war with the virus from the start.

Sometimes millions of people die, as in an actual war, but in the end, we always win.

But just to be clear, you do think microorganisms pose a threat?

Oh, in the most dire terms, bacteria.

No.

You like saying no.

Yes.

Not bacteria, not viruses.

So fungus.

Yes, that's the usual response.

Fungi Seem harmless enough.

Many species know otherwise, because there are some fungi who seek not to kill, but to control.

Let me ask you, where do we get LSD from?

Where do you get it from?

It comes from ergot, a fungus.

Psilocybin, Also a fungus.

Viruses can make us ill, but fungi can alter our very minds.

There's a fungus that infects insects, Gets inside an ant, for example, Travels through its circulatory system to the ant's brain and then floods it with hallucinogens, thus bending the ant's mind to its will.

The fungus starts to direct the ant's behavior, telling it where to go, what to do.

Like a puppeteer with a marionette.

And it gets worse.

The fungus needs food to live, so it begins to devour its host from within, replacing the ant's flesh with its own.

But it doesn't let its victim die.

No, it.

It keeps its puppet alive by preventing decomposition.

How?

Where do we get penicillin?

From fungus.

Dr.

Schoenheiss, you're in distress.

Fungal infection of this kind is real.

But not in humans.

True fungi cannot survive if its host's internal temperature is over 94 degrees.

And currently, there are no reasons for fungi to evolve to be able to withstand higher temperatures.

But what if that were to change?

What if, for instance, the world were to get slightly warmer?

Well, now there is reason to evolve.

One gene mutates and.

Anascomycetia candida, ergot, Cordyceps aspergillus.

Any one of them could become capable of burrowing into our brains and taking control not of millions of us, but billions of us.

Billions of puppets with poisoned minds permanently fixed on one unifying goal.

To spread the infection to every last human alive by any means necessary.

And there are no treatments for this, no preventatives, no cures.

They don't exist.

It's not even possible to make them.

So if that happens.

We lose.

So after that ominous introduction, we are here for the medical mailbag.

Juliet Hockman is back in the country.

So am I.

Welcome, Juliet.

How was your trip?

Thank you.

Good to be back.

It was great.

How was yours?

I saw the pictures.

It looked amazing.

It was great.

It was fantastic.

Unfortunately, as so often is the case these days, I picked something up somewhere.

Somewhere between French Polynesia and here.

So I'm suffering today but we'll make it through we'll make it through but, yeah, I wanted to use that clip because the question that we have today comes from a reader, and why don't you tell us what that Question is.

A reader and a listener.

Yeah, shout out to Julia Swanson, who lives here in my neck of the woods, One of our awesome lifesport athletes, actually, who was very curious about something that she'd read about a product or a.

I don't know if we want to call this a product or a thing.

Anyway, a fungus, as we'll soon learn, called Cordyceps sinensis, which has been used for a long time in Chinese medicine and is beginning to make claims about being a performance enhancement substance for endurance athletes.

So thanks very much for your curiosity on this topic and I'm interested to see what you found out, Jeff.

Yeah, it is an interesting topic and actually the.

One of the things that's most interesting about it is how it came to be in the consciousness of the endurance sport community.

This goes back now several years.

I'm trying to remember how long ago it was, but it was quite a while ago and some Chinese athletes were running this race at altitude and all three of them broke these very long standing distance records, like just gigantic records that they broke.

And they broke them by quite a lot.

And they said afterwards when being interviewed and they were their coach and their nutritionist and everybody else, they said, oh, it's because we've been supplementing with Cordyceps sinensis that allowed them to see these giant improvement in performance.

It turns out that maybe that wasn't really the case because two of the three were eventually found to have other substances in their bloodstream that are not quite natural and were not necessarily cordyceps.

Whether or not cordyceps actually helped them get those kinds of levels of achievement wasn't all that clear.

Still, cordyceps has been used in Chinese traditional medicine for hundreds of years, but never really as an endurance sport supplement.

So I found a paper that talks about cordyceps and why it does the things it does as well as what are all the different effects it has.

And I gotta tell you, it was a very dense paper and it was really hard to get to the bottom of why.

There are two chemical compounds in the Cordyceps fungus.

One of them is called cordycepin, which is an adaptogen.

It's one of those molecules that we've talked about previously.

When we've talked about natural products like New Zealand blackcurrant, or when we've talked about tart cherry juice, we've talked about how a lot of these natural plant based products create these very complex organic compounds within their flesh.

And the Cordyceps fungus has one of them.

It's called cordycepin and it's hypothesized to be the main reason by which this fungus exerts all of its bioactive roles.

The problem is nobody's been able to actually understand at a cellular level what it's doing or how it works.

And there is a lot of thought that cordycepin seems to have some impact on cellular processes like DNA replication, RNA to protein.

And as a result of that, there's been a lot of interest in looking at it for different reasons in human health.

And this paper, which was published in the journal Molecules, sounds like a pretty broad topic.

Not molecule, that journal.

It's in everything.

Yeah, we cover everything.

So it was published in the Journal of molecules back in 2020 and basically just looked at the promise of cordyceps.

I should mention there is a second compound in the Cordyceps fungus, and that second compound is adenosine, which is a very known bioactive compound that has a lot of different roles.

It's predominantly involved in cardiac issues.

So it causes vasodilation, it causes increased heart rate, things like that.

But there are some thoughts that it might do other things.

Now, the amount of cordycepin and the amount of adenosine found in this fungus is not clear to me.

It's not actually stated in this paper.

But they go on to say that, look, cordycepin has a lot of potential for clinical effects.

