Book Review: Play On
Have you ever seen a hyena with bad knees?
“It’s a chicken-and-egg problem: Do they stay healthy because they’re so fit, or are they so fit because they stay healthy enough to train so hard?”
Play On is a 2018 book by Jeff Bercovici. The subtitle is The New Science of Elite Performance at Any Age. Quite the tempting subtitle for an old guy with bad knees. Overall, it's a solid book although sadly it didn't have any secrets that will have me feeling how I did before I ever hurt my knees (in fact he says: "There’s a saying among surgeons: once you go into a joint, it’s never the same.").
Let's start at the end
Helpfully, he wraps up the book with a short summary of his advice, saying:
When I told people I was working on a book about all the different things athletes do to stay healthy and competitive as they age, I was often asked: Have you learned anything so compelling that it changed what you do in your own life? It’s a good question.
Here's an even shorter version of that short summary (these are quotes from the book, with my comments in brackets):
Periodize, periodize, periodize...ramping up training gradually, preparing my body specifically for the demands I plan to place on it, and avoiding the buildup of fatigue or the sorts of sudden jumps in volume or intensity that lead to avoidable injuries...
Making unloading and mobility part of every workout. It encompasses recovery as well as range-of-motion work that prevents the sort of movement limitations and compensations that can build up over time and lead to injuries.
Polarize it... 20 percent or less of your workouts should be at high intensity, and the balance should be performed at such low intensity that they require little or no recovery...[avoid] going too hard on easy days, and then not being able to go as hard as you want to next time out because you’re still fatigued from a workout that didn’t serve any particular purpose.
[I liked this quote from earlier in the book: "During recovery runs at altitude on days after a hard workout, Meb would start at a 7:30-mile pace. That doesn’t sound so slow, but it’s 50 percent slower than his race pace. If I were to polarize my workouts to the same degree, 80 percent of my runs would be walking briskly."]
Eating for muscle...I’ve upped the amount of protein in my diet and the number of times I consume it during the day (although I stop short of having a protein shake right before bed). [He says elsewhere in the book: "Ingesting more than 25 or so grams of protein at a time merely leads to formation of excess urea, a by-product excreted as urine which plays a role in the formation of kidney stones. It’s better to, like Kirsty Coventry, eat smaller amounts of protein every three hours throughout the day. Moreover, there’s compelling data showing that protein consumed right before going to sleep is particularly effective at boosting protein synthesis. "
I'm not convinced the "every three hours" thing is really true...if it was, wouldn't I have read it in other books as well? Personally, I eat a handful of almonds and a thick slice of cheese a bit before bed many nights. I tried to choose foods that help you sleep.]Collagen/gelatin/bone broth. Yes, it’s a huge fad, but it’s the rare nutrition fad with data to back it up.
Self-talk. Before I learned what a powerful performance tool it can be, I never gave much thought to the particulars of my internal monologue. Now I do. [From earlier in the book: "Self-talk, in particular, has shown itself in study after study to be a powerful tool with surprisingly concrete benefits."]
Midfoot running...I’m going out on a limb a little bit in advocating it...But after wading through conflicting research and talking to a few biomechanists, I’ve becoming convinced there are some concrete benefits for runners to forgoing a little cushioning and learning to strike the ground with your midfoot or forefoot rather than your heel.
Getting swole (literally)
I left out one of his bullet points because it was a little too out there. One chapter discusses different technologies that make hard training easier on the body. One of those is using anti-gravity machines:
That’s the nature of this weird-looking $75,000 contraption, made by a California company named AlterG. Trent demonstrates how it works. Hilary is zipped into the inflatable bubble by a rubberized disk she wears around her waist, much like a kayaker’s waterproof skirt. “Right now, she’s at ten percent deload,” he says. Air pressure inside the bubble is buoying her up just enough so that she’s striking the treadmill as though she weighed 94.5 pounds rather than her real 105.
The idea here is that there's a benefit to runners training at their race pace. If you practice running slow, you'll get good at running slow. You need to run fast in workouts if you want to be ready to run fast in a race—you need to be comfortable moving your legs at a race cadence. But the harder you run the more pounding you put on your body (especially when recovering from injury). The anti-gravity machine allows you to train at race speeds without quite as much impact.
The second focus of this technology chapter is more achievable for those of us who can't drop 75K on a space treadmill, but is perhaps even weirder: using blood flow restriction training. My instinct is to say "no way this works", but there seems to be a fair amount of research ("BFRT has been shown consistently in the literature to increase muscle strength, hypertrophy, and angiogenesis.").
