Back Pain Masterclass: Exactly How I Treat Athletes

Episode Transcript
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Speaker 1 (00:11):
Hello everyone and welcome back to another episode
of the Shift Show, where mynumber one goal is to give you
the tools, ideas and the latestscience to help you change
gymnast lives.
My name is David Taylor.
Today on the podcast, I'm veryexcited to bring to you pretty
much how I treat back pain.
I think more or less like myversion of a masterclass podcast
on treating low back pain.
I gave an in-service to thedoctoral students at champion
who are rotating through beforethey may be going to do like a

(00:33):
sports residency or somethingelse, and essentially just sat
down for an hour and a half withthem and said, like this is my
framework for how I treatathletes for back pain, from a
gymnast with back pain from likeback walkovers and back
handsprings to, you know, aneveryday baseball athlete or
softball athlete who is, youknow, having pain with throwing
or hitting or deadlifting in thegym and just talk about some
adult fitness people to justactive, healthy people who want

(00:54):
to work out and be active.
You know how we help them forback pain.
So at this point in my careerI've unfortunately treated like
1000 people for back pain and Ifeel like I have a pretty good
understanding of like thesystems in which we use the
research around it, what thingsseem to be helpful and kind of
how to apply that really dorkystuff to an everyday.
What do I do right now to feelbetter, which I think is the
most important for patients orgymnasts or athletes that we're

(01:14):
working with in general?
So during this part of the yearI always try to share more
medical stuff as we go closerinto season because
unfortunately, as season comescloser for gymnastics and many
other sports, you know, backpain, injuries as long as, like
hip and knee, shin splints,shoulder issues, that kind of
stuff starts to kind of creep upa bit.
So I wanted to get informationout there to help the ATS, the
PTs, the chiros out there.

(01:34):
And if anybody wants some ofthe medical resources from shift
, they're all on sale this weekfor 25% off using the code
season 25.
Because I want to try to helppeople get access to information
on, you know, injuries that aregoing to happen in the next
kind of six to nine months asthe season progresses.
So yeah, you can learneverything from how I treat
gymnast for back pain or hipinjuries non-op operative rehab,
acl stuff, slap repairs,rotator cuff stuff pretty much

(01:57):
all I've learned.
I put into courses and or PDFguides, which are online, you
can check out in the show notesbelow, just to hopefully get a
big chunk of that money savedfor you and learn a lot of stuff
if you're going into season,working with teams or working
with anybody else.
So this is kind of my approachto spondylitis, back pain,
sciatica, stuff like that,summarized in a little bit of a
quick masterclass version forpodcast.
If you want the full thing allthe exercises, all the

(02:18):
worksheets, all my hands ontechniques, check out the
resources from Schiff's onlinemedical library.
So hope you all enjoy thisconversation about back pain.
All righty, I think we're goodfor this, okay, so in the hope
of giving people more exposureto a wide variety of things that
you probably don't see, soMaddie is with Lisa and I, so

(02:40):
she sees like 11 spines a day.
You guys are with Lenny.
You see more ACLs and stuff.
So as part of our staff meeting, we're trying to get more
exposure to everything.
But I also feel like the timeat Champion.
You want to spend an hour withsomeone who's done a lot of the
thing, right?
So like to ask Lenny aboutquestions about the ACL, or Mike
about the shoulder, dan aboutlike knee pain, kevin about
running.

(03:05):
It's probably good to have likea long session to try to share
my framework for how I thinkabout things and then answer any
questions that you guys have,because you only obviously are
here for a limited amount oftime and or we'll see so many
people, so you want to have allthe things you're prepared for.
So we're going to the goal ofthis.
We have an hour and a half.
The goal is like 30 ish minutesof a vow and then maybe like a
little bit 40 minutes ish oftreatment stuff.
I think that's the mostimportant is like knowing what

(03:25):
to actually do with somebodywhen they're really, really in a
ton of pain.
And then the last two, uh, thelast chunk of it maybe 20
minutes, 30 minutes is a casestudies, um, to kind of use two
examples of the stuff that wetalk about.
Um to again hopefully have youguys leave here and feel
moderately confident with theinformation.
Obviously you need reps to be inthe trenches more, but I would

(03:47):
say lumbar spine is probably thething I've treated the most
like not being facetious orhyperbolic, but I probably
treated a thousand people forback pain since grad school to
now, just because of the natureof how gymnastics.
And then I got baseball, then Igot softball and everyone just
started coming to me forwhatever back injuries.
And so the reason I say that isnot to flex on people, but to
say is that when I first startedout, it was the thing that I
needed to read about the most.

(04:08):
Like I felt moderately preparedfor spine stuff when I came out
Like I knew how to treat people.
The clinical predictionguideline had just come out 2015
or so, so I had that, but I didnot feel as though I really had
a good handle on what to dowith somebody who was in the
trenches painful at the moment,and so I actually think the
spine course at my at my collegewas really good and uh, we had

(04:31):
a guest lecturer come in andtalk about like McKenzie stuff,
which was awesome, but yeah, Ijust didn't feel really prepared
.
So when I got out, I wastreating in my first job was
pretty much all insurance basedclinic stuff was sorry, maddie,
I'll move this.
You don't see?
My coffee um was, uh, a lot ofchronic pain and a lot of
workman's comp and a lot of genpop.
It was not the people we seenow which are like the pro

(04:51):
baseball players, the gymnast,the, whatever it was, very much
like the everyday person.
So good and bad.
Because good that it forced meto be a master of the back right
first, so learn the anatomyreally well and learn all the
courses that were available.
Bad because that's a toughpopulation to apply things to,
because it's a mixed bag of howmuch they want to work and who

(05:12):
they.
You know what they're doingthere.
Car crashes are sometimesawkward with insurance and stuff
, and so, yeah, I didn't feellike I had a full timeline to
help them and really prove tomyself that what I was doing was
working.
But in the course of thathappening, that was when, um,
pain science was like all therage, right.
So pain science had just becomereally popular, but, like Laura
Mosley and uh Butler and someother people, so there was a ton

(05:35):
of books, courses, stuff and Ilike, um, just got thrown into
that because the population Iwas treating definitely had a
mixture of, like, chronic painand or chronic re-injury.
I guess is a way, chronic painis not chronic re-injury, right.
So I did have some of thosetruly sensitized people who were
like legitimately fearful oftheir back and the whole MRI
thing.
So there was a time in my lifefor two years where, like,

(05:56):
really a lot of that was superimportant and I think I helped a
lot of people because I leanedinto pain science quite a bit
right, and then I started seeingmore athletic people so
gymnasts, dancers, ballet inparticular so spondy started to
come about more and that Ididn't really feel like the pain
science stuff explanation wisefor education, which we'll talk
about actually was reallyhelpful, but in terms of
treating people and helpingpeople it didn't really do it,

(06:18):
because sports are really highforce right Throwing a baseball,
doing gymnastics multiple timesbody weight, you're having a
fracture right Like you trulyhave something that would cause
a significant amount of pain ifyou break your back right.
So that is actually when Istarted working here and I met
Mike and Lenny and I wasactually talking with Dan a lot
of the time.
I started watching StuartMcGill's work quite a bit more,
reading all his research, tookMcKenzie courses.

(06:39):
I did a lot of strengthconditioning stuff then as well
after my SDS.
So like watching Eric Cressyand Mike Boyle and see how they
deal with people after pain.
So it was a lot to take in.
But I actually think it was thebest thing that ever happened
to me, because every single likesystem at the time from PRI to
SFMA to McKenzie I just tookevery course and read every
textbook and then took a hugestep back and was like, okay,

(07:00):
what's my system Like what worksfor me?
Probably 20.
Back and was like, okay, what'smy system like what works for
me?
Probably 20 of every one ofthose systems I would say I
probably don't really use and orthink is solid for everybody.
But if you pick the right thingsand apply them in the right
spots, I feel like that's maybewhat makes me a quote-unquote
good clinician for spine pain,because one.
I've seen a lot of it and Iknow the research really well.
But I also know when to pullout a mckenzie exercise or when

(07:22):
to try something more painsciencey with someone or when to
do just straight up loadingwith someone and just get
somebody stronger if they'relike a younger athlete.
So yeah, that is that top chunkis like all the research and
the textbooks and stuff are inthe in-services.
There's like docs from lastones they have.
But I don't want to give you 49pages of all the stuff.
But if you have a specificquestion about where to look for
those things, I can happily doit.
But so that is kind of thefirst two years I had and what I

(07:44):
found from that.
The summary is that 80% of painscience and biomechanics and
pathomechanics overlap.
Okay, so the same time when Iwas getting into the world of PT
stuff Instagram, social media,advice was all time high.
Right, there was literallyevery day 40 exercises for back
pain, 13 exercises for this and19 things for that.
And so, as a new grad, me andDan were like dude, what the

(08:09):
hell?
Like we have no idea what isgoing on, it's just tons of
exercises.
And that era was also like maxbashing of anything that wasn't
their own system.
So people were shitting onevery other PRI or SFMA or
whatever, just saying thatnothing works.
And it was really frustratingbecause like, okay, well, if
nothing works, what do we dowith somebody when they have
ripping sciatica and they walkin?
What do you do with somebodywho has a stress fracture and
has like acute spondy?
Like what do we do with thesepeople?
So that's when I think Dan andI it was great to have Dan,

(08:29):
because Dan and I were both like, okay, well, this is what I'm
reading, this is what I'mthinking about, how do you treat
this, how do you treat that?
But hadn't treated a ton oflumbar spine?
So we could take all the stuffthey use and then apply that
even more right.
And I would say again, 80% ofbiomechanics and pain science
overlap.
If you look at the root levelno pun intended of what is the

(08:54):
mechanism of, like cellularphysiology or pathomechanics,
which we'll talk about here,like what is the actual baseline
level, mechanical argument andor chemistry argument, whatever
else, it is right.
So there's two examples here ofthings that would both help
somebody to explain what's wrongwith their back.
Right, explaining what is goingon after a good subjective is
half the battle, because mostpeople spend 10 minutes with a
physician and don't actuallyknow why their back keeps

(09:15):
getting flared up.
So on the pain science side,you would explain to somebody
like, all right, you're doingthe same thing over and over
again, right, what's happeningis that areas of your back
perceive that as a threat.
Those are nociceptors, right?
Sends a signal up to your brainand your brain says, oh no,
this is probably not good for us.
So let's create a pain responseright Within a pain neurotag.
One response is create aperceived threat, interpretate

(09:36):
it as pain output right, andthat causes the person to not
move comfortably.
Right, because now they havethis guarding response Maybe
it's a muscle spasm.
Maybe it's a muscle spasm,maybe it's extremely sensitized
motion when they bend forwardright.
And what we're doing withexercise and PT is we're
essentially giving somebodyeducation to calm down their
sensitivity level.
Because when you explain tosomebody like yeah, a lot of
people get back pain, peoplehave disc bulges, you know,

(09:59):
people have arthritis.
It's a thing You'd be totallyfine.
Most people get better.
Here's what's going on.
Here's how we solve it.
You're reducing threat at acentral level.
Right, because you're calmingsomebody down.
They just feel better whensomebody is oh, this person
knows what they're talking about.
They seem like they've seenthis before.
The other people have gottenbetter.
I'm going to get better.