The problem is none of them have really been studied all that well.

And so at the end of the day, they end up in all of these suggested roles as saying, we need to do more research.

So, for example, cordycepin in diabetes, they say cordycepin has very good potential for being a safe antidiabetic pharmaceutical agent.

But there's no evidence that it actually works that way or that it has actually had a clinical function in that regard, just that it has potential.

And this goes, and this is exactly the same conclusion that is made for cardiovascular diseases like hyperlipidemia, anti inflammatory effects, immunomodulatory effects on osteoporosis and on arthritis.

So in every one of these, they summarize the evidence that's known to date, which is not a whole lot.

And they finish by saying this just shows that cordycepin may have a role in treating this particular type of disease.

Okay, yeah, just as you're talking, I'm googling it and I just.

For our listeners, if you Google Cordyceps sinensis, you're going to get a whole bunch of pictures of something that look like deep fried caterpillars, about the size of a match, a wooden match.

But it does look like it's been looked at for a number of different possibilities from what you said.

Diabetes, kidney, liver, heart, all stemming from this idea that's been used for a.

Long time in Chinese medicine, but nothing concrete.

There's been no real good studies that have said that, yes, this is a candidate, this is something we've refined into a drug.

And just to go back to your comment about the caterpillar.

So Cordyceps sinensis is a fungus that is quite rare.

It is only found in the high altitude of the Himalayas, and it infects a specific kind of moth where it does exactly what the Cordyceps from the Last of Us does.

So all Cordyceps species infect insects and they're called entomopathologic fungi.

And so they infect an insect, they secrete some kind of hallucinogen which makes the insect not behave in its normal way and instead behaves exactly the way the fungus wants it to, so that the insect will go to a place where it dies.

And in its last sort of act before it dies, it bites down hard on the leaf or the branch that it's sitting on so that it can't be dislodged by wind or rustling or whatever.

And then the fruiting body of the fungus erupts through the head of the.

It's awful.

It's just awful.

If you want to.

Oh, my God, I can't unsee these images right now that I'm looking at on Google.

This is nightmare stuff.

It is nightmare stuff.

And I got to say, like, for something to have evolved this way is just fascinating to me.

Like, the evolutionary pressures that would have driven this is just fascinating.

And if you want to see a really interesting clip, just go or go to YouTube and look for the Planet Earth clip on Cordyceps and you will see.

Very nicely narrated by David Attenborough.

Very nice.

Yeah, very nice.

Nicely narrated.

Slow motion or not slow motion.

Time lapse of several types of species being infected by and then consumed by Cordyceps.

It's quite interesting, which begs the question, why would anybody want to eat this stuff?

Well, and that's where I'm going to.

Have these going to get into my brain and it's going to take over my brain before I kill myself.

That's why I thought so.

When I saw the Last of Us, I didn't know anything about it.

And I watched that introductory, the sort of prequel clip that I just played for everybody.

And I remember being just absolutely fascinated.

I Thought this is such a novel sort of take on the whole zombie trope.

Because usually the zombie trope is something comes from outer space and causes reanimation of the dead.

That's not at all what happens in the Last of Us.

In the Last of Us, a fungus gets into the food chain and people consume it.

And it has evolved so that it actually can infect humans.

And so very quickly humans behave the way these insects do.

It's really.

It's a great premise for a science.

Okay.

I feel like we have enough things in the world to worry about besides the possibility of a fungus taking over the human food chain.

So we got a little bit derailed there.

Is there any evidence that Cordyceps sinensis has a performance enhancing power for people like you media?

Thank you.

Thank you for bringing us back because I could talk about the Last of Us for a while because it is great television.

But yeah.

So we found a few studies.

Cosette Rhodes was the intern who was assigned to this project and it was a project she found herself going down several rabbit holes.

But in the end she wasn't able to find a whole lot.

Julia had intimated in her message to me that she thought there actually was a fair amount of research.

The problem was a lot of the research is not in medical journals and therefore I could not obtain the full articles.

A lot of them are in journals called things like Nutritional Supplements or things like that or Herbal Remedies.

Yeah.

Molecules is a scientific journal.

A lot of them are not journals that are indexed by the Index Medicus.

And therefore I wasn't able to get the full article, but I was able to find enough, I think.

And what we found was, I'm not going to belabor this.

I think there's a couple of studies we found that suggest that it's right now a little bit preliminary to suggest that using Cordyceps fungus is all that helpful.

First study was 15 elderly patients.

I'm sad to say that they classified elderly as 50 to 75.

How dare they?

Yeah, we were reviewing this yesterday and I was like, 50 elderly.

Come on.

Anyways, it was double blinded, placebo controlled study.

They gave 12 weeks of the Cordyceps placebo and then they measured a ton of parameters, like just a ton of stuff.

VO2, max heart rate, max work rate, max ventilation.

Just on and on it went.

Now, these were not athletic people.

These were fairly sedentary people.

But what they found was that just by taking Cordyceps, they did find a slight change in a couple of physiologic parameters, one of them being ventilatory threshold, which is not something I'm familiar with, it is not related to actual respiratory ventilation, but rather it seems to be ventilatory threshold at the level of the cell.

So it seems to be that the level of exercise at which you exercise before you start producing lactate, it seemed to be very.

There seemed to be a very small increase in the ventilatory threshold.

So you could work a little bit harder before you started producing lactate, which is interesting, but it didn't show up really anywhere else.

And then the other one that they found was a change in metabolic threshold, which is another one I'm not.

I wasn't really familiar with.

But it's similar, basically just shows that the metabolism of energy stores was slightly more efficient if they took cordyceps.