Here's how it supposedly works. You put a tight band around your arm or leg. The anatomy of our circulatory system is such that you're not preventing blood from getting to the muscles...just from leaving:
the limbs [are] bound tightly enough to compress shallow-lying veins, which return blood to the heart, but not deeper-lying arteries, which carry it outward to the extremities
Then there's some hand-waving about the beneficial things that happen in the muscles when that blood is forced to stay there:
the capillaries...distend more than usual... the [muscle] tissues...marinate in the chemicals released by that vascular flexing, including lactic acid and nitric oxide, which triggers the formation of new muscle.
It’s mind over matter: it doesn't matter how hard you actually worked out, if your brain is convinced that you worked out hard, it will cause your body to respond as if you worked out hard (see my review of Endure for more mind-over-matter discussion):
"The brain doesn’t know if I ran, if I pumped weights, if I just sat here. All it knows is it received a signal from the muscle cells that said, ‘This muscle exercised.’"
The result is you get stronger muscles without over-taxing the rest of your body (i.e., bones/tendons/ligaments). I'm...not sure whether this is actually a good idea. This is something I've thought about lately, and there's two arguments I can see. The first argument is that having stronger muscles helps protect your ligaments and tendons from getting overworked and tearing. There seems to be some amount of truth to this, and I've seen the claims that, for example, strong hamstrings help prevent ACL tears.
But our ligaments and tendons can get stronger over time, too. That's part of the idea behind the Knees Over Toes Guy workouts: if our knees are going to end up over our toes in normal athletic activity, then we need to train them to be ready for that (but yes, he believes in strengthening muscles too). In other words, if we strengthen our muscles while avoiding strengthening the ligaments and tendons that hold them together, we could be increasing our injury risk — we can run faster and jump higher, but we haven't given our full body the time to adapt to that new level of activity. Our ligaments (which adapt slowly) can't take the impact that our muscles (which adapt quickly) are now capable of putting them under.
Have you ever seen a hyena with bad knees?
The advice from Play On that I'm most likely to add to my routine is consuming more collagen.
In addition to eating more protein, there’s one other nutritional intervention that shows significant promise for older athletes in particular: gelatin. Recent studies have provided evidence that consuming it helps prevent and heal a variety of soft-tissue injuries. The science behind it seems to be absurdly simple in the way science rarely is...collagen supplies proteins that enable the body to form its own new collagen, which is not only the major component of tendons and ligaments but also of the tissue matrix that binds individual muscle fibers to each other, allowing them to transfer force without tearing.
That "absurdly simple science" is appealing, but I have to point out that we shouldn't be too quick to trust it—after all, eating fat doesn't make us fat. (On the other hand, eating animal muscles does help us build muscle...)
Although he doesn't make this argument, there's also a pretty simple evolutionary explanation: humans were eating "the whole animal" for hundreds of thousands of years, so our bodies evolved to use those things we were eating—including the skin, cartilage, and bone marrow. Only in the last couple hundred years have we stopped eating as much cartilage. So this isn't a "high tech hack" as much as a "return to the way of the ancients". (Again, this is just my own argument that I have no particular evidence for.)
Healthline and WebMD are both mildly in support of collagen, pointing out some of the favorable research but also saying things like "The effects of collagen powder and other collagen supplements continue to be researched and debated." I've never been much of a supplement guy, so I plan to make use of this alternate suggestion:
If that sounds like too much commitment, you can do what Baar [a nutrition expert] had athletes on England’s Olympic team do in 2012: anytime you have chicken or turkey, swallow as much of the cartilage, gristle, and even bones as you can chew up. Baar calls this the “hyena diet.” Have you ever seen a hyena with bad knees?
Surgery
Another chapter deals with surgeries. He asks a question that I've often wondered about:
Usually “clean-out” denotes some minor arthroscopic procedure like removal of bone chips, spurs, or scar tissue causing pain or limiting range of motion...Elite athletes get their joints serviced like the rest of us get our teeth cleaned...
...the correlation between abnormal MRI findings and pain or dysfunction is far from precise. Study after study has shown it’s common for “healthy” people to have herniated spinal disks, meniscus tears, and other defects without any symptoms, and to have symptoms without observable defects.