(10:20):
A lot of these things arehelpful, along with exercise and
activity modification.
Like right, there is one partof the exercise exposure is that
McKenzie exercises and McGill'sexercises could be just
reducing sensitivity becausethey're doing something that's
not interpreted as painful orthreatening.
Right, when you find exercisesif they only deadlift or squat
and that's all they know, forexercise they try to do really
hardcore planks but maybe theirQLs are sensitized, they spasm

(10:42):
every time they do a side plank,right.
But if we teach them bird, dog,dead, bug breathing, positional
work and it's not painful butthey're using their back muscles
, your brain's like, oh well,wait a minute, maybe I can use
my back and it's not as bad as Ithought it was.
That's graded exposure to thenhave a lowered sensitivity,
right.
And that is a lot of the stuffthat we'll talk about after.
The anatomy stuff is likeexercise, all that kind of stuff

(11:03):
we do, running programs, manualtherapy it is just lowering the
gate of sensitivity, right.
So that is the entireexplanation for flexion
intolerant back pain.
In the pain science world.
Somebody walks in and isterrified of their MRI,
terrified of all the things thatthey've been said to.
They said they're broken, theirdiscs are slipped, their hips
are rotated, they're never goingto get better.
That person needs just a soliddose of pain science to walk

(11:24):
them off the ledge.
And that can be super athleticpeople.
I've worked with pro athletesand Olympians who are just as
nervous and are scared becausethey have to compete for a
scholarship or they have tocompete for a spot on national
team and when you tell them youhave a disc bulge and you start
going anatomy route, it startsto freak them out as versus of
the other side.
So it's not only about the proathlete doesn't need that.
But I would say, in general,athletic people, people who work

(11:46):
out, people who are very active, they want the mechanical
reason, they want to understandwhy their back hurts from a very
nitty gritty patho anatomicalmodel.
And so the exact sameexplanation would be that, okay,
repeated or sustained movementshave created a posterior
lateral disc migration rightthat has put pressure on the
annular wall.
The annular wall has thenabutted into the nerve root, the
dorsal nerve root.
That has caused either localneuritis or some sort of

(12:09):
chemical inflammation which thencaused maybe a muscle spasm.
As a protective splint, amultifidi has spasmed and then
of course you have this largepain output to protect you and
the reason you feel so crappybrushing your teeth or bending
over to touch your toes, isbecause you have chemical
inflammation.
You have true neural irritationfrom the disc bulge causing an
annular wall fissure right.
That's a true nociceptivestructure that can create pain.

(12:30):
Or there's true inflammation inthe nerve root from a neuritis
right From some sort of eventwhere they threw really hard,
they landed really hard on a skijump and they flexed their back
really hard.
That can cause an acuteneuritis, the same way that when
you whack your arm really hardon your funny bone you have that
tingly sensation right whichcauses a sciatica and the whole
nine yards.
So the way you would help thatperson to get better is what

(12:50):
we're going to do directionalpreference movements to help
reduce the pressure on the nerveroot, not heal the annular
fissure with exercise.
But over time, if we takepressure from the things that
are sensitive, the body willnaturally reabsorb the posterior
lateral disc wall.
If the annular fissure is notbroken through to an excursion,
it should more or less, you know, calm down on its own.

(13:10):
A lot of people have thesethings.
It's totally normal.
You know, if I sat, probablyafter I talked for an hour and a
half, I'll have a mild discbulge, you know.
But my back feels fine, youknow, I'm okay.
So that is the entire thing fora disc bulge in the mechanical
patho-anatomical lens, right.
But I would say again, 80% ofthat overlaps, right.
It's just a matter of how youdeliver that with somebody.
Yeah, are there any questionson that?
In terms of those two thingsBecause that's still a very

(13:31):
popular school of thought that Ithink everybody deals with is
the pain science biomechanical,pathomechanical and I still see
it all on social media.
I read it all, I understand it,I know what it is, but a lot of
people who are yelling theloudest treat the least right.
Until you've treated 500 peoplefor back pain, hopefully
successfully, I'm not sure youhave a leg to stand on and tell
everyone that PRI is dumb orSFMA is dumb or McKenzie's

(13:54):
stupid.
You should never do that right.
Like it's a little bit of aslippery slope there.
Okay, so all the stuff more onthat is in research evals books.
I don't want to bore you withexplaining that.
I'd rather just get to theclinical stuff.
Okay, the subjective isprobably the most important part
of the entire eval For this inparticular, I think that's in PT

(14:15):
as a whole.
But really understanding whatmakes you worse, what makes you
better.
When was the first time you hadpain?
What do you do naturally tomake it feel better?
Like, do you have leg symptoms?
Do you not have leg pain?
What do you do naturally tomake it feel better?
Like, do you have leg symptoms?
Do you not have leg symptoms?
How would you describe yourpain?
Is it sharp, is it achy?
All of those things?
If you ask a good subjective,the person will tell you what

(14:35):
direction is cranky.
Right, that's what we'relooking for is the provoking
directions, and then thedirectional preference is what
alleviates that, which istypically the opposite.
Okay, so if somebody tells you,for example, the case study, at
the end we'll talk about Frankieand actually Kylie.
Ironically, kylie was like thefirst person I ever treated for
back pain when she was youngerwas like tell me, what made you
worse?
And they were like okay, I, uh,I was ramping up for season.

(14:56):
I got a bunch of hittinglessons the week after my back
started to get stiff.
I went for another hittinglesson Next morning.
I couldn't wake up.
You know, something happened inthat lesson.
Like, okay, well, what werethey doing?
A lot of extension and rotation.
It sounds pretty sharp andintense.
Right now they're really havinga tough time.
Right, you're starting to think, okay, extension and
compression might be the onethat makes them provoked and
then the opposite would be thething that makes them better.

(15:17):
Right, same thing with the othercase study is Matt.
He was one of the adult fitnessclients here.
He just came to me after twoother PTs and doctors and
injection essentially said thatstarted with he worked at a lab
all day as a chemist.
He went to the gym, drove tohalf hour to the gym, warmed up
quick because he had to get homefor his kids, did a deadlifting
session, felt kind of weirdduring it, went home, sat on the
couch with his kid all night,had dinner, woke up the next
morning completely crippled so Icouldn't go to work.

(15:38):
Right of telling you, sat atthe lab all day, sat at the car
all day, right, sitting's notbad for you.
But it's a common theme therethat probably over the course of
multiple weeks he kind ofskipped his warmup, kind of
deadlifted a little too heavy,kind of did a bunch of things he
maybe wasn't ready for right.
So he's telling you essentiallywhat we're going to then do in
the movement assessment.
So, yeah, all those things, redflags, when did it start?

(16:00):
When's it better?
Do you have leg symptoms, doyou not?
What have you done?
Have you seen another PT?
Have you had imaging?
I really don't think imaging isthe devil, as long as you use
it in the right context.
If someone hasn't gotten betterin a month or two and they're
still really struggling, that'sa huge role to play in knowing
what's going on, especially withthe young athletic back pain
population, like spondy concerns.
And then what other things arelike in your daily life making

(16:23):
really, really bad right,sitting versus standing, driving
versus being up, walking around, laying on your stomach versus
sitting on a couch, like theywill tell you over time, the
things that tend to make themworse.
Okay, so, obviously red flagsrule those out.
That's pretty important.
But, um, yeah, I think that'spretty self-explanatory.
I'm intentionally going throughthis fast cause I think it's
boring.
Um, okay, so my entire approachto helping people with back

(16:46):
pain is a ton of education,right, like massive amounts of
education, like there are fourtime.
There are four sections of backpain progress Acute oh my God,
this is terrible, my life isending is like the chemical
irritation, probably two to fourweeks in that phase, if it's
pretty cranky.
Then you move on to like the bea normal human again phase,
which is like can I go to school, can I carry my backpack, can I
just exist in day-to-day lifewithout my back feeling really

(17:08):
like I'm walking around sideways?
That's the second phase.
The third phase is be generallyathletic.
Again.
Right, can I Squat?
Can I do hinging?
Can I do some split squats andstep-ups?
Can I run?
Can I jog?
Can I skip?
Can I just do athletic thingswithout flaring myself up?
The fourth phase is getting backto whatever sport they want to
do.
I want to hike, I want todeadlift, I want to throw a

(17:30):
baseball, whatever else.
It is so educating somebody onhow.
Hey, like something picked thescab and it's going to take a
long time for us to get throughthis.
On the earlier side, if it'sthe mild muscle spasm, it could
be a month, it could just belike literally one week for each
of those things.
If you have a mild facetsyndrome where you just tweaked
your back from a hitting lesson,it might be one week in each of
those things.
You might feel fine all the wayto the opposite, which is a

(17:51):
spondy or a stress reaction intoa stress fracture, is a full
bracing in California, orbracing in Boston, not bracing
in California.
Three months of relative restto let the bone heal and then
another three months of slowlygetting back to athletics.
So that's six weeks for each ofthose phases.
Or somebody has a microdisectomy and that's a really
aggressive nerve root bulge thatis causing foot drops, sciatica

(18:11):
, really bad stuff.
They got to get a microdisectomy and a laminectomy and
it usually takes them againthree to six months to get back
to all of their activities.
Right, when we say cleared, wemean like I never had back pain,
I'm pitching 95 miles an hour.
We don't mean like I can walkmy dog and I'm relatively okay,
like our.
Our version of cleared and backto sport is like everything,
like we feel really good.
That's why we work withsporting people, right.

(18:31):
So I really want to spend a lotof time educating somebody on
pain science, pathomechanics,the timeline, explain to them
what we'll talk about here insome way shape or form in a very
lay terminology of what happensto the disc or the spine or the
facets when you move certainways and how the sport they're
doing or the activity thatthey're doing is probably
causing significant overloadonto those structures and

(18:52):
workload volume and likerepetitions, like all that stuff
is really important in theeducation.
I am trying to put myself out ofa job when I treat people for
back pain.
I don't want them to come here.
I've treated people once everytwo weeks who have the worst
ripping sciatica you've ever hadin your life, right?
So I want people to treatthemselves.
I don't want them to need me todo some fancy manual therapy to
then fix them and then theyneed me every single week, right

(19:12):
, I want to get people on theirown feeling better and feel like
they know what they're doingand they can treat themselves as
fast as possible, and so theeducational piece serves that
massively right.
Of course they will need somehelp from us to create programs
to do that, but I'm more or lesstrying to do that, okay.
The second piece that's reallyimportant, which sometimes gets
lost in the world of physicaltherapy, is actually treating
their back right.