Again, going back to this idea that cordycepin seems to have some impact on cells and cell function, but what they don't say is whether or not either of these things had any impact on performance.

Were these people able to do anything more or were these just physiologic parameters that changed very slightly?

And to be clear, there was no change in anything else.

The thing that we traditionally look at, VO2 max or heart rate, didn't change at all.

A second study was from.

When was this one?

This one's this year.

And small sample.

Cordyceps treated.

Sorry, Cordyceps treatment resulted in cellular level changes that may lend themselves to bettered recovery after high intensity exercise.

So it was very similar.

This was younger people, this was all people in their 20s.

And what they did is they gave them some Cordyceps sinensis and they looked to see if any specific parameters were influenced.

None of them were any of the performance parameters.

None of them changed.

But they also did some muscle biopsies and they found that a very specific marker called necrotic cell infiltration seemed to be diminished.

If you took cordyceps, I don't know what that means.

It sounds bad to have necrotic cells infiltrating, so it's probably good.

But again, the results are not overwhelming.

We're talking about.

I don't know what their units are.

They're.

I don't really know what they mean.

But basically with cordyceps we went from 10 to eight, so I don't know, but it was a statistically significant result.

So those were two of the basic science studies we found.

We did find another basic science study that looked at cordyceps on VO2 max.

And here it was again, younger people, 18 to 35.

These people were exercising, they took.

They took cordyceps for a while and basically no difference in any of the measured parameters.

So at least off the top, it would seem the cordyceps is probably not doing what those Chinese runners got from it.

There is, however, a study that came out in 21.

Sorry, I think this study came out more recently 22.

This study came out in 22 and it looked at 12 marathon runners.

And this is the one that seemed to get the most kind of play in the press and seemed to a lot of the Cordyceps adherents were very excited about.

And basically what they looked at was a variety of different physiologic and performance parameters.

And they were able to show that taking cordyceps did result in a statistically significant change in time to exhaustion.

So remember, time to exhaustion is get on a treadmill run at this ridiculously high pace until you can't anymore.

They also found a VO2 max change that again was statistically significant.

So that sounds great, but the numbers are a little less overwhelming.

So the time to exhaustion went from 16 and 3/4 seconds to 17 and a half seconds.

So 3/4 of a second change, that works out to less.

I think that's about 5%.

So relative 5%, but absolute of less than a second.

And then VO2 max, not insignificant.

Again, it was statistically significant and I would say that absolute numbers also probably a little bit.

So it went from 53 and a half in the placebo group to 55 and a half in the cordyceps group.

And those were the two major findings from the study.

I don't know.

Would you think 53 and a half to 55 and a half?

It's not nothing.

Yeah, it's not nothing.

What do we count as statistically significant?

Well, statistically significant just means that the results are not due to.

Are unlikely to be due to chance alone that the results measured are representative of a true effect.

Whether or not it's clinically significant, then you have to decide whether or not A change of VO2 max from 53 and a half to 55 and a half is clinically significant.

It's not.

Again, it's not nothing.

I don't know.

Anyways, I think at the end of the day, once again we're dealing with a natural product, a product that has been used extensively for hundreds of years.

Barring the horrible transformation of this fungus to be something from the last of us, which I think is still exceedingly unlikely, then I can't say there's any safety.

Now we Looked, we tried to find something that would suggest that there's downside to this and there really isn't.

It actually.

The Cordyceps fungus contains a host of other micronutrients and minerals.

Again, the quantity of those is not that great, but they're there.

And they also are not hugely expensive.

Somewhere in the range of a dollar a day.

If you want to take this stuff.

Does it come in the form of a powder that you mix into something or is it.

No, it comes from capsules.

Capsules, yeah.

Maybe it comes.

I didn't look long enough.

It probably does come in various forms, but the ones I saw were all capsules.

I think at the end of the day, this is going to be like a lot of the other natural products we've talked about, where there's a lot of traditional reasons that this has been used.

And there's a lot of belief traditionally that this helps in various ways.

I don't think that we can say that there's compelling evidence that it's going to help with endurance performance.

There's certainly nothing to suggest it harms in any way, shape or form.

And so I think for that reason, if people want to use this, by all means, go ahead.

Let me know what your experience is.

Look, if you want to eat ground up caterpillars infected by a fungus, go right ahead, knock yourself out.

I'm interested to know how they get the stuff, because it doesn't seem like you can just harvest this easily or cultivate it.

No, you got to go up to the Himalayas and find a poor caterpillar that's clinging to a leaf in his last death throes.

Yeah, there aren't that many of those around.

I'm surprised it's not more expensive.

It's pretty crazy.

We have a little bit more time here.

Juliet and I wanted to address another question that came to me from one of my Patreon supporters, Arturo Ruiz.

Art knows that both you and I spend a lot of time traveling to races and also going on vacation and somehow being able to manage our training around our vacations.

And he was interested in what our tips are.

And I'm sure there are other listeners who would probably be interested in that too, for both of those.

So I thought today we might just address the first of those questions, which is, what are our tips and tricks for traveling to races?

Which is honestly very timely because I'm leaving this coming Friday for New Zealand.

So it gives me a chance to go over in my mind all the things I need to do and then and then in another episode, we can discuss our tips for training while away on vacation.

Okay.

Yeah.

So why don't you start?

What are some of the things that you do that makes you most efficient and makes you a better kind of traveler to races with less stress and less need to rent a gigantically oversized SUV when you get there for all your stuff?

Right.

I think a lot of it for me is I'm not a last minute packer, I'm not a last minute test studier, I'm not a last minute paper writer.

