Injury Prevention and Sustainable Exercise

Brent: I was very athletic. I could jump very high. I have long arms. I could two-hand dunk, I could one-hand dunk, I could dunk just standing right under the rim, and I could reverse dunk. But is that something that's gone? Are my dunking days over, or could I train and get it back?

Michael: You know, if you're otherwise healthy and don't have any injuries or movement deficits, at 43 I think it's still a reasonable goal.

Brent: Welcome to Death Clock. I'm your host, Brent Franson. The goal of what we do here on the Death Clock podcast and in the Death Clock app is to make it easier for you to be healthy and do the things you need to do to live longer. In the app, we're trying to make it really easy for you to centralize all of your health data in one place, and then have a health concierge API that helps you understand your own health and what you need to do in order to live longer.

Brent: We don't have ads on this show. The way that it's supported is through the app, so if you enjoy the show, find it informative, and like what we're doing, please download the app, check it out, and let us know what you think. Today we speak with Dr. Michael Fredericson on fitness and injury prevention. It's an episode that covers all things fitness to think about as we age to maintain our health.

Brent: Dr. Fredericson is at Stanford University and on the faculty of the Stanford Longevity Center. He's been the team physician for the Stanford track team for 30 years, and he works with the U.S. Olympic team. He's been a doctor in and around fitness, injury prevention, and longevity his entire career. He's a wonderful guest. I hope you enjoy.

Brent: Dr. Michael Fredericson, welcome to the show.

Michael: Thank you. I'm really excited to be here today.

Brent: Today we're going to talk about optimizing fitness for age and injury prevention. But before we do that, can you give us a sense of your background?

Michael: Yeah. I'm a professor at Stanford University and a medical doctor. My main specialty is physical medicine and rehabilitation, which is essentially non-operative orthopedics. Within that, I specialize in sports medicine, direct our sports medicine fellowship program and clinics, and wear another hat as co-director of the Stanford Center on Longevity.

Michael: I'm also the founding director of the Stanford Lifestyle Medicine program. Basically, I have my foundation within the sports medicine world and have been moving over the past ten years more into the longevity space.

Brent: And you also work with the Stanford track team and Olympians, so you're directly involved with athletes as well.

Michael: Yeah, I've been taking care of the Stanford track team for over 30 years. I've worked with USA Track and Field and worked at the Olympics. That's definitely been a big part of my career.

Brent: What has sparked the transition and increasing interest into longevity? How do you define that, and why has that occupied more of your focus recently?

Michael: It happened naturally and really goes back to my roots and why I wanted to go to medical school: to keep people healthy using natural ways. Everything we do in sports medicine is about optimizing health and performance.

Michael: We do that to help people perform at an elite level, down to the everyday person who just wants to stay active and healthy. I felt I was at a point in my career where I mentored a lot of students who are now leaders in sports medicine.

Michael: I've done a lot of research, and while I can do more—and love it too much to give it up—I asked where I could make the biggest impact in the next stage of my career. I felt this was the direction to go to reach the most people and have the biggest impact on health, longevity, and performance.

Michael: How do you stay active, healthy, and perform at a high level as you get older?

Brent: How does the Stanford Longevity Center define its mission? My view is that there are two primary groups in longevity. The first group, where I would place Death Clock and myself, is what I'd call the incremental decade group: we know a lot about sleep, diet, exercise, and proper screenings.

Brent: If we do those things proactively from middle age, we can prevent chronic diseases that shorten our lifespans and get another ten good years. Then there's the second camp, which is more cutting-edge or bleeding-edge, looking at pharmacological interventions and approaches aimed not just at an extra 10 years, but an extra 20, 50, or 100 years, or solving mortality entirely.

Brent: There's an insinuation in that second camp that we might solve mortality, which I hope is the case, but I find their promises a bit overly aggressive. Do you agree with that spectrum and those camps?

Brent: How would you define how the Stanford Longevity Center thinks about it?