(19:32):
Like people will spend 39minutes on their hips and their
T-spine and how their left lungis rotating their right back,
and sure, that's definitelymaybe a role for that.
But if somebody pays you out ofpocket because their back hurts
and you don't work on theirback, they're not coming back
Like you're not going to helpthat person.
So the eval I could probably doin 15 to 20 minutes pretty well
to get mostly there.
I then continue the eval withtreatment.

(19:53):
So treating somebody withMcKenzie exercises is a good way
to treat them, but also confirmthat they have a directional
preference, right.
And then, of course, we have,like the, if you want to do
manual therapy, if you want tomake an exercise program, that's
probably the next half of the,about two as well.
So I'm trying to treat thething that actually hurts Right,
and again, by doing goodsubjective and ruling somebody
in.
The exercises you use arepretty straightforward, right.
If somebody has clear flexion,intolerant, discogenic back pain

(20:16):
, cat cows and press ups andstanding back bends, going for a
walk is 90% of their program tostart, right.
Big thing that I think isdifferent about me and the way
that we treat here is like theother 23 hours of the day are
more important than their hourthat they're here with us.
So I care way more about whatthey're doing in their home life
and their daily life that theydon't realize is keeping them
flared up than giving them amagical exercise that they think

(20:38):
I'm a God, right, like I, theperson, you listen to them, like
Matt, for example, the chemist,like, walk me through a typical
day before you were hurt.
And he's like, yeah, I, just Iget up and I have breakfast with
my kids.
I uh, I drive 45 minutes intoBoston and I have about a couple
of meetings.
I work in the lab for six hoursrunning experiments and then I
usually get out of there, grab aquick bite to eat, drive 45
minutes to the gym and then I'musually pretty crunched for time

(21:00):
with traffic.
I warm up real quick, get myworkout in, I go home and I have
dinner with my kids.
What is consistent about theentire day?
Homeboy sat for eight hoursright.
Sitting is not bad for you.
Sitting is not like the devil.
I don't want people to thinkthat Sitting is the new.
Smoking was a huge rage thingand like your spine just needs
to move a lot in differentdirections.
Often it's too much of onething is problematic.
In the same way that I askedFrankie, I was like talk me

(21:24):
through a practice.
She's like well, I warm up, Ido kind of stuff we do throwing
drills.
I play long toss, I'm a catcher, so I do a lot of really
explosive throwing to secondbase drills and then I sprint
and I have hitting practice.
I take a lesson after I go lift.
My lift is mostly backsquatting and dead lifting with
some accessory work, and then Igo home and I do my homework.
That girl's just living inextension rotation for four
hours.
In practice she's lifting inback squats, right.

(21:45):
It's very common of what herthing is.
So everybody has a thing, right.
The gymnast, you could argue,is a extension rotation too.
But if you listen to theirstuff it's like just all landing
compression over and over andover again.
They're taking thousands ofimpacts at multiple times body
weight.
So compression and the endplate hitting the facets is the
big thing for them, right.
So that's why this objective isso important, because the

(22:06):
actual exercise applicationbecomes much easier if you spend
the right time to rule somebodyin right into the right
category.
So I try my best to get a lot ofeducation, give them some basic
things to do to remove thething that's cranky.
Modifying sports, you know,changing their practice routine.
Maybe they're not doing as muchflexion in one thing or

(22:26):
extension in the other, buttrying to modify their workload
right.
And then trying to give themexercises is the opposite.
So I usually tell people in theacute phase every two hours for
the first two days I want youdoing some sort of exercise
that's going to help youBackbends, press-ups, going for
a walk, whatever else you needneed, right.
So the other person it's catcows, rock backs, deep belly

(22:47):
exhales to try to open thefacets up and open up the space
in there, yeah, okay.
So treat the thing that hurts,take away the things that are
causing the issue, right.
And then the next thing istrying to get some sort of an
understanding of what's aboveand below.
So Matt, for example, stiffesthips on the planet right Could
had like 95 degrees of hipflexion and IR, but he was deep

(23:08):
squatting because he was doingCrossFit.
I love CrossFit, but homeboydoing a front squat when his
shoulders are stiff and his hipsare super stiff, he's going to
round his back very aggressivelyat the bottom of cleans right.
And so he needs hip mobilityand ankle mobility and T-spine
mobility to help pull off someof the flexion forces on his
spine right.
He also probably needs to do adifferent version of squatting
for a while that isn't as backintensive, right.

(23:31):
So a low bar box squat, forexample, is the most back
intensive, whereas an uprightgoblet squat is more knee
intensive.
So maybe we give him single legexercises for a while until he
feels better, but when he doesreenter, it's going to be goblet
squats, not low bar box squats.
Yeah, same thing with Frankie.
Frankie was back squattingright and her workouts.
So she was doing heavy backsquats because that's just what

(23:52):
her team was doing and notinherently bad.
Back squats aren't bad, butwhen she already has extension
and compression based issues androtation based issues, then
putting her into extension andasking her to back squat a lot
might be problematic.
So maybe for her as well, wecan switch her to a different
version and when she does goback to it we can find some
other way to make her feelbetter.
Okay, so subjective, treat thething that feels bad, try to

(24:15):
help above and below Right, andthen eventually the goal is to
get them back to a two daystrength program.
Right, the role of manualtherapy we do manual therapy.
I think it's important, I thinkit's really good.
All manual therapy is just away to reduce sensitivity.
It is non-specific, nociceptive, anti-nociceptive input.
Right, I am not repositioningsomeone's QL or moving someone's

(24:35):
upslip, right, and I have yetto find research that shows
that's what we're doing.
You know, I've read a lot ofresearch on soft tissue stuff,
all that jazz, and I don't thinkthe evidence is strong for
alignment, repositioning orupslips and downslips.
I used to teach that, literallytook an entire course on it for
two years and taught it and didit.
But then I realized that I wasfull of shit when I started

(24:56):
treating people and I was like,yeah, I just popped your hips
back into place and like youshould be fine, come back next
week.
We'll be Like straight up lyingto myself, right, and so when
you dig really deep in theresearch on all that stuff
upslips, downslips, positionalalignment it doesn't really have
a strong leg to stand on rightVersus exercise and pain.
Science and workload managementis pretty solid.
There's pretty good evidence onexercise, managing someone's
workload and then trying to helpsomebody.

(25:18):
Mckenzie's hit or miss,depending on the studies that
you look at.
Some say it doesn't work at all.
Some people say it's likereally good, like reduces the
disc bulge, pre-post MRI.
So I'm a big fan of what helpspeople feel better and I've
definitely seen that McKenzieacutely helps a lot of it.
I want to move away from it asfast as I can when somebody
feels better and go to exercise,but generally speaking, in the
acute phase it's one of thethings that we have for the
biggest categories we see, whichare flexion intolerant or

(25:39):
extension intolerant, tolerant,okay, so yeah, but exercise
workloads and pain scienceeducation have really strong
evidence and I find that themajority of what we do is there.
But if someone is in a lot ofpain and a heat pack and five
minutes of manual therapy and ordry handling is very effective
Sometimes.
If that makes them feel 20%better to then go exercise more
comfortably, of course I'm goingto do that right.
The big thing for me is usingmanual therapy to help them do

(26:01):
directional preferences and likemidline core work faster, right
.
So if we do stuff with them andthey feel better for a couple
hours and they can then go homeand do more press-ups or go for
a walk or tolerate being ontheir feet maybe it's all
placebo, I have no idea, but ifthat helps them exercise more
comfortably, that's the firstgoal is to get somebody into the
exercise move because they'reterrified, right.
Anybody here who's had acuteback pain knows if you don't

(26:22):
actually understand what's goingon in your back, it's pretty
terrifying, right.
It does not feel awesome.
So, yeah, okay.
So, locally, treat people withthat.
Above and below, we talk abouthip mobility and orthorhizic
mobility along with exercise.
Selection is a big one.
People don't realize that yourself-esteem should not be rested
on how much you can clean.
Right, you can definitely justfront squat to a box, and you'll

(26:43):
be okay.
If their goal, though, is toclean an Olympic lift, then
that's up to them, and we haveto help them get back there.
But in the short term, there'smany other ways to help modify
someone's activity.
Okay, that actually worked outreally well, where we got
through most of the eval stuffin like 20 minutes that the
strength coaches could jump in.
Are there any questions on theeval stuff?
Because we're going to gothrough some special tests that
match after the anatomy.
But on the medical side, do youguys have any questions about

(27:04):
stuff?
Keep in mind, in three months,someone's going to walk into
your clinic with raging sciaticaand you have to treat them.
So if you have a question, asknow.
Do you tend to see some peoplewith just one direct or
preference?
Yeah, that's a good question.
So what if someone comes inwith a bunch of them Totally?
Yeah, so they're usuallyoverlapping.
I would say the only overlap,though in the super duper acute

(27:25):
phase.
So somebody with a spondyfracture gymnast, dancer,
baseball player, hockey player,whatever they have acute back
pain from the fracture and theydescribe any extension.
Compressions like the sharp,bright, take your breath away
pain, but then forward hurtsalso because the muscles are
extremely spasmed right andsensitized right, and we'll talk
about why that is because StuMcGill's work has shown that in

(27:45):
deadlifting it tends to be likea buckling event which causes
like a multifidus spasm, whichis like that really intense
flexion forward, sharp, likekind of stabby pain you feel
when you have flexion and talland back pain.
But those don't, those peopledon't feel awesome when they
extend, right.
And that first two week periodit's generally that one is
clearly the mechanism of injuryand the other one just sucks
because everything is sosensitized.
So, yes, I will see it, but Ithink I'm much more aware now of

(28:09):
why the other direction mayhelp and if they're completely
different forms of pain.
One is like sharp acute matchesor subjective matches, a
special test that we do andwe'll talk about like a
sensitivity algorithm and itmatches all that.
I'm like, okay, this person'sgot more.
I think it's more extensionbased.
I'm going to go with thistheory for a week or two and
then we'll reevaluate in twoweeks and if they're better,
right, there are times whensomebody, literally we had

(28:30):
someone.
We treated somebody for Lisalast week who was a rower.
She had just gone through likea brutal rowing erg workout and
this girl could not even standor something.
Everything just hurts.
Right now let's just try tohelp you feel better and give
you like a lot of exercises andthen, like, as weeks go on, it
maybe will emerge more.
But yeah, there's definitely aa problem sometimes when you

(28:54):
just keep hammering specialtests on somebody who's painful,
um, they get pretty upset andyou just start to murky the
waters.
So, yeah, maybe that's aclinical expertise thing, but,
like I don't know, after 15 to20 minutes of just not really
getting anywhere and not beingable to someone to move at all,
I'm like, all right, this islike an ethical thing.
Like I just feel bad to makingyou keep doing stuff.
And well, I'd rather treat thatperson and see if they get
better.
Right, treat them with thepress-ups or going like for

(29:16):
directional preference stuff andsee, let me know how you're
feeling and if you're not better, we'll figure out another way
to kind of go forward.
Yeah, does that answer yourquestion?
Yeah, okay, anything else, howdo you talk someone off the
ledge that comes in, yeah, likeoh, I'm not going to need

(29:38):
surgery, stuff like that.
Yeah, that is a great question.
So I think explaining tosomebody the timelines is really
important.
Because if you explain tosomebody the natural timeline of
somebody who has a really baddisc bulge or sciatica or a
spondy, and you say like, yeah,well, generally it's four to six
weeks for each of these phases.
So you're coming to me at threedays or week one, someone will
text us and say, like I'd likesomething happened last night.
Can I come in tomorrow?