I just never was.

And so for me, it takes a lot of the stress out.

If I start packing a solid week before I just pick a corner of my house or the spare bed, whatever, and as I think of things, I start to lay them out and I take up the whole queen or king size bed in the guest room as I lay things out.

Because I'll think, oh, race belt.

Oh, don't forget the scratch.

Oh, don't forget whatever it is.

And if I'm flying to the race, obviously you are constrained in terms of how much stuff you can take.

If I'm driving to the race, I have no problem taking both pairs of bike shoes, both helmets, both, everything's right, my own pillow.

But let's focus on the flying element because we are of course, weight and bag constrained for that.

So I start, one thing is I start packing really early.

Another thing I like to do is I really think through, particularly for some of our A or B races, where I'm going to eat.

That really impacts how I think about the four or five days or two or three days or whatever it is before the race.

Again, if we're driving, I'll take all my own food.

If I'm.

Because I like to eat what I like to eat.

If I'm flying, I'll definitely make sure I have race nutrition.

I may take a couple of other things, like a tea that I really like to drink, stuff this light and easily packable.

And so those go on the bed.

And so I really try to think through day by day, exactly what I'm going to need.

I look at my training schedule, I put out the kit or the clothing that I'm going to need for the training schedule.

I definitely, in a one corner of the bed put exactly what I'm gonna need for race day.

Trying to keep everything as minimalist as possible while still making sure I have the things that make me feel confident and cozy.

What about Pico?

I think those are all great.

And I think if I was Gonna boil it down, I think what you are getting to is just being less stressed by having the things you need out in advance, but then also having those things that you need when you get there.

And also being less stressed by being self sufficient because you've got your nutrition with you, you've got your tea, whatever it is, the things that you don't want to have to be scrambling for.

And I echo that and I don't know why.

I have so many problems convincing people to learn how to break down and put their bike back together.

That to me is one of the skills that every triathlete should have.

I understand it can be daunting, especially with some of these superbikes.

No question.

Listen, I have a diamond and I spent a lot of time watching videos on YouTube learning how to take apart my diamond and pack it properly.

And the thing is, if you are self sufficient in a way that you can pack and you can break down your bike and then put it back together, you don't need to worry when you get there.

How am I going to get it built up?

What's going to happen if I'm going to 100%?

What's going to happen if this, that and the other?

No, you will put your bike together and you will know how to deal with some of the common fixes like, oh, my disc brake is rubbing.

How do I fix that?

These are all things that I have learned over time by breaking down and packing my own bike.

And these are skills that are very easily obtainable and I highly recommend it.

And that brings me to what bike kind of transport you are going to get.

I think that I've gone with various different types of bike transport packages.

I've used soft cases, combination cases.

I finally decided to just go with a dedicated hard case because I got tired of getting to where I was going and finding out that the TSA did something.

And with a hard case, it's pretty foolproof.

And I feel like luggage handlers don't break anything.

The TSA can't break anything and it works a lot better.

And speaking of the TSA and being self sufficient, I did find a hack for transporting CO2 cartridges.

And I'm a little hesitant to say this because I don't know if it's going to be on a watch list, but TSA, TSA and Canada's equivalent of the TSA do not allow CO2 cartridges, despite the fact that every single airplane seat has a very large CO2 cartridge right below it in the form of the inflatable Life vest.

So every single inflatable life vest on an airplane is powered by a 30 gram CO2 cartridge.

But they don't want us bringing our 16 gram CO2 cartridge for some reason.

Reason.

So it turns out if you go to the TSA website or the Canadian version, you will see that CO2 cartridges are allowed if they are part of an inflatable life vest.

So you carry an inflatable life vest around with you.

I bought on Amazon for almost nothing an inflatable life vest and I throw in two 16 gram cartridges and I have yet to have a problem.

The worst thing that will happen is that you'll get some agent who decides that today's the day I'm going to be not nice and I'm going to take them away.

But that's the worst that'll happen.

And knock on wood, I haven't had a problem.

Now I'm flying to New Zealand this week.

I won't do that simply because I don't want to deal with two agencies.

I have to deal with the TSA and the Canadian agency and it's just not worth it.

And there are multiple bike shops that have been advertising that they're going to have CO2 cartridges to loan.

So I'll just deal with that.

But that's my way of doing it.

I also use checklists.

Andrew Patterson, fan of this show, the man who is behind The Ironman Hacks YouTube channel.

He also has a app for your phone that includes a customizable checklist which I have customized so that every time I go for a race I pull it up and I'm able to check as I go through.

And like you Juliet, I start about a week in advance putting my things together and yeah, I find checklists are helpful.

Making sure you're as self sufficient as possible and knowing how to break down your bike.

Those are my three big tips.

Yeah.

To add to the bike packing piece I.

There are certain bike bags that will also allow you to literally just remove your wheels and nothing else.

I do have a superbike for my TT bike.

I don't know how to break it down.

I think it would be very difficult if it's.

It's a.

It would be a very difficult bike to break down and.

But I now have a bike case that all I have to do is take the wheels off and that helps a lot.

And then it is a soft side case.

But what I do is I take an old sleeping bag that we no longer use, a child's L.L.

bean sleeping bag and after I pack the bike up as it should be in the case and I throw in a little extra bubble wrap and then I also wrap the whole thing on the inside with the sleeping bag.

At a lot of airports you can actually stand there while TSA checks the bike there.

You don't have to go through security doors or anything.

And I will stand there very politely at a respectful distance and just keep an eye on them and make sure that things go back after they checked all around more or less the way that I packed it.