Michael: To distinguish, I'm one of the co-directors at the Stanford Center on Longevity, which focuses more on health policy and broader longevity issues. That's why I started the Stanford Lifestyle Medicine program, housed within the Stanford Prevention Research Center, to address what you're describing.

Michael: The American College of Lifestyle Medicine, currently the fastest-growing professional organization in medicine, focuses on using lifestyle interventions to prevent chronic disease. That's great, and if most people did it, it would add years to their lives.

Michael: How do you take that further to not just prevent disease, but optimize health so healthspan improves alongside lifespan? How do you keep functioning at your highest level as you get older? I'm still an athlete and want to keep improving as I age.

Michael: That's why I brought together about 40 to 50 experts from Stanford and externally who conduct cutting-edge research in longevity. Our goal is to give people an evidence base of science-backed facts they can rely on.

Michael: We're not selling or promoting anything. When something new comes out, we provide expert opinion, because it often takes five years after a trend starts before a formal study confirms whether it's worthwhile.

Michael: As part of our lifestyle medicine program, we publish a monthly newsletter and maintain a wealth of curated information on our website to help people find what they need.

Michael: We hold frequent webinars, including an upcoming one on joint health. We're also working on education for the next generation, including establishing a teen lifestyle medicine organization.

Michael: Kids can start lifestyle medicine clubs in high school and think about these habits early. Starting at 50 helps, but it doesn't have the same impact as starting young.

Michael: To answer your question, my main interest is in how to maximize health and performance as we get older.

Brent: There seems to be a disconnect between the two camps. Camp one waits for rigorous research to guide decisions on screenings, diet, and exercise.

Brent: Camp two looks at early indicators and experiments without waiting. Examples include full-body scans or using GLP-1 agonists for longevity rather than obesity treatment.

Brent: Do you or the center have published perspectives on those types of interventions?

Michael: Our lifestyle medicine team tackles individual topics as they arise to provide evidence-based guidance to the public.

Michael: We might avoid extremely speculative topics, but we aim to offer guidance on things people are actively experimenting with.

Brent: Is there guidance on full-body scans?

Michael: We haven't formally addressed that. There are pros and cons, including radiation exposure. Personally, I got a coronary calcium score because the radiation was minimal and the value was clear, but I didn't get a full-body scan. Imaging often reveals benign abnormalities that don't need treatment.

Michael: An MRI of almost anyone's back or joints will show degenerative changes, but that doesn't mean it causes pain or requires intervention.

Michael: Early cancer detection is a different story, but we haven't issued a formal statement on whole-body scans for asymptomatic individuals.

Brent: A CT scan for a calcium score feels like an established preventive tool given what we know about heart disease.

Brent: Whereas full-body scans for asymptomatic people carry risks of false positives and unnecessary downstream diagnostics.

Brent: The rate of false positives and subsequent diagnostic testing can make whole-body scans tricky and unproven for asymptomatic individuals.

Brent: Let's move on to physical performance and fitness as we age. I think of it in three main categories: cardio, strength, and flexibility (e.g., running, lifting weights, and yoga).

Brent: Do you agree with that standard classification for physical health, or do you view it differently?

Brent: Is that standard classification accurate?

Michael: Beyond aerobic endurance, strength, flexibility, and joint mobility, I add balance and movement coordination. You naturally lose balance as you age, increasing fall risk.

Michael: To stay athletic, strength and flexibility aren't enough if you lack motor coordination to move smoothly and fluidly.

Michael: Pumping iron in the gym won't automatically make you a better martial artist or athlete; functional movement coordination is essential.

Brent: Why does maintaining athletic performance matter for general health and longevity if someone isn't a competitive athlete?

Michael: It may not be strictly necessary for living longer, but if your goal is performance and being the best version of yourself for as long as possible, movement quality becomes very important.

Michael: If you want to maintain high performance, that requires a broader approach than basic health maintenance.

Brent: I'm 43 and fairly athletic—I used to be able to dunk and do a standing backflip. I can't dunk anymore, but I still consider myself active.

Brent: What would an ideal weekly routine look like for someone in their mid-40s wanting to maintain physical health and performance?