(29:59):
Like yeah, it's going to takefour to six weeks in the best
case scenario.
So like, let's not jump toconclusions and say that, like
you know, my back's going tofall off, I have to quit sports
forever.
You know, let's try to getthrough the first couple of
weeks here and see how we'regoing.
I try to tell people to thinkin weeks, not days, with back
issues, because if every weekyou're slightly better than the
week before, we're moving in thepositive direction, then that's
good, right.
So, week after week after aweek, if they realize that you

(30:21):
know, four to six weeks is along time, you know, for someone
to kind of go through all that.
Usually, if anybody has a backpain the day the second you have
back pain.
You want to not have back pain.
Like God damn it, I can't workout, I can't go to gym.
Every time I move it hurts,like this is fricking annoying.
You know, you want it to goaway right away, right, and so
three days even, or five days, Idon't feel great, but like I'm
definitely not like, oh my God,I'm dying, phase Right, um, yeah

(30:44):
, so talking about the timelinesis really really important.
And also just like I don't wantto say normalizing this, but
like when you're calm and you'relike, yeah, like this happens,
everybody a bummer.
And then like they're going on,like man, it hurts so bad, like
I can't feel my leg, it's in,and they're like my back hurts
oh my God, what, your leg it'snot moving.

(31:04):
Like we're so fucked, likeyou're going to like if you
start panicking, they startpanicking, which I think is part
of being a new grad.
It's just like it's stressful,bro, when you see a post-op
rotator cuff repair the.
So the same thing happens for aback pain, when you sit with a

(31:26):
lot of people and you hear thesame things and you understand
that these people get better andeven if it's the worst case
scenario, right, minus red flags, but the worst case scenario
somebody literally comes in witha huge lateral shift, raging
sciatica, foot drop.
You know that 5% of people whohave that they need surgery.
But they do really well withmicrodisectomies, right?
So even in the worst casescenario, when someone is really

(31:46):
having a tough time, they can'teven lay on the table If they
get a few weeks into it and yourealize like hey, unfortunately,
you know, I think the MRI showsyou have this huge annular wall
fissure and, like you have thishuge disc bulge that's pressing
on a nerve root.
That's why your foot's notworking.
That's why you, like, you knowyou need, you probably do need a
microdiscectomy.
Like I can think of one guy he'slike always sticks out to me.
He's a construction worker.
He was swinging a hammer for asewage tunnel and he missed the

(32:08):
dirt and he hit the concrete andso he literally swung a hammer,
hit a concrete and just likeyou talk about the worst case,
no, he literally blew his discout.
Like I never used rare case butlike even he was better.

(32:30):
In three months he was back towork, he was totally fine.
So like, once you see a coupleof those.
You can be a lot calmer on theother side of the table.
But a lot of high level athletescome to you when their or
figure it out and they'reworried about you know their job
.
Like the pro guys are worriedabout their job.
People are worried about theirscholarships.
People are worried about, like,do I have to stop sports?
And like, if you can remaincalm and just be like, yeah,

(32:50):
we're going to, we're going toget through this.
It might be a bumpy road but,like takes a long time.
Unfortunately, you know, thesethings are like six months in
nature, but so is the.
They tend to be a little bitbetter.
Yep, good question.
Okay, so this is perfect totransition to.
I personally think and I thinkmaybe I learned this from back
stuff but also I thought I knewa lot about the shoulder till I

(33:13):
met Mike and then Mike explainedlike the capsule, ligaments and
all the different things.
I was like I don't knowanything.
I was like I'm a moron.
So I think that when I reallyunderstood the anatomy, it helps
me put people in categoriesbetter.
But knowing the anatomy reallywell and the biomechanics really
well helps you be like agile onyour feet when something's not
making sense or when, like, youwant to change an exercise, you
can think about like, well, howdoes a split squat change it
versus a regular back squat,like you know what's happening

(33:34):
to the disc and the pedicle andstuff like that.
Cause, spines are the same,right, if you treat a 70 year
old with back pain, right, or a13 year old with back pain, the
spine itself is the same.
Obviously they mature indifferent phases of growth,
plates and stuff, but more orless the anatomy and the
structure is the same.
So if you understand howcertain things work and forces
work, I think when things arehappening in front of you in the
clinic you're like, okay, thatmakes sense they have.

(33:55):
You know, matt has 40 degreesof uh, or sorry, has uh, 140
degrees of hip flexion.
He's going to deep squat, superduper.
Well, it's going to make sense.
But now he has 95 degrees so hetries to squat really narrow
his hips don't move.
Well, it puts a flexion forceon the back relatively.
Maybe that's contributing tosome of his issues.
Or you understand that whenFrankie hits really hard and she
has no hip adductor mobility tostride well or throw well,

(34:18):
she's going to turn into herspine early and she might get a
right sided pars issue right.
She might get a right-sidedpars issue right, like that's
how these things kind of cometogether.
So yeah, I tried to draw my bestdiagram here, so I'll go
through this quickly and thenwe'll talk about this.
This is like a if I justsummarize my whole career, it'd
be like in one box right thereit's just all the movement
patterns and what things we'retesting.
But when somebody essentiallycomes to us we're trying to
figure out what quadrant is mostprovocative or both.

(34:40):
So I kind of so this is atop-down view of the spine and I
kind of think about this intofour quadrants, so this way and
this way.
So annular wall, the outer partof the disc nucleus, discogenic
material on the inside, thenerve root and the central nerve
spinal cord is actually reallyclose to the annular wall.

(35:02):
In textbooks it looks like it'sso far away, but they're just
mushed in together really far.
Spine is process and thentransverse process this is a
side view.
So bone, disc bone, uh, spineis process, and then facet
joints, that kind of overlinkthis way.
So obviously we'd be likedrilling a line through there
this way and then a line throughthis way to the front to see
how this moves.
So when somebody has um, you tosee how this moves.

(35:24):
So when somebody has, you knowthe basic movements that you can
do, right, like what?
Forward, backwards, rotation,hanging and compression, right,
that really is more or less allof us in a nutshell.
So we either bend forward orbackwards, we rotate to one side
and then we can stretch or wecan compress, compressing, being
, landing, hanging, being likegymnastics, circus, trapeze, a
little more rare, butessentially it's an opposite
motion.
So when you bend forward andyou rotate to the right, which

(35:44):
way is the disc moving?
Yeah, back into the left, right.
So if I have someone who comesin and they have one sided um,
disc issues and or back painwith like a butt nerve pain,
right, if that person, I canthink of the guy who was
shooting last week.
He's a sailor.
He sails to one side, right.
So he's always turned androtated to the right, this way,
so he flexes and then rotatesand compresses to the right,

(36:07):
right.
So the opposite motion of thedisc, right, if he spends most
of his time in this directionright Forward, right rotated and
side bent, the disc tends to bemoving this way right.
So he might over time and thiswas over like multiple days of
sailing he said that his backwas getting stiff and then he
went for some really, reallychoppy waters and he was hitting
a lot of like really heavywakes right.
So essentially what's happeningis that the the, the disc is

(36:28):
essentially moving more kind ofbackwards this way until
eventually it bumped onto thenerve root.
That's when he started feelinglike hip and buttock traveling
pain, more sciatica type stuff,and then it's not worth going
down the rabbit hole of this.
But obviously there's a hugespectrum of how involved that is
.
You have someone who juststarts to kind of have flexion
forces and they have no discbulge at all but the annular

(36:50):
wall can transmit nociception.
The structures, the multifidi,the nerve itself can be
sensitized to that right.
There's ligaments that are onthe back structure posterior
anterior.
The repetitive flexion force.
Somebody can tend to have like asensitization of this back of
the area and it usually goesfrom like nothing to stiffness,
stiffness to soreness, sorenessto bad back pain, bad back pain

(37:11):
to leg pain right and then legpain to like crippling both.
And then you have people thathave like really bad sciatica
pain but no back pain.
And then after they get better,their leg gets better but their
back gets worse.
So kind of like it travels downfarther to the leg.
The more intense it gets, itgets better.
It's coming up the legtypically with people like that.
Is that a bird?
I thought that was Kelsey, I'mjust kidding.

(37:32):
So as they go forward this way,so that way, so this person,
their provocative stuff is goingto be so flexion right, and
that would be right, rotationright, and then you would argue
like compression right, arguablyalso right side bending.
So what exercises when we talkabout treating somebody, are

(37:57):
going to make that person better?
Extension right, insertMcKenzie right.
So usually extension is alwaysthe directional preference of
choice.
To go central first, because ifthe annular wall is intact,
there's no fissure here andthere's no exclusion.
There's a closed vacuum circuitlike a labral seal where there
actually is an internal pressurestate where you can have
somebody do central extensionexercises and have a migration

(38:20):
of the disc forward.
Right, because it's like a ballbearing that when you lean
forward it goes back and backgoes forward.
So if the negative pressuresystem is maintained, you'll
actually have movement back andforth.
When someone has an excursion.
It's like letting the air outof a tire right.
It doesn't really matter if youpush really hard the other way,
it can sometimes cause nomovement because they've lost
the vacuum seal.
Yeah, make sense.