So I feel that I have nobody to blame on the other end if something is broken.

The other thing that is helpful, and I've employed this at least twice, is knowing who if you need to phone a friend if you get there and something is broken or you're feeling stuck, or you're just so frustrated when you try to reassemble your bike.

I have three guys that I will call at any time of day or night on FaceTime and say, oh my God, I'm losing my mind.

FaceTiming show me what to do.

And on all the times that I've called them, they have saved me in terms of either assembling or in one case disassembling my bike.

It's also good to know who to call if you do have a question.

Yeah, but I agree on your self sufficiency thing.

That is really key.

I'm always astonished when athletes say, oh, I'll just pick my nutrition up at the venue or I'll just buy this at the venue.

The only thing in all the years of racing I think I've ever bought at the venue or at the town where we're racing is one year I it just got extremely cold extremely fast and I needed a better I had a winter jacket, but I needed a better fitting winter jacket than the one I brought with me for sort of aero efficiency.

But other than that I've never bought a single thing upon arrival.

So be self sufficient.

I think that's a really good call out.

Yeah, totally fair and art, thanks for that question.

Keep those questions coming.

If you have a question you'd like for us to answer, it doesn't have to be medical, see?

Or if you have something you want for us to consider on the medical mailbag, I hope that you'll send it in.

You can email me@tridocloud.com or you could submit it in the private Facebook group for the podcast.

Just look for Tridoc podcast on Facebook.

I will answer the three easy questions then I will grant you admittance and Once you're in there, you can join the conversation, ask your questions and we will be happy to answer them on a future episode.

Juliet, thank you so much for another good episode and we will hope that in the time that I'm in New Zealand and back again, cordyceps will not evolve in a particularly diabolical way.

Stay away from the zombie caterpillars, people, and good luck in New Zealand.

Jeff, go fast.

Have fun.

Thanks.

Bye.

Bye.

My guest on the podcast today is Dr.

Kevin Stone of the Stone Clinic in San Francisco.

Dr.

Stone is a world renowned orthopedic surgeon.

He's a TED Talk speaker, the founder of the Stone Research foundation, and the author of this book here.

If you're watching on YouTube, this is play how to Recover from injury and thrive.

Dr.

Stone was trained at Harvard University and Stanford University and also served as a team physician for the U.S.

ski team.

His expertise and patient stories have been featured in Triathlete Magazine, New York Times, Runner's World, Run to the Top podcast, and many others.

But I am glad to say that he's here with me today on the Tridoc podcast for at least the next little while.

Dr.

Stone, thank you so much for being here.

I have not had a chance to get through this book just yet.

I have started and in the first chapter or so that I've made my way through, I was impressed to see that a orthopedic surgeon was actually focusing on the mental game.

So tell me what brought you to write this book?

Who's it for?

And what is your hopes for it?

Yeah.

So the fun of trying to communicate what we try to communicate every day, one on one with patients, is can we make a bigger impact?

Can we communicate what we see?

Which fundamentally is, number one, so many injuries are mental errors.

And number two, if you can use your injury as an opportunity to become back fitter, faster and stronger than you've been in years, then we've achieved our goal of helping you not only get better, but truly be better at the sport that you love.

And so many of the injuries that I see, so much of the arthritis I see has held people back instead of propelled them forward.

And that's our goal to do that.

It's really interesting that you mentioned that.

I had a guest not too long ago who talked about how he was diagnosed with osteoarthritis in his hips and it took him a long time to accept that he would need to have the hip replacement surgery.

And during that period, from his diagnosis until accepting the surgery, it was exactly that he was being very much held back.

He wasn't really able to progress in the sport.

He could see that he was getting diminishing returns from his training because of all the symptoms he was having.

But as soon as he went forward and had the surgery, he was kicking himself for not going ahead and having it sooner.

He felt almost reborn in a way, because his pain was gone.

All of the preconceived notions he had of how he would be more limited were not at all true.

You must encounter this with some of your patients.

I would imagine we all have this thought that once we're injured, we are simply not going to be the same afterwards.

How do you overcome that?

Well, a number of ways.

Number one, making an accurate diagnosis right off the bat.

So things that need to be fixed, fix them right away and move on, rather than living with injuries that are going to hold you back for so long.

Then number two, we're in what I call the anabolic era of sports medicine, where we can put stimulating factors around tissues that are injured rather than cortisone, which shut down the cell metabolism and damage their surrounding tissues.

And then number three, we've gotten better at replacing the meniscus cartilage and replacing the ligaments and regrowing the articular cartilage.

Things that we didn't think we could do in the past.

And so in this biologic year, in this anabolic year of orthopedics, there really is an opportunity to come back better than you were before.

And so the old days of live with a pain or no pain, no gain, that's really out the door now.

I have talked so many times about the misconceptions around inflammation on this program.

I've talked a lot about how inflammation is a double edged sword.

We need it in order to heal, we need it in order to actually benefit from our training.

Inflammation is a huge part of adaptation to training, but we also know that it can go too far and cause significant problems, significant debilitation in the form of things like osteoarthritis, for example.

So where has the progress come in understanding how to balance the benefits of inflammation with the detriment?

And as you said, we used to just use cortisone for everything.

All that ails our joints was fixed by steroids.

And we know better now.

So how did we learn that?

And how do we now understand when to control inflammation and when to let it actually take its course?

That's a great conversation.

Healing injuries and healing are like require the whole chicken soup of healing.

If you just have the chicken and all the water, it's not so good.

If you miss the salt, it's not so good.

You need all the factors involved in order to get to a solid healing response.

That's normal tissue, not scar tissue.