All that makes sense. But I’ve always wondered if it’s the whole story. If conservative management is usually the medically appropriate option, then why isn’t that how doctors treat professional athletes, who receive the best health care in the world because their health is worth millions of dollars to the people paying for it?
This is something I've thought about a bunch, since I myself have had the type of issues that a knee scope could "fix" (if knee scopes actually worked). He discusses a few possible reasons for this discrepancy:
"If you’re earning $10 million a year, a surgery that adds another year or two to your career but raises your risk of debilitating arthritis in 10 years’ time isn’t necessarily a bad trade-off, just a depressing one."
Athletes have access to the best, most cutting-edge healthcare that money can buy: studies show "there’s a 17-year gap between the scientific validation of new medical knowledge and the point when that knowledge becomes the basis of standard treatment." (Included in that "healthcare" is access to top doctors. Perhaps there are a few rare doctors out there who actually know how to do an effective knee scope, and the rest are just guessing?)
Athletes are more likely than the general population to be elite at sticking to their PT plan.
My personal experience makes me think of another possibility: many of the studies I've seen, like the one I linked above, track the patients' pain levels. But what if that's not the relevant variable? My clunky knee just feels wrong. Would you rather deal with "everything works smoothly but is a little extra sore all the time" or "I'm not in pain, but things just feel wrong in there"? Psychologically, it might be easier to play at an elite level in the former case.
But who cares if we haven't figured out how to make knee scopes actually work...now we have cartilage-replacement surgery too:
A higher quality of cartilage can be attained with a procedure called autologous chondrocyte implantation...chondrocytes, or cartilage-producing adult stem cells, are harvested from the knee...cultured in the lab to increase their number...[and] reimplanted in the knee underneath a flap put in to hold them in place. Compared with microfracture, ACI produces more durable tissue...
...In three clinical trials of ACI involving a total of 183 athletes, 78 percent were able to return to their pre-injury level of play within 25 months. But that “within 25 months” part is the rub. To allow the new chondrocytes to take root, the patient must abstain from impact sports for up to 18 months...
At the Scripps Clinic in La Jolla, California, a doctor of biophysics named Darryl D’Lima is perfecting a [different] treatment that involves using a 3-D printer to apply a new matrix of living cartilage stem cells exactly where they’re needed...In a beautiful irony, the exact characteristic of cartilage that makes it so reluctant to regrow on its own—its lack of vascularization—is what makes it easier than most other types of tissues to print.
Imagine an 18 month rehab!
As time passes, time slows down
Not all of the chapters are about medical procedures. A good portion of the book talks about the psychological benefits of being an older athlete. Older athletes will more often have a calm, passionate mindset that helps them stick to training regimens, deal better with losing, and stay mentally focused in the heat of the game. And once you've built up an expertise, you don't need to practice as much to keep your skills:
older expert pianists exhibited a performance level comparable to their younger counterparts while putting in fewer than half as many weekly hours at the keyboard—10.8 hours for the older ones versus 26.7 for the youngsters.
And of course, older athletes who have seen it all on the field are able to use their increased experience to make up for their (somewhat) decreased explosiveness:
“You can’t surprise me on defense,” [Tom] Brady said in an interview ... “I’ve seen it all. I’ve processed 261 games, I’ve played them all. It’s an incredibly hard sport, but because the processes are right and are in place, for anyone with experience in their job, it’s not as hard as it used to be. There was a time when quarterbacking was really hard for me because you didn’t know what to do. Now that I really know what to do, I don’t want to stop now.”
Bercovici argues that "the faster you think, the longer you’ll be able to play—because you’ll be able to avoid the kinds of injuries that cut athletes’ careers short." You analyze, and you analyze, and then you make the perfect play at the perfect moment: "In fact, biometric data from the 2014 World Cup showed [Leo Messi, a four-time winner of the award for the world’s best soccer player] ran less per minute of play time than any other player in the tournament except goalkeepers."
In discussing this concept of "the game slowing down", he tells the story of US soccer player Carli Lloyd, who patiently turned her youthful energetic playstyle into a more experienced, analytical style over the years. I loved this:
The more [her trainer] saw of Lloyd, from her inner drive to improve to her ability to summon genius with the ball at her feet, the more Galanis [the trainer] came to believe she had it in her to be a once-in-a-generation player. Maybe more. Mentor and pupil drew up something that sounded crazy: a three-stage, 10-year plan to become the best soccer player in the world.
If anyone out there wants to be the best frisbee player in the world, I'm available for free mentoring!