(38:42):
Pressure is deep focused rightnow.
I just want to make sure thatmakes sense.
Hey, the other thing thatsometimes people get rarely is a
lateral disc bulge where itgoes straight sideways and then
that person someone's forwardand backwards does not make that
person feel better.
So you would exhaust exemptionand then go to the opposite side
bending right, which would bethis so left rotation, right or
left side bending right.

(39:02):
Traction hit or miss, becausetraction does change this.
But it also is pulling on theligaments and the structure that
also might be sensitized muscleligament areas.
So I do have like, if youtraction somebody and it feels
better, do it, but somesometimes people just hang and
it like makes their back feelnot great after a long time.
But so extension would just bepress ups right, this way, and
then lateral side gliding wouldbe.

(39:23):
If I hurt this way, this wayand this way, the straight
lateral bulge would be goingagainst the wall and doing side
glides right.
So I'm trying to close downthis side this way.
And then there's a version ofMcKenzie exercises where you
like lay on your stomach, youflex your left leg up and you
side bend and then you dopress-ups, which is the opposite
motion.
It's called like a roadkillpress-up, right or reptile
press-up.

(39:43):
So that's like closing down theopposite side.
If somebody had a rightposterior lateral disc bolt or
right into tolerance with a leftdisc bulge, posterior laterally
, they would side bend, extendand then come up this way, yeah.
Or people can kind of go likeside glide this way and lean
backwards this way, like that'salso an option for people.
So generally you do extensionfirst and then you have somebody
do the opposite.

(40:05):
Yeah, questions on that.
That's 80% of the people you'regoing to see it's like flexion,
intolerant back pain in someway shape or form.
Okay.
So the opposite of that.
I don't have an eraser.
So the opposite of that wouldbe baseball player, softball
player, lacrosse, maybe.
Sometimes Field hockey tends tobe more flexion intoler talent

(40:29):
because they're bent over allthe time.
But let's say Frankie hittinglesson or Kylie sitting in the
back Just kidding, lol.
So Frankie's was a right.
She's a right sided hitter, soshe had extension was painful.
Right, rotation Right.

(40:50):
So extension and rotating tothe right.
We had extension was painful.
Right rotation, right, soextension and rotating to the
right.
And you could argue, obviouslythat's side bending as well.
So what exercises will make herfeel better?
Deflection, right, so that sheactually enjoyed sitting in
class because it made her backfeel better.
Left rotation, right and leftside bending, so that is having

(41:13):
somebody go on hands and kneesand do cat-cow's just in the
hollowing part and then theyrock back and do like a
quadruped rock back which flexesL5-S1.
And then they do a little bitof like deep exhale, breathing
in that last rock back becauseit opens the facets up, it opens
up some of the space, right.
So having somebody rock back inan exhale, you could have
somebody kind of lean to oneside and do that, if it feels
good, like reach over to oneside and take exhales that way.

(41:35):
But generally for these peoplethe facets on both sides are
cranky, so opening up the facetsbilaterally feels better.
Yep, okay, and the reason Ihave the side one over there is
because I think that you have toremember that this stuff is all
mushed in a very small space,right.
So here this is just like thebones and neural.
But there's multifidi rightBetween each level.

(41:56):
Here there are transversealleys, there are rotaries right
.
Those are all like the jointposition level things.
They're interspinal segments.
They're not unconscious control, they happen automatically as
you weight shift, go back andforth.
They're very low distance, butthey're like joint position
sensors.
They sense when vertebrae aremoving side to side or out of

(42:17):
alignment or they have like abuckling event or they're very
much there for like subconsciousrepositioning right.
So you can't control them,right?
I can't be like flex your L5multifidi, but you can flex your
transverse or your abs or stufflike that.
So you have these little guysright.
And then we have like just likethe meatiest of the meaty, huge
back extensors, iliocostalis,like massive, massive guys that
are on top of all that right.

(42:38):
And then of course you haveobliques that would be over the
top here, obliques this way,obliques this way.
You have transverse, like it'slike a lot of stuff in a small
space.
So I personally, I just kind ofabandoned the idea of telling
somebody exactly what's wrong.
I tried so hard to prove tomyself that it was like like
facet, you could argue right,when you see a fracture on an
MRI, you could argue that thefacet is obviously involved.

(43:00):
But how do you know it's notalso the nerve root or a
multifidi, or an end plate orthe annular wall, like it's all
very much sensitized, likereally really bad so plate or
the annular wall, like it's allvery much sensitized, like
really really bad so instead.
That's why I go towardsdirectional preferences and
movement categories, because Idon't know if I can prove to
somebody that it's going to beone multifidi or one side like a
facet is a little bit moreobvious.

(43:20):
But in generally speaking,you're probably stressing all of
it right.
When you have a reallyaggressive disc bulge and that's
causing neural stuff, you couldargue the ligament, the joint
space, the annular wall, it'sall probably symptomatic and so
we would treat everything withextension-based issues right.
So yeah, I kind of talk more inmovement categories now than I
do specific structures.
If somebody wants to get realnerdy, then I'll explain to them

(43:42):
all the possible things thatare involved structure-wise if
they want to be that granular.
But generally speaking, mostpeople don't care.
Um, and I think that's actuallya good.
One moment is like most peopledon't care, I just want to feel
better, right, like.
The analogy I always use isthat I know nothing about my car
.
If I bring my car to themechanic with the check engine
light on and I can't drive itbecause something is making a
loud noise and they give me a 30minute explanation of the

(44:04):
carburetor and the reverseengineering and all the
mechanical pieces and the fluidsand this, I'm like, bro, I
don't give a shit, I just don'twant to die on the highway,
right, I just don't want my carto blow up.
Like I understand it has to befixed and like I'll do it.
But like they, I just want toknow what to do to fix my car
Right.
And the same thing.
People come to us they want toknow that you know throw like I

(44:32):
just want to play right.
So like that's more of theconversation we're having with
people.
Like all the back end work, thethousands of hours behind the
scenes, to know this really welland have this in your head is
important.
But like very few of this will,like very little of this will
come out and be explanations tothe person, right, unless they
want to go down that level,right.
But in general I would say thatpeople don't care and I think
that sometimes we over-explainbecause we want to sound smart

(44:55):
because we have an ego and we'reinsecure about sounding smart,
and then we lose the person inthe process.
Right, like I can't, unless Ihave a student I can't remember
the last time I explained thisin depth here.
The student I'm obviouslytalking somebody through like
generally speaking, get like 15minutes into a vowel.
I'm like all right, I think Ikind of got this like all right,
like let's just treat you,let's make you feel better,
let's make your program blahblah.
What do you watch on netflix?
Like all that kind of stuff.
So, yeah, people don't reallycare.

(45:16):
Um, all right, any questions onthe background?
Because this chart will notmake sense, if anything.
This is confusing here and thisis probably like the bread and
butter of like what you're goingto do with people and the bread
and butter on the strength sideof when somebody comes back to
the gym, what we're being verycareful about if we know what
category they are.
Cool, okay.
So I think, for the sake ofargument, I'll have somebody

(45:39):
demo these, just so we can seethem and go through them fast.
There are three columns Okay so,high, high gravity, high force,
medium force and low forcecolumns.
Okay so, high, high gravity,high force, medium force and low
force.
This is personally the systemI've developed is I want to know
if somebody is so painful, sosensitive, they can't even exist
and they're so cranky that I'mnot gonna be able to do much
with them.
But if they get like throughthe first level of tests and

(46:02):
it's really painful, but then asthey go farther down the line
they're less and less sensitiveto not sensitive at all, I know
generally we're probably goingto start exercise farther along
to treat them.
Yes, multisegmental flexionthose are all SFMA terms.
So multisegmental extension, astork test, quad rock back, msr
is multisegmental rotation.

(46:22):
Yeah, the right side is thetissues that we think are
involved more or less.
The right side is the tissuesthat we think are involved more
or less.
Kyle, you are right in front ofme.
Do you want to be the demo?
Okay, so this obviouslyoverlaps to a bit with, like
you're looking at someone'smovement, assessment, if you
like to, their other hip stiffor their shoulder stiff,
whatever.
So if you just stand right inthe middle and I'm probably
gonna use that table buddy ifyou want to, just a flippy

(46:44):
floppy.
So if we're suspicious thatsomebody has, would you guys
rather me go down one entireline of tests or do all the
standing ones, then all the oneson your back, then all the ones
on your what's ones, like allthe flexion ones and all the
extension ones.
All right, you're gonna be upand down a lot, I apologize.
Okay, so I do these all on anassessment together, right, I do
like forward, backwardsstanding, all the standing stuff

(47:04):
.
So the first thing to be ifsomebody has leg pain and
symptoms that were concerned, ora disc, would just be toe touch
, so feet together and just dothree toe touches, right, and
we'd be like how does your backfeel, how does your leg feel?
Give me a number one to ten howbad your leg pain, how bad your
back pain, right more or less.
And then the next thing withthat would be same movement but
not as much gravity.
So hands and knees on the table, you know, quad, rock back.
So she'll just go hip distanceapart and just rock your feet

(47:27):
all the way back and you wouldsay does that hurt your back?
Does that make your leg changeat all?
Do you have more or less backpain?
So this is the same flexionmotion at like L5-S1, without
gravity's force and compression,which would be a little bit
more intense standing up versussitting.
And the last one would be allyour special tests of like a
slump, straight leg raise right,sit on the edge.
Do the tension test, leg raiseon your back.

(47:48):
That is stressing the sciaticnervous system in the back right
.
Got it Okay?
So if those were all positive,we would be pretty confident.
Somebody has discogenic backpain positive.
Special test for slump positivenumbness, tingling, traveling
pain.
Ridiculous stuff kind of makessense, right, and those would be
my like asterisk signs that Ikeep coming back to week after
week.
So let's have you stand back up.

(48:13):
So if we thought that it was onesided disc pain, we'd have
somebody flex and rotate to theopposite side.
So obviously we're causingrotation, we're causing flexion
and causing side bending and youwould have somebody who has a
posterior lateral disc bulge theopposite way.
And then when you do the handsand knees position, we're going
to go like a.
It would be a thoracic mobilitydrill on the strength side, but
elbow reaches under and try totouch your opposite knee right.
So creating flexion there whenthey reach all the way through

(48:36):
is less, less gravity, samemotion, yep.
And then on your back we wouldhave somebody.
If they're, we're reallyworried, they're extremely
sensitive.
If she had right-sided flexiondisc issues, I would flex her up
and then adductor and rotateher across this way to see if
just that little motion ofcoming up and across is
sensitizing.
You know buttock pain, backpain at all.