But let's drive down to one specific part of inflammation, because I know you've already talked about, hey, if you're injured, you need inflammation to identify the injury.

And rush blood cells there and rush stem cells there and rush factors.

There's.

But on the other hand, if it stays too long, the tissue becomes degenerative rather than healthy.

Collagen formation, the most common example of that for most people is lateral epicondylitis, where they injure their tennis elbow.

They get that moment of pain, and instead of it just going away in two or three weeks, it takes six months or a year.

And so what happened in that example is that you tore the fibers a little bit, they didn't heal properly, they became degenerative.

And then that dead kind of area of tissue never heals properly without some new stimulation or surgery or injection.

That's the common thing that we all hear about where inflammation has gone wrong or not completed the process.

But let's focus on one of the micro parts of it that's getting a ton of attention in our research.

Remember, I'm not just an orthopedic surgeon in San Francisco, but I run a public nonprofit research foundation.

And so much of our work is around how do we accelerate healing.

One part of inflammation deals with specific cells called macrophages.

And there are generally multiple types of these, but there are generally two types that we're focusing on called M1 and M2.

So if you think simplistically about it, when you have an injury, even a bruise to your leg, the M1 macrophages are the cells that go in and eat up the dead tissue and clear away the damaged processes there.

The M2 macrophages are the ones that rush in behind it and shift to a healing or anabolic environment where they're helping the cells lay down new collagen.

And cells can shift between M1 and M2.

And so one of the areas there's hot area of research right now is how do we stimulate a more rapid conversion to these more pro healing environment cells that will accelerate healing.

A lot of our effort is on how do we accelerate healing.

So most athletes will say, look, why does it take me a year to come back from an ACL reconstruction or an Achilles rupture?

And we know that if we can Accelerate that and get people back with fully healed tissues in a much shorter timeframe, then that's a real contribution to the world, and it's a big part of our interest.

So the whole story of inflammation is a hot topic, and we're getting very specific about how to interfere with it.

Yeah, it's almost like we need to.

There's a control room and there are switches we need to activate, other switches we need to turn down.

And it's finding the almost the equalizer for inflammation that allows us to enhance the parts that we want while turning off the parts that we don't want in order to get to where the end result that we're really looking for.

And that turns out to be incredibly complicated and obviously not just related to injury, but related to so many other disease processes that we as human beings encounter.

I wish it was as simple as a control room, because in the analogy you gave where you turn down some and turn up others, it turns out that the ones that you turn down at one point, you have to then turn those back up again at other points.

So certain things that we think about as an inflammatory factor are in fact important early on.

Not.

It's important not to be there at the next stage and then important to be there again at a later stage.

And so this weird interaction between proteins that we thought were negative in an environment, it's turning out that they're positive and other at other times in the healing cycle.

So we can't say, hey, we're just going to go in and reduce these inflammatory factors or build up those inflammatory factors the way we used to think we could do.

We now realize that you need a professor in the environment, and the professorial cells are stem cells.

They're the ones that run to the site of injury and direct this complex healing response.

We used to think that it'd be a good idea to inject stem cells into an injury.

And people ran around the country and they would get their fat or their bone marrow aspirated, or the worst, they'd run to Canada or Cancun or Mexico and get their cells harvested and grown up and injected back in.

It turns out that's not the best way to do it.

It turns out that each of us, no matter what our age, have billions of stem cells within our bodies.

Yes, when you're younger, you have more.

When you're older, you have fewer, but you still have billions of these things.

And so it's a better strategy to figure out how to mobilize your own cells to go to the site of injury than injecting a few thousand or a few million from an external source, most of which probably die and don't really do the actions that we were hoping they would do.

And so the field is evolving now and our research is on how do we create more potent recruitment factors rather than inject just cells.

And that's research I've reviewed on this podcast before, talking about both stem cell and PRP injections, talking about the lack of results that really support it, except in very small studies.

And it's interesting, I think, the way you have described why those studies have failed and how stem cells are beneficial, but how they could be more beneficial by creating this active recruitment, creating a better environment, they're going to exert their influence as opposed to just pushing them in willy nilly and hoping for the best.

It intuitively makes a lot of sense, but obviously a lot of research to be done in order to figure out how to make that happen.

Now I want to go back to something you mentioned just very briefly.

You said something about age.

We know.

And again, something else I've talked about frequently here is how age impacts inflammation.

We know that as we age we are in a more pro inflammatory state.

How does that play a role in our response to injury?

Are we really in a more pro inflammatory state or do we just have more areas of our body that are aged or injured or arthritic or whatever?

So we don't know how to selectively affect the parts of the body that need stimulus and the parts of the body that need inhibition particularly?

Well, yes, we can put a solve on one part, one joint, or use a electromagnetic therapy on one part of our body, or use any injection in one part and hope that it just stays right there.

So we're going to get better at that.

We need a lot more research on how to do that and how to be much more targeted.

I think the beauty to aging is that you're smarter about your body and what to do and what works for you.

And a stunning part of the research over the last number of years, and that wise physicians have known for hundreds of years, is that each patient is remarkably different.

How you respond to one stimulus is not necessarily how the next person responds.

How fast you heal is quite different from other people.

So a big part of this going forward process will be to really understand you, the individual sitting in front of me as the physician.

Part of that is going to be aided by artificial intelligence because by next year you will not come see a doctor without in your pocket.

You're having your voice agent reminding you of all the things you forgot to tell the doc or what your experience was with one therapy or another in the past.

And no doctor will be listening to you by next year without his own siri like voice agent listening to both sides of the conversation and reminding that doctor about stuff they might have forgotten about or new knowledge or things that are unique to you that they have in their records that may be an association that you wouldn't have put together.