Michael: It depends on your specific goals. Training to play hockey, run long-distance races, do martial arts, or play pickleball will each require different emphasis.

Michael: Basic guidelines recommend at least 150 minutes per week of moderate aerobic activity. Increasing that to 300 minutes may offer additional benefits, but returns diminish beyond that.

Brent: My ideal target routine would be about two hours a day combining strength training, cardio (running or cycling), and yoga a few times a week.

Brent: I aim for an hour of strength training, an hour of running or cycling, and yoga sprinkled in. That's my North Star for overall fitness.

Brent: Even if I'm exceeding 300 minutes per week, is that effective since it's spread across disciplines?

Michael: That routine covers strength, flexibility, mobility, and balance, making it great for general health. If training for a sport like pickleball, you need sport-specific movement and reaction training.

Michael: You need to train lateral movement, reaction time, and functional exercises in the gym rather than relying solely on fixed machines.

Michael: Functional movement training replicates real-life demands and gives you the biggest return on investment.

Brent: For me, functional movement means keeping up with young kids. Yoga helps with bending down, and strength training lets me easily lift my toddlers.

Brent: Cardio on local trails helps my mental health and patience as a father.

Brent: Regarding running: does running wear out knee cartilage, or should we eventually transition to low-impact activities like swimming?

Brent: How do you view running for aerobic fitness as we age?

Michael: A 20-year Stanford study following runners found that running did not lead to knee osteoarthritis; in fact, runners had lower rates of knee arthritis.

Michael: However, if you already have significant knee arthritis, high-impact running isn't ideal, and cross-training with swimming or cycling is safer.

Michael: If your knees are healthy, there's no reason to stop running out of fear of developing arthritis.

Brent: People worry that running wears down knee cartilage over time until bone rubs on bone, requiring knee replacement.

Brent: They feel they should stop running early to preserve their knees.

Michael: Research doesn't support that. Long-term studies show runners maintained healthier cartilage than non-runners. If you have pre-existing joint issues or prior injuries, you may need to adjust your volume or terrain.

Michael: Steep downhill running is actually more stressful on knees than uphill running. But for healthy knees, no evidence suggests running causes damage.

Brent: Is running on dirt trails better for the body than running on paved roads?

Brent: What's your what's your direction to me there?

Michael: It doesn't really matter.

Brent: The idea popularized in *Born to Run* is that dirt offers lower impact, making it better for the body than pavement or concrete. Does research show a difference?

Brent: Doesn't matter.

Michael: Studies haven't found a direct link between running surface and overall injury rates. Softer dirt surfaces feel good and challenge balance, but uneven trails carry a higher risk of acute injuries like ankle sprains.

Michael: Listen to how your body feels; science shows no significant difference in overall overuse injury rates between surfaces.

Brent: Is there a threshold where extreme running volume—like 70 miles a week for ultra-marathons—becomes harmful?

Michael: Consistently pushing your body to extreme limits over many years can cause adverse effects, such as an increased risk of atrial fibrillation and cardiac tissue fibrosis.

Michael: Extreme chronic endurance training maintains high systemic inflammation, which can elevate risks for conditions like neurodegenerative disease.

Michael: Consistently pushing extreme volume for years is generally not ideal for long-term health.

Brent: How do you compare steady Zone 2 cardio against workouts that incorporate high-intensity sprinting and varied efforts?

Brent: Is a steady Zone 2 routine preferable, or is a varied program with sprint intervals and hiking better?

Brent: Do you prefer A or B or.

Michael: Variety is better. High-intensity interval work yields greater cardiovascular adaptations in less time while training your power systems for real-world demands.

Michael: Slow jogging alone won't prepare your body if you need to sprint during a game or handle quick bursts of activity.

Brent: In high-impact sports like pickup basketball, middle-aged players frequently tear their Achilles tendons. Should older adults approach cutting sports cautiously?

Brent: Is it safe to play cutting sports if you train properly, or should middle-aged adults avoid them?

Brent: And so somebody got injured. But fine to do it. If you're, you know, you're you're training for it. You're thinking about it functionally.