(48:56):
But if, generally speaking, ifsomebody can't even get on their
back and do a flexion adductionwithout sciatica symptoms, they
are like super duper flared upright and they'll usually do
like one of these and they'lljust like lay in the back and
and they can barely rockbackwards.
And then you do one of theseand go over and like, oh yeah,
it's getting me really bad.
I'm like, all right, a vowel'spretty much a wrap, I'm going to
go the other way and treatsomebody OK.
So that is all flexion and thenflexion and rotation.

(49:21):
The one that is not on here iscompression.
Maybe it's on this one.
Oh, yeah, it.
Yeah, we'll do that, sure.
Um, okay, do you need to writeanything down?
No, I was moving maddie.
Okay, pepper.
Um, did you just thumbs down me?
Your emoji is thumbs down, okay.
Extension.
Um, so hands on hips, justthree backbends.

(49:42):
This would be for suspectedbilateral pars.
Bilateral facet um, feelspretty shitty when you have
something acute.
Press-up test on your stomach.
So the thing we use to treatsomebody with flexion-based back
pain, it's a special test forthis.
So just relax, press all theway up.
They would have localized verybright bilateral pain.
Okay, and then on your elbowsfor me the hands-on PA shearing

(50:04):
test, palpate to find S2 on thesacrum first, so the PSIS is
around S2, come into the middle,move up one more level, that's
S1, and I'd move up to L5.
And I'm kind of going betweenthose two levels because I'm
trying to shear the bilateralpars right or the bilateral
facet.
So I'll use the back of my handhere and I just do a PA mob on

(50:26):
each level to see if itreproduces very similar types of
pain.
Right, put them on their elbowsand intentionally to have them
in relative extension that way,okay.
And then standing, so a storktest up, down, up down.
But you're helping learn somuch.
So stork test.
So just stand here, reach down,touch the back of the opposite

(50:46):
thigh is the cue.
I usually come back here and Iput a hand on their shoulder and
give them a little overpressureto kind of get a little extra
and then the version of this ontheir stomach is a prone on
elbows with rotation.
So back to your prone on elbowsposition and you're going to
put one hand behind your back.
Yep, I'm going to take my handand hold her hand down there and

(51:08):
then she's going to rotate andI'm going to over pressure her
into extension rotation.
If she did right side there I'dobviously go the other way.
But to show you guys, so you'repushing someone into unilateral
extension rotation, right.
And then the same test you cango on your elbows is, instead of
doing a bilateral pa like this,you grab one hand on the
opposite hip like cool if I grab, yeah, so here, and then the
other hand goes on.
Thumb is going to be actually,I'll show this one is going to

(51:30):
be right off spinous process,like off maybe an inch is is the
pars, is where the pars isunderneath.
So this hand is going to pullback up towards the ceiling and
this hand is going to push down.
So I'm doing a unilateralshearing force this way.
So hand here, hand here, andI'm shearing one level and then
I would feel the spinous processmove to four, come back over PA

(51:53):
, shear this way and you'reessentially trying to ruin a
unilateral pars issue.
So I would say I'm doing bothat the same time.
My movement is this so I'mpulling the hip up as I push the
spine down.
So you're trying to cause thefacet to move forward relative
to the one below it.
Yeah, are you directly on myspinous process?
Yeah, I'm just off it right.

(52:13):
So you can actually feel whenyou do QL work.
If you come up higher, like ifyou go into QL, you can feel
someone's transverse process.
If you push far enough, thatlike bony thing you feel in QL
is transverse process and thenspinous process is obviously
what you can feel.
So somewhere between you know,the intersection between those
two points is where the facet isand the transverse process

(52:34):
comes off right, so the spinousprocess moves over.
That will be along the area ofthe pars articularis.
I'm so far away from it becausethere's so much tissue in
between.
But if you push you're going tomove the pars relative to the
one below it because they theyangulate at at 45 degrees.
So when you are here and youpush you're hitting one on top
of the other and the parsinterticularis and the neural
ring is right behind that.

(52:55):
So someone has an acute fracture.
They'll be an unhappy camper.
Yep, um so bilateral.
Sorry, uh, stork prone on elbow.
Unilateral pa shearing.
We're trying to go for parsfacet neural arch and the neural
ring, cool.
And then let's stand up forcompression.
So compression is a little bittougher because there's not as

(53:18):
much tests on it, but jumpingwould just be the first one.
So just jump up and down.
Yep, exactly so, multiple hopsin a row.
Heel drop test is from StuMcGill.
So push up on the balls of yourtoes and drop down really hard,
like try to give yourself athud.
So if the shearing, if the samejumping and landing, is more
forces like a depth drop, but ifjust the small movement of
hitting your heels causes likeaxial back pain, you would think
that either bilateral pars arebeing stressed or the end plates

(53:41):
might also be stressed.
They have some like issues withthat.
Some people are justcompression intolerant.
And then sitting on the cornerwe do a seated compression test.
I actually use this one for theother to rule inflection,
extension too.
But sit up nice and tall,you're going to grab the bottom
of the table right, and then now, if we think it's extension, I
want you to just arch your backas much as you possibly can, and
then pull up into the table,and then you would obviously

(54:03):
have pain there.
That's someone who jumps andlands a lot like volleyball
players, basketball players,gymnasts got this too as well.
And then the opposite if wethink somebody has like a
flexion and compressionintolerant uh, follow through of
baseball is a big one um,landing and forward like skiers,
for example.
So around as much as you cangrab the table, pull down.
That would cause back pain tooas well.
Mm-hmm, uh, yep, Okay, cool.

(54:30):
And then last one, very unique,but sometimes it happens.
It's just like the tractionforces can pull on Sharpies,
fibers, which cause pain as well.
So it's like mostly likegymnastics, circus, trapeze,
crossfit sometimes is very rare,but they would just hang and
just see if that hurts theirpain.
They'll tell you that my backhurts when I hang.
So you probably skip that test.
But on your stomach, with yourknees very close to the edge,
like here for me, there's aprone spondy test as well, but

(54:50):
it also gives you tractionforces.
So, bend knees up, you're goingto grab the back of her calves,
I'm going to traction and thenextend her and that's going to
mimic the same type of tractionforces.
So here.
I'm going to pull back and thenup and I would just kind of let
her hang there and I would justsee, obviously, if that causes
similar back pain.
So cool, you're trying to holdthat for a specific time.
Are you looking for provoc?
Just provocation?

(55:10):
Yeah, like this is probably agood thing to know too.
Like I don't use the proneinstability test, like I just
don't know.
Like I'm pretty sure that whensomebody comes to me that's a
young gymnast who's super floppydoesn't really work out a lot
of physical prep, I'm prettysure she's lax and it's going to
have some instability.
But I just don't know if theprone instability test tells me
more than just doing adirectional preference, than
treating somebody with exercise,you know.
So the clinical guidelines aretough, because I've had people

(55:31):
email me and say my PT used theclinical practice guideline for
manipulation because I fit thatcriteria and they had a spondy.
They manipulated somebody withspondy because they followed the
guideline, not just using yourbrain, right?
So, yeah, it's a way to loseyour license.
Okay, I think we're good.
Thank you, okay.
Does anyone have any questionson the special tests?
We are perfecto.

(55:55):
Okay, I'm going to skip theabove and below assessments,
right, like you should know howto assess thoracic mobility, hip
mobility, but it's more so theconnection of like if someone's
flexion intolerant, the thing wewant to look at overhead
mobility, thoracic spinemobility, hip flexion and hip IR
, ankle mobility, and thenknowing how to brace under like
heavy loads, versus withextension.
Right Overhead mobility,thoracic extension and rotation,

(56:17):
hip extension and hip rotationis a big one and just having the
lacking hips means more happensat the back.
Right.
Frankie's case study right, ifshe steps like this and she
doesn't have adductor stride andshe doesn't have the right hip
mobility to dissociate, she'sgoing to turn early from her
back and that's why she wasgetting a lot of right-sided
back pain because she wasleaning into her back when she
tried to hit.
Yeah, same thing happens withthrowers over the top Gymnast.

(56:39):
There's overhead mobility, hipextension mobility, back bends
in half like a teepeeDeadlifting.
Right, if I don't have theability to really hinge well and
keep my hamstrings to move andmy hips to move back, I tend to
have a little bit more of aflexion position, right, but
even so, if someone got perfectalignment, but if their hips are
stiff, the flexion forces arehigh on the low back.
So, yeah, you're just thinkingabout like, okay, what's missing

(57:01):
above and below that might be,because when someone's in a lot
of pain, they can't do a ton ofexercise.
This is a good time to clear upa lot of that extra work.
Okay, so I do want to talkabout the other sheet, which is
like the exercise one, becausethis is helpful for you guys to

(57:21):
treat people, but then also forthe strength coaches too as well
.
So, any questions up until thispoint.
Let me pull this up.
So I think something that we doreally well here I learned this
a lot from Dan, I think we putour heads together quite a bit
is people can actually exercisea lot when they are in, when
they're kind of coming out ofpain, I guess I would say.
But people are able to do a lot.

(57:42):
So the first phase, the firstmonth, I would say for most
people, I would say the firstmonth, I would say for most
people then we need this, we'regood, I would say the first
month for most people.
The goal is to get somebody toa two day exercise program that
has mostly, I would say, midlinecore exercises, trying to get
every category anti-flexion,anti-extension, anti-side
bending, anti-rotating,breathing work, positional work,

(58:04):
all that kind of stuff.
So you want to get somebody toall of that whenever they can
tolerate it.
Right, it might be a bent kneeside plank.
It might be a regular dead bug,not a wall press dead bug.
Maybe it's going to be just abird dog and not a bear crawl or
a cross crawl.
But generally speaking, betweenhome exercise programs for their
directional preference,mobility work for above and
below, and then for single leg,things are typically tolerated

(58:28):
much better in someone who's gotback pain.
So split squats, step ups,sleds, single leg hip thrusts
those are generally treated morecomfortably in somebody with
acute back pain.
Between those movements, bodyweight and then all the midline
core stuff, you can write a full, good program, right, and I'm
just going to quickly show whatthat looks like, because this is
everybody that I treat with anytype of directional preference.