So the potency of artificial intelligence, as we can positively use it in the medicine side of this field is that we'll get much better about understanding individual responses in what therapy should I give you versus what therapy should I give the next person?

Coming along.

I wanted to go back to your book for just a second because I really enjoy the way the sections are laid out.

You go into almost a.

Like, you have a focus on your joint section where you talk about injuries and then on your knees.

And you use specific case examples, often with athletes that most of my listeners will be familiar with.

So, for example, you talk about.

About Diana Nyad and her issue with her shoulder, and then you talk about Steph Curry and his knees.

There are various other anecdotes here, and you use those as a springboard to talk about what can be done and how those injuries can be used, as you say, as an opportunity.

So many age group athletes, we're not professionals.

It's not our livelihood.

And yet at the same time, it has a huge impact on who we are as people.

We invest so much time, so much energy, so much effort into all of this, that when we have an injury and we are forced to take some time off in order to recover, it can become a very dark place very quickly.

We don't have the resources that a Steph Curry does with being able to see you anytime they want and having all of the PT I'm sure that he had available to him and everything else we have to continue in our regular day job and then go back to whatever PT we're able to manage and somehow get through.

And as you said, it does often take a year before we're back to what we want to be doing.

What can you tell that person, the age grouper who is trying to get through their injury?

How do they make use of their opportunity?

How do they make use of this technology and these new breakthroughs to be able to come back stronger and better?

Yeah, it's a great question.

We're trying to see if we can help each patient first see themselves as an athlete in training, not a patient in rehab.

So if you start with that premise, then you can look around you and say, okay, what are the resources surrounding me that I have as an athlete in training?

And almost everybody has a gym somewhere nearby them in America today, certainly, and even around the world.

And all of us have the outdoor environment to use as our gym and get creative in how we use it.

So it starts on day one with how you visualize yourself.

If you can do that, then you can partner with your physician and all their resources.

In our clinic, we have athletic trainers and physical therapists and nurses and all the people to help our injured patients get off on the right foot.

After that, it's really treating yourself the way a pro athlete would treat themselves.

So a pro athlete would optimize their diet, optimize their training program, optimize their coaching program.

And no matter what your level of being able to afford or the time you have in your day, you can always do that for yourself.

So many resources online, for instance, you and your podcast, educational information, it's all there for the taking today.

It's just, you've got to take the first step and say, okay, this injury is a bummer, but I'm going to turn it into a positive outcome.

And not only that, I'm not going to quit until I'm better than I was before I got hurt.

So if you can do that, I think you're off on the right foot.

Additionally, there are people like our clinic in San Francisco and others all around the world who provide information.

I write a blog every week.

That book, Play Forever, is on Amazon.

We're trying to put out educational information that can help people with a wide range of injuries.

I think the information's there and encourage people to go take.

Yeah, and that's a huge.

I think that's something that can't be overemphasized, and that is, as a patient, being in charge of your own recovery, having the right mindset, having the right sort of ability to reach out there and find the information that you need.

And never take no for an answer.

Always be pushing back and asking questions and understanding that there are limitations to current therap and medicine.

But you should always be looking for ways to advance your own care and advance your ability to progress with your healing.

I think everything you just said is really spot on.

I wanted to go back for a second just to the concept of inflammation, because one of the things that comes up frequently that my listeners submit is questions, involves supplements.

Many of those supplements are Natural products, products like tart cherry juice, derivative, tree oils, all kinds of things, and, and most of them have anti inflammatory effects.

Again, a lot of this is coming from this general media sense that we all have this, you know, pro inflammatory diet, we have to do something about it.

But I always kind of find myself wondering, well, are we going to be drowning ourselves in anti inflammatory polyphenols and all of these natural occurring chemicals and are we somehow going to be disadvantaging ourselves if and when we do run into an issue?

Is that something we should be worried about or is it fair game to be taking all of these anti inflammatory antioxidants, all of these natural occurring things and we shouldn't worry too much about it?

So the specific risk and worry that you are referring to came up when people realized that each of us have millions of cancers within our body every day.

And our body eliminates them primarily through an oxidation process where identifies the abnormal cell, knocks off the cell or mutation and moves on in life and we all go on and live.

And the question that came up around that is if you overloaded the system with antioxidants, would you be handicapping your body's ability to clear itself of these dead or negative or mutant cells?

And nobody knows the answer.

So that was the first part of the question.

The second part of the whole space was are there specific supplements that you can take that make a difference?

And over the years we've looked at all of them, not necessarily in the best way, but we really looked hard at glucosamine.

And we felt that amongst the supplements out there that you could spend your money on, glucosamine had about the best data because patients number one horses and dogs, when given glucosamine, diminish their limping dramatically and they don't know about placebo.

And glucosamine is a supplement that benefits.

Cartilage health, correct it the most common, yes, in the science, but the most common thing that we hear from patients is that they feel less stiff.

And that was reflected in the animal experience as well.

So while there is conflicting data about every supplement, including glucosamine, of the data out there, of the body of work out there, if you're going to spend your money on one supplement or one antioxidant, or one thing to add to your regimen, it appeared to us that glucosamine was the only one that had enough data for us to say that makes sense to spend your money on.

Now in terms of your diet, as we said earlier on, there's a phenomenal amount of individual variation where people will eat one set of foods that are supposedly pro inflammatory and never notice a difference at all.

And another person has a flare up of a disease related to inflammation.

So the wide variety of human response made it virtually impossible for us to give clear recommendations on does it make sense to overload on various antioxidants or various other supplements.