Michael: Unprepared "weekend warriors" get hurt because their tendons aren't conditioned for explosive loads. Incorporating eccentric calf raises and plyometrics into strength training builds tissue tolerance.

Michael: Sudden explosive movements without preparation frequently tear calf muscles—a condition common enough in middle-aged players to be called "tennis leg."

Michael: If an explosive motion doesn't strain the calf muscle, it often ruptures the Achilles tendon instead.

Brent: How do you treat a torn calf muscle compared to an Achilles tear?

Michael: A calf tear usually heals well without surgery. In contrast, an Achilles tendon rupture typically requires surgical repair.

Brent: I used to have a vertical leap high enough to dunk easily with one or two hands, or reverse dunk. Now I notice I jump lower. Could I train to dunk again at 43?

Brent: And I do shoot around as a warm up for strength training just to get the blood moving. But is that something that's that's gone? My dunking days are over or I could train and get it back.

Michael: If you're healthy without existing injuries or movement deficits, dunking again at 43 is a reasonable goal. By your 60s I'd advise against high-impact jump training, but at 43 it's achievable.

Brent: Moving to strength training: do you prefer machines or free weights for building and maintaining muscle in middle age?

Michael: Machines have an unfair reputation. They build strength just as effectively as dumbbells or barbells and are simpler for gym beginners to navigate.

Michael: Dumbbells and free weights challenge balance and multi-planar coordination better for functional athletic training.

Michael: For general health and basic strength maintenance, machine workouts are completely fine.

Brent: The best workout is the one you actually do, so beginners shouldn't stress over machines versus free weights. How should middle-aged adults approach ramping up strength training after a break to avoid setbacks?

Brent: I learned firsthand that ramping up too quickly can lead to severe joint pain and long recovery delays.

Brent: It's crucial to progress slowly because recovering from injuries takes much longer as you age.

Brent: So how do you think about the ramp up going from nothing to something?

Michael: As you age, recovery takes longer. Allow 1 to 2 rest days between heavy sessions targeting the same movement patterns.

Brent: Does that rest rule apply per muscle group? I follow a push/pull/legs split and feel fine lifting consecutive days if alternating targeted muscles.

Brent: Is recovery muscle-specific, or should all strength training be avoided on consecutive days?

Michael: Recovery is largely muscle-specific. Unless a session causes total-body central nervous system fatigue, training upper body one day and lower body the next is fine.

Brent: Is resting specific muscles necessary primarily to prevent injury, or to maximize hypertrophy and muscle repair?

Brent: Is avoiding consecutive days on the same muscle group primarily for injury prevention or for better muscle growth?

Michael: It's important for both. Hard workouts create microscopic muscle tears that need time to rebuild into stronger tissue. For injury prevention, training with lingering muscle soreness impairs biomechanics.

Michael: Altered movement patterns from fatigue significantly increase your risk of injury.

Brent: Are certain muscle groups particularly important to prioritize in middle age? I've found that regular leg training alleviates my knee pain from a prior ACL injury.

Brent: Building shoulder strength feels far more useful for daily health and stability than benching for chest aesthetics.

Brent: If time is limited, which muscle groups yield the highest return?

Michael: The glutes are priority number one. If you could only pick one exercise, squats are a top choice to preserve lower-body power.

Brent: So squats are the premier strength exercise?

Michael: Yes. As people age, glute muscle loss makes rising from chairs difficult. Having glute reserve capacity helps you recover faster from illness or hospitalization.

Michael: Core strength is equally essential. A strong core connects upper and lower body movements smoothly while protecting the spine.

Brent: How do squats, glute strength, and core stability help prevent low back pain, which is so common in middle age?

Michael: Proper form is key. Hyperextending the back under heavy weight can cause issues, but with good mechanics, strengthening muscles around joints relieves spinal stress and prevents pain.

Brent: Are you a fan of standard barbell back squats, or are there alternative ways to squat for people who find the barbell uncomfortable on their back or shoulders?

Brent: Many people dislike placing the heavy bar on their back.