(58:50):
I'm trying to get back tosomething like this so all of
their mobility work above, soT-spine hip, whatever their
directional preference, rightTimes 10 in a warmup and then
maybe a split squat and then adead bug, a single leg hip

(59:15):
thrust and a bird dog, and thenthis day over here would have a
step up side plank, and then,what am I missing?
Split squat, step up.
If they can do a box gobletsquat, maybe, if it's too high

(59:36):
or it's uncomfortable, theycould do another single leg
hamstring or double leghamstring, like maybe a physio
ball curling to substitute forthe lack of deadlifting, so
something else that feelscomfortable.
And then an anti-rotation pressout.
So something else that feelscomfortable and then an
anti-rotation press out, right.
So three sets of eight to 10.
And after this a 10 minute walkif they are flexion intolerant,

(01:00:01):
and a 10 minute interval of abike if they are extension
intolerant.
Right the opposite motion toget them.
So that's a good 30 minuteprogram, right, somebody could
do that every single day andfeel fine.
But like I've had people who arelike super acute and really are
like nervous to load at all,but all body weight, all basic
dead bug stuff, maybe somebreathing work and beginning,

(01:00:21):
they can tolerate this prettywell.
So I would say 80% of peoplewith back pain can do much more
than they think that they'reready for, depending they know
positionally how to do it andthey understand why we're
avoiding certain exercises,right, sleds are a really good
option to here as well.
I'm a big fan of like doing asled push there.
I'm just a March that way.
So Alex, who Kelsey's treatingand is just starting fitness now

(01:00:41):
, but this is, this was herprogram for like three weeks and
she's like likes being able todo something right.
There's a whole argument ofexercise, endorphins, pain,
science, that kind of stuff, butI'm trying to get everybody to
a two-day program.
This is like the second phasefor most people.
Yep, okay, so just want toreview on this chart real quick.
Then we'll talk about some casestudies of exactly how we

(01:01:03):
treated these people.
We could use ones that are notFrankie and Matt, because
obviously we just talked aboutthem, but in this chart.
So this is a little bit of Dan,a little bit of me, but every
lower body pattern is importantto treat somebody with low back
pain and we're trying to pickoptions that are more or less
friendly for their back.
Right, if somebody comes in, Ialways go the opposite.

(01:01:24):
If somebody comes in withraging patellar tendinopathy and
you have to give them a squatpattern, if you want to lose
your license or lose your job,what was the first exercise you
would give somebody?
What's the most?
Knee dominant patellar tendonloading.
We can give somebody A sissysquat or a single leg slant
board squat, right, like thatperson's knee would just feel
horrific, right so what's thecomplete opposite end of that
spectrum?
So what's the first thing theleast amount of patellar loading

(01:01:46):
, most amount of hip and backloading that we could give
somebody.
So say, everybody like comesinto you guys, like I don't know
what I did, man, my, my back'sreally sore, you know, and you
want to avoid that.
What's, what's the thing thatwould make you lose your job?
If somebody had back painflexion, intolerant back pain,
like I sit all day and likesomething's wrong with me and
like my back's killing me andthey had to do a squatting
pattern, a low bar box squat,right, you're literally just

(01:02:09):
tipping over.
It's like an RDL or like a goodmorning, right?
So think of the opposite.
Now, if somebody comes in withflexion, tolerant back pain and
you want to give them the mostknee dominant squat to take them
away from that forward tipping,what's what's more?
Knee loading, a goblet squat oreven a Spanish squat right,
spanish squats are great, right.
So up, very upright torso, veryyou know vertical right so very
upright torso, very you knowvertical.
Up and down.
They're pretty much a neutralcore alignment right.

(01:02:30):
They're really not flexingtheir spine at all.
What about positions of theweights?
Because that's another big onetoo as well.
When you have a goblet squat,what's happening on your back?
Relative force wise, it'sextension force, flexion force,
it's flexion right.
So they're bracing into flexion.
So we use that in new people toactivate their core more, which

(01:02:52):
is helpful.
But the weight is in front ofthem and the lever is pulling
them forward.
It's a mild amount of flexionforce.
So what could you do with theweight position to change that
Less back?
Where would you put the weightsfrom a goblet position?
Where else can you hold weightsby your sides?
We got this guys yeah, justholding weights by your sides,
right, so someone's no longertipped forward.
So an upright goblet or anupright um dumbbell suitcase

(01:03:13):
carry squat or farmer carrysquat to a bench is like minimal
back stress.
So that's a really good thingto start somebody with when
they're first nervous andgetting back to I threw my back
out last year and I'm reallynervous.
I don't want to do anything.
So, like we would do an upright, just dumbbell squat, just quad
city, you know what I mean?
Okay, so with the hingingpatterns, right, let's talk
about that.
So if you wanted to lose yourlicense or get someone's back

(01:03:33):
extremely flared up with flexion, intolerant back pain, what
would you give them for anexercise?
What's up A good morning, right, a super aggressive good
morning.
What about deadlifting?
Cause like there's a lot ofvariations of deadlifting.
What's up A barbell deadlift,conventional right On a deficit?
Right, they're on a plate andthey're going to a deficit.
You'd fuck that person's backup, right.
Which is why sometimes I'm hitor miss on Jefferson curls,

(01:03:55):
because long-term maybe it has asolution, but like that's a
slippery slope there, right.
So extended range of motionconventional narrow stance,
barbell deadlifting is likeextremely back intensive.
If you're trying to get yourback jacked in your training,
it's perfect.
I do so many D-ball carries andso many back extensions because

(01:04:15):
I want my back to feel good.
Reverse sled drags, but likeit's just not the right option
right now, okay.
So think about another hingemotion.
That is way the other end,right.
Not loading the back as much.
Much more user-friendly doesn'thave to be a deadlift.
A glute bridge, right.
So a single leg hip thrust isawesome here.
That's why we start almosteverybody with single leg hip
thrust when they're getting back, because you can choose the
loading on your hips right.

(01:04:36):
You can move your leg out moreto get more hamstring dominance.
You can really isolate one sideand go partial range of motion
to get maximal glute engagementright and that person can
control their spine reallyreally well.
Right, almost every gymnast thatwe treat here I always start
with single leg hip thrust.
Back in the day it was just meand Duesh.
We had a ton of reallyhigh-level college girls coming
that all like didn't have backpain but definitely had back
pain at some point in theircareer, and I was like we're not

(01:04:57):
doing any deadlifting for thewhole summer because if they
hurt their back they're going tosay it's my fault or Duesh's
fault, with deadliftingequivalent of like 18 chain hip
thrusts for the entire summerand got so jacked.
But we were just so nervous toload them because we didn't want
someone to think that thedeadlift is what caused their
back pain, right, um, eventhough it's probably all of
their tumbling and series thathas a stress fracture, they

(01:05:18):
assume that deadlift equals backpain.
So, yeah, so a single leg hipthrusts are really great, right,
let's talk about, um, splitpelvis.
What's a really good startingspot?
Single leg work and splitpelvis work is fantastic for
people with back pain because ofwhat we talked about.
But what would you start withfor somebody to test the waters?
Yeah, body weight, split squatright.
Maybe the two AirX pads, ifthey're really nervous, right.

(01:05:39):
If you wanted to make it moreextension based, how would you
progress that?
So you want more extension loadon somebody's split squat.
What are you going to do withtheir position where the weight
is all that kind of stuff?
So Frankie's coming back fromspondy fracture, she's braced,
she's six months out, she feelsgreat, but she hasn't lifted in
a while.
What do we want to avoid?
What's going to put a ton ofstress on her back in a split

(01:06:01):
pelvis position?
Think about elevation of theleg Rear foot elevated, split
squat, the barbell.
So back squat position.
Rfes are a ton of extensionforce on the back right.
So how would we?
What's the opposite of that?
How would we start here?
What's the complete opposite ofthat?
Front foot elevated and youwould hold the goblet right

(01:06:21):
Because somebody else who hadflexion intolerant back pain.
We'd avoid goblet, but we wanther to have a goblet position to
put her more flexed right Totip her forward.
So, front foot elevated deeperinto flexion.
Lean forward a little bit, holdthe goblet right.
That's exactly what we want andwe're thinking more.
Don't make the back get flaredup, not what's optimal strength
and performance?
Loading right, because by yourside you can lift 70s, probably

(01:06:42):
for sure.
Definitely can't hold a 140goblet right.
That's probably probably notgoing to happen.
So split pelvis for there.
And what about single leg?
What's the first thing we'd dowith somebody's single leg?
Step up, yep, high box, low box.
Where are we putting the weight?
Low box, Less hip flexion.

(01:07:05):
If they're flexion intolerantOn the sides, exactly.
So by your side.
Step ups right, very good.
So entry point if you're tryingto load somebody and not make it
, you know only body weight,split squats, regular.
We'll just load and then changethe elevation based on what
intolerance they have.
Step ups right, by their sides,right, and then whatever hinge
feels comfortable theresquatting.
When they go back, we just pickthe squat.
That is the opposite of howthey got cranked right.

(01:07:26):
So back squat versus extensionright.
So back squat people.
Frankie didn't do back squatsfor a while.
She front squatted with strapsinto a box and then Matt did
back squats because he needed alittle extension to get him out
of flexion, okay.
And then all the accessory work.
You know everything under thesun for their hips, for their
upper back, right.
So Copenhagen, psoas, flexormarches, all that kind of stuff

(01:07:48):
is really appropriate.
I do think that there'sdefinitely a role to play in
just hammering someone's glutestoo as well.
So lateral sled drags,copenhagen's for adductor, side
plank clamshell all that stuff'sreally really good right,
because you could argue that'soverlapping a bit.
So okay, yeah, any questions onexercise programming selection.
We're going to go through acouple of case studies, but this

(01:08:09):
is the majority of what I do.
I'm more of a strength coachthan a medical provider, I think
after the first month ofsomebody with acute back pain, I
think that's way more aboutknowing what exercises stress
what parts of the back, what toput somebody to start with when
they've come from somewhere else.
And I think a lot of mydiscussion why people get better
is because they come here whereMatt had never learned how to
deadlift properly.
Jonah was literally the firstperson who taught him how to
deadlift properly.

(01:08:29):
He just deadlifted because hejust deadlifted in college but
he never really got properinstruction on how to brace,
where to put his hands, where tothink about putting his torso.
So he really didn't have a goodeducation there and Jonah was a
huge part of him getting backsafely and not being so worried
because he knew how to brace, heknew how to actually position
himself and Matt literally PR'dhis deadlift last year on like
405 for three, like somethingridiculous, after blowing his

(01:08:49):
back out twice in a row lasttime he tried the deadlift.
So a lot of that's to Jonah andnot to me, because Jonah
actually was helping him programthe right way.
Yeah, so that's all theexercise selection stuff.
But let's go through two casestudies.
We have perfectly 20 minutesfor each.
Let's go through.
I want to go through a casestudy that is the worst, like
your worst nightmare walks inthe clinic and I want you guys

(01:09:10):
and you say you have a strengthcoach that they're going to go
back to eventually, but likewhat would be the most
terrifying thing to walk intoyour pending.
Someone doesn't like cancer,right?
The other 95%, what do youthink?
Someone that's walking out withexcruciating pain.
There we go.
All right, here we go.
Let's do the real bad one.
So we have, let's go.
Let's do flexion.