So we come down to it today where eat what grows in the ground as much as you can.

Bias your diet towards protein whenever possible.

Bias your beverage to water whenever possible.

Make that your first beverage that you lift in the morning and every time during the day.

And certainly between any alcoholic drink, stay hydrated and biased towards protein.

Eat fewer processed foods.

Eat what's in the ground.

That is basically the safest core advice to use.

Excellent advice.

Now, I recently reviewed the evidence on collagen which is not particularly strong.

I'm curious, as an orthopedic surgeon, you mentioned protein.

We came down on the medical mailbag segment of this program.

We said that traditional proteins, the whey proteins, were basically just as good as collagen.

There was really no benefit to taking collagen as a primary supplement.

But if people wanted to, there was certainly no downside.

I'm curious what your thoughts are.

Somebody who's probably researched the subject.

Eat a steak.

That was our feeling as well.

Although as a vegetarian, I'll just take.

The protein powder and to give explanation for people who want to know, well, why it's because the enzymes in the stomach break down the collagen protein very quickly.

And so you're spending money on something that doesn't taste very good.

Or you can spend money on something that tastes better and is a nicer food and makes you happier.

I would tell you spend the money on something that's nicer and makes you happier.

And how about hyaluronic acid?

That's the other one that they like to throw in there.

So it's a brilliant thing to inject into tissues and joints.

We almost never inject it anymore without adding an anabolic to it, meaning PRP or other things.

So that we get, because we have great data that shows that when we do those injections we can stimulate the lining cells of the joint to produce more ha.

So so in the past, our HA injection data gave patients relief of about three to four months.

When an anabolic is added to it, it goes out to about 18 months.

Orally, hyaluronic acid, same problem of proteins broken down very quickly.

Not a benefit orally.

Many women have had it injected.

Injected in their face.

In plastic surgery experiences, it acts as a natural lubricant, but orally just doesn't get there.

All right, I want to finish up with the time we have just on cartilage, because that is really the root of so many problems in terms of injury and also in terms of degenerative illnesses.

I myself, at my n of 1, had a labral tear in my hip and was developing pretty bad osteoarthritis.

I had a labral repair.

I had microfracture surgery to try and regenerate some cartilage.

I saw your section in your book here talking about why microfracture frequently.

Knock on wood.

I have.

I am now almost 15 years out from my surgery, and my orthopedic surgeon has been very pleased with how things have gone, and so am I.

However, I know that my experience is not everyone's.

Where do things stand right now with the ability to either regenerate, replace, or somehow repair cartilage?

Because we know that remains a major issue for people as they age, especially in the form of osteoarthritis.

So it's a brilliant question.

And so just for people to understand, there's generally two types of cartilage that people are thinking about.

One, meniscus cartilage or labral cartilage, as you saw in your shoulder or hip, which is a fibrous tissue like squid, and articular cartilage, which is the white, shiny surface when you crack open the chicken leg.

And that's a hyaline or glass like cartilage.

That second type hyaline cartilage, when it gets damaged, is where the arthritis occurs.

It exposes the underlying bone, and that's the pain generator that we see in knees and other joints.

So we have developed a program for regrowing meniscus cartilage.

We started that in 1984, and we built the first collagen scaffold to regrow the meniscus.

And we developed a program for articular cartilage regeneration called articulate cartilage.

Pace grafting started in 1991 and published our 2 to 25 year data on patients.

And we found that we were able to grow pretty good cartilage, just not as good as we'd like to.

And so the California Institute of Regenerative Medicine gave us a $1.1 million grant to add growth factors and stem cells and other anabolics to that pace graft technique and see if we can grow better cartilage than we could before.

So we're right in the middle of that study.

Now, we've done it in rabbits and goats, and we're about to do it in horses.

And the reason for horses is not only do they reflect humans, but many top horses get cartilage injuries, as do top dogs.

They're very valuable animals.

They're important in both racing and in work.

And if we can save their cartilage, it makes a big difference to the life of that animal as well as lives of many people around the world.

So we're extremely excited about the cartilage regeneration space.

We think we're getting better and better at it.

Come look@stone research.org, you'll see all of that research there come supported.

It's a public, nonprofit research effort, but we think that's the key to keeping you playing forever and having you drop dead at age 100 playing the sport.

And how far do you think we are from seeing that kind of technology being used in humans?

Oh, we're using it in humans now, and we're just not quite as good as we want it to be.

But we're pretty good and we will get a lot better over the next.

That is exciting news and we will continue to watch.

Dr.

Kevin Stone, I can't thank you enough for joining me today.

It's been a fascinating conversation for me as a physician, so I have definitely enjoyed it.

I am hopeful that our listeners or my listeners will have picked up on as much as I haven't enjoyed it quite as much.

If you have enjoyed any or all of this conversation, I highly recommend Dr.

Stone's book, which is Play how to Recover from Injury and Thrive.

I myself am just partway through it and I have enjoyed it immensely.

So much.

I will post a link to where you can get the book in the show.

Notes.

As always, I also wanted to mention that, like you, I had one year where I got to be the team physician for the Canadian Alpine Ski team.

So we have a slight overlap there, but very slight.

Kevin Stone is a orthopedic surgeon.

He works at the Stone Clinic in San Francisco.

He's an author, a researcher, and the founder of the Stone Research Foundation.

I'll have links to all of the things that we mentioned here in the segment.

Dr.

Stone, thank you so much for joining me.

It was really a great conversation.

My name is Stephanie Van Bever and I am a proud Patreon supporter of the Tridoc Podcast.

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