Michael: Barbell back squats tend to irritate my lower back, so I prefer performing squats with kettlebells or dumbbells.

Brent: Holding kettlebells at your sides or performing goblet squats?

Michael: Goblet squats, holding a kettlebell close to the chest, work extremely well.

Brent: Holding the kettlebell handle near your chin avoids putting heavy axial loads across your back.

Michael: I don't load heavy barbells anymore. My goal isn't maximal hypertrophy or heavy lifting, but maintaining strong general conditioning safely.

Brent: Moving to flexibility and mobility: yoga offers flexibility, balance, and mild cardiovascular benefits. It stands out as a complete modality.

Brent: If someone dislikes yoga, what are the best alternatives for balance and mobility—Pilates, Barre, or structured mobility work?

Michael: My wife teaches Pilates and yoga. Offerings vary widely, ranging from intense conditioning classes to low-intensity mat routines.

Michael: Depending on the style, some Pilates classes elevate your heart rate while others focus purely on core control and stability.

Brent: Unlike cardio or strength training, mobility and flexibility options seem more limited to taking structured classes like yoga or Pilates, or doing self-guided foam rolling on a mat.

Brent: Do you have to find a class style you enjoy to build an effective mobility routine, or is there another way?

Michael: I agree that finding an instructor or class format that suits your preferences is key because style and intensity vary widely.

Michael: You can also do a lot at home. Every evening while watching TV, I spend time foam rolling and stretching. My wife and I wrote a book on foam rolling techniques paired with targeted stretches.

Michael: Combining soft-tissue foam rolling with static stretching is extremely effective.

Brent: Let's do a quick rapid-fire round for short takes on common topics. First: saunas.

Michael: Huge believer. Saunas offer significant cardiovascular and recovery benefits.

Brent: Cold plunges?

Michael: They have benefits, but using a cold plunge immediately following a strength training session will blunt hypertrophic adaptations and muscle growth.

Brent: What about creatine supplementation?

Michael: I am a huge fan of creatine monohydrate.

Brent: What is your personal daily dosage?

Michael: I take 3 to 5 grams per day. Maintaining muscle mass is a priority for me, and creatine helps significantly.

Brent: What is your perspective on intermittent fasting?

Michael: It offers health benefits for many, but doesn't suit me personally because restricting my eating window makes it difficult to consume adequate calories and protein.

Brent: Regarding protein: guidelines often recommend 1 gram per pound of body weight. Hitting almost 200 grams daily through plain chicken breasts and eggs is tough. How much protein do we actually need?

Brent: How do you view daily protein requirements?

Michael: Base protein targets on lean body mass rather than total scale weight. That reduces targets to more realistic levels without requiring extreme intake like 220+ grams daily.

Michael: Calculating requirements relative to lean mass yields much more appropriate numbers.

Brent: How do you estimate target intake based on that?

Michael: We need more than the basic RDA, but non-bodybuilders don't need the extreme high levels often touted online. Consulting a dietitian is the best way to determine your targets.

Michael: Determine your precise lean body mass and calculate your daily dietary protein intake from there.

Brent: How would you describe your own personal diet?

Michael: I advocate for the Mediterranean diet: mostly plant-based with nuts, seeds, healthy oils, whole grains, and occasional lean meats like poultry or fish.

Michael: It offers sustainable flexibility while providing strong clinical evidence for reducing systemic inflammation in the body.

Brent: Dr. Michael Fredericson, thank you for your time. Where can listeners find more information about your work and Stanford Lifestyle Medicine?

Michael: You can search for my faculty page under Stanford Profiles, or visit Stanford Lifestyle Medicine. Our team publishes free public resources, health articles, and a monthly newsletter.

Michael: You can register for our free public webinars and conferences to access evidence-based health information.

Brent: Dr. Michael Fredericson, thank you so much for joining us.

Michael: Great. Thank you.

Brent: Death Clock is recorded in Boulder, Colorado and San Francisco, California. Produced by Patrick Gudino, music by Patrick Lee, and hosted by Brent Franson, founder and CEO of Death Clock.