(01:09:30):
Let's do like an.
Let's do somebody high stakes.
Let's say we have a 21-year-old.
What sport do we want to gohere?
Baseball, because we're in theelement.
So a baseball player.
We'll say it's a catcher.

(01:09:50):
So they have a cute right-sidedsciatica and low back pain.
Let's just say you're not anathletic trainer who's literally
at their school.
So one week ago so let's justsay they had a huge practice
they're getting ready forpreseason was deep squatting,

(01:10:14):
throwing a ton of you know,catching, second whatever else
it is.
Woke up the next day, went toclass and just got horrific
sciatica.
Had to cancel class.
And he's now a couple of dayslater to get to you.
Let's say he's walking in witha really, really bad left
lateral shift and they'redefinitely flexed.
Okay.
So that person is here and overto the side, right, they don't

(01:10:34):
put any weight on their rightleg.
They're doing one of these guys, right, they feel real bad.
So about a week goes by andyou're the first person who's
seeing them.
You're in a cash-based clinic.
Heard Kylie's the best PT intown.
I got to go see her.
So what are you starting with?
They're sitting on the table.
They're like leaning againstthe table like this, like what's

(01:11:01):
going on?
What do you ask them?
First, yeah, and he says well,I was practicing last week and I
fucked my back up.
He says I was.
I caught a huge pen for mycatcher and we did a bunch of
drills a week ago on Saturday,woke up Sunday, was in horrific
pain, couldn't go to classMonday and then it took me three
days to get to you.
It's Thursday now.
So I was huge catching practice.
You know I'm D1 catcher forwhatever getting drafted If I

(01:11:23):
get a scholarship goes throughall that.
Yeah, he's a big dude, hardcore.
So, yeah, just caught one day.
Woke up the next day, real badpain Next day couldn't walk,
couldn't go to class, hasn'tseen doctor said you know, go to
PT first and then we'll get youan MRI in the in the wings.
Yeah, okay, great.
So this, yeah, exactly so 90%of these people.

(01:11:45):
They wake up, roll out of bedeight minutes before class.
I go to class, I sit in class.
I go to lunch, I sit in classagain, I go to practice, I warm
up and I play.
He sits in class all day long.
That's like every college kid.
I sit for homework, sit forclass.
Yeah, good question.
So sitting all day makes himbad?

(01:12:06):
He says I feel better when I'mup, moving around.
I'm not lying to feed this casestudy.
This is actually what peoplecome to you with.
I want to walk, I want to getaround, I want to wear my
backpack and I want to just laydown.
I don't want to be sitting ormoving forward.
I want to be up and moving or Iwant to be flat.
People want to go from here tohere all day long.
That's all I want to do.
Feel better from here to hereall day long.

(01:12:27):
That's all I want to do.
So, yeah, feel better when I'mwalking around.
Leg kills me when I put pressureon it, but generally speaking,
feel better moving.
Tried to bike, didn't go well,yep.

(01:12:50):
So, yeah, foot's working fine,but definitely feel butt and
hamstring.
He's got like traveling paininto hamstring and butt.
So right-sided buttock pain andlike thigh hamstring is the
worst.
Back feels we'll say this isprobably a seven out of 10.
Back feels like a five out of10.
Definitely the leg is the worstpart.
I want to know if somethinglike this has happened before.
Leg is the worst part.

(01:13:11):
Good question, yes, in highschool.
High school had a little flareup of his back.
Um, no, leg pain got better intwo weeks PT.
Interesting, yep, just stopplaying, stop catching for a
couple of weeks, got better.
This is a person, by the way,I'm not bullshitting.
So, yep, all right, cool.

(01:13:32):
So we got kind of what we think, right.
What do we think?
What category?
Flexion, intolerant flexion,rotation, right.
And I'll speed run this thisdidn't happen.
This was extremely painful.
This didn't happen.
This was extremely painful,right.
And then the only thing thatfelt a little better on his leg
was lying on his stomach.

(01:13:53):
So lying on his stomach andjust being there for like 30 to
60 seconds made his leg feelbetter and his back feel worse.
What do you guys do with that?
Keep going, exactly right.
So you educate that person like, hey, this is actually a good
thing, right.
There's like a stoplight inmckenzie that if you do an
exercise and it makes your legsymptoms get better, but then,

(01:14:13):
uh, over time it gets worse,that's a red light.
Goes farther down to his calf,farther to his foot.
That's a red light, right.
Everything else is a yellowlight or green light.
Lays on his stomach, does somepress-ups, does whatever legs
getting better, backs feelingworse.
Generally speaking, you keepgoing right.
So, with this, the, with this,the hands-on part of this eval
lasted seven minutes.
He couldn't move at all.
Every single position wasterrible and he was like in a

(01:14:33):
giant lateral shift.
I'm like I think I know whatcategory we're in.
So we did three rounds of 10press-ups, baby press-ups, plus
30 seconds of prone on elbowlying, and I would say it made
his leg pain slightly better.
I have a question so lateralshifts kind of trip me up.

(01:14:56):
Are we treating that?
Yeah, yep, so you treat lateralshifts with an anti-gravity
extension, so like if you havesomeone who's standing is really
all the way over here, you wantto lay this person down right
and they're probably going to beover here, and you just see if
this person can kind of armycrawl back to midline and that
usually makes their back feelreally bad but their leg feel
like not worse, and then youjust see if somebody can

(01:15:18):
literally just go like this 10times and you just then you rest
for 30 seconds like start, yes,or I would have them lay on
their side.
I would have them try to see ifthey can lay on their left side
with their knees in a bolster,because that's going to give
them a right lateral glide or aleft lateral glide to help the

(01:15:40):
right side.
Yes, so long story short here isthat for three days he just did
walking, press-ups, lateralshifts, manual therapy and drugs
.
He took a lot of NSAIDs, highdegree NSAIDs from his doctor,
not weed, okay.
So he comes back.

(01:16:00):
That's Thursday, he comes backMonday.
So by Monday he's been doingreligiously all his exercises.
So he has one out of 10 legpain and he has still like five
out of 10 low back pain Feelsokay but not better.

(01:16:21):
So before we treat him again,what other things do you want to
test now that he's not somiserable?
What's really important forcatchers?
Hip mobility, right.
This dude needs hip mobility,right.
Homeboy had hockey hips.
He's like no IR and no hipflexion and he would always just

(01:16:41):
be way up on his toes in a deepsquat because he had no hip
mobility.
So he would try to like rest onhis ankles.
Way more Shocking that hisknees also hurt.
He had a meniscus tear.
So yeah, he's got no hipmobility.
So today, along with whatever wegive him for a home program, we
also want to give this dude anymobility.
He can just kneeling.
Literally just do just kneeland a mild adductor stretch and

(01:17:02):
just see if you can just rock alittle bit to open your groin up
Right.
Or, you know, figure fourstretching won't go great.
But anything this guy can dofor adductor and outer glute,
you know, eventually it'll be IR.
But IR might make the back abit cranky, so we add that in.
What are we going to do now forhis back Right, also included,

(01:17:23):
we did some manual therapy.
Dry needling just helps get himover the hump.
But that's not treating him aton.
The exercise matters more.
So what, what's the new thing?
What are we trying to get himto do?
A little too early.
I like the thought, but alittle too early.
Yeah, we need exercise right.
So, exercise-wise, what are westarting with him?
Right, we do some bodyweightstuff, maybe a bodyweight box

(01:17:44):
squat.
Maybe we try the split squats,we try the step-ups, all
bodyweight.
Maybe Bfr is great here just toget him to do something that's
a little bit like active right.
We're not going to bike, we'renot going to do a deadlift,
we're not going to do any deepsquatting right, but all single
leg work and then all themidline core work.
See if we can get a dead bug, abird dog, a side plank, an
anti-rotation, press out, buildthat two-day program that we
talked about right, and see ifhe could just move a little bit

(01:18:06):
and educate him like, hey, Iknow it's going to feel a little
uncomfortable maybe during itor after, but as long as the
next day you wake up and you'reokay, like we need to be active,
we need to move, we want to getyou to keep it going.
Now, dork aside, side note, thethought process here is that
exercise helps also because whenyou have acute nociceptive
drive Paul Hodge's work showsthere's like a redistribution of

(01:18:27):
activity within muscle groups.
So if your back is reallysplinted your QL, your low back
you're not going to want to loadyour back, so you're going to
lean on other muscles, which iswhy they limp a lot and leave
the other way.
But also within muscle fibersthere might be like a
redistribution of activity.
So we're trying to get someoneto use the muscles that are
acutely guarded or sensitive,right, ql, low back, multifidi.

(01:18:52):
I don't think we're gettingsomeone stronger, I really don't
.
I think we're reducingsensitivity through graded
exposure and then we're alsotrying to give somebody
something to load the areas thatare acutely spasmed and
sensitive.
Again, with the thought processbeing is like normally, this is
a pain science thing.
Your tolerance for activitieshere.
Right, throwing, swim, you canjust more or less destroy your
back in a good way, right, andtake a lot of training load.
When you have some sort of anociceptive drive that shuts
things down, your body plummetsdown right your tolerance of

(01:19:16):
load in that position.
So, brushing your teeth,putting your shoes on right,
like sitting for a long time,going to the bathroom, those
things trigger pain because it'sso guarded, right.
So the role of physical therapyand whatever is like okay, can
we lay on our stomach?
Can we walk?
Can we do a dead bug?
Can we do a bird dog?
Can we do a goblet squat?
Right, we're trying to bringsomebody through this graded

(01:19:37):
exposure to restore theiractivity tolerance.
Whether that's true mechanicaldesensitization and we're just
taking pressure off the nerveroot, or it's more of a pain
science side of grad, of likegraded exposure.
That way, right, but that iswhat's going on.
So, yeah, a full two-dayprogram, right, for this catcher
is the next thing.
So we do that for two weeks.

(01:19:58):
So he's three weeks out now.
We have no leg pain.
Yeah, yeah, heat, 10 minutes ofsoft tissue cupping tools to
feels better and then maybe somedry handling if that person
likes it.
Right, but only in the in thehope of exercising more
comfortably.
I just want to do that for 10minutes so that he can then go
to the gym and work out Exactly.

(01:20:19):
Yeah, so three weeks no legpain, stiffness in the back, but
no pain, feeling overall better, but no leg pain, no stiffness,
pause.
What would you do if three weekshe comes back and he's still

(01:20:39):
real jacked up, like shifts alittle bit better, but like legs
killing him, not getting better?
You're trying everything, can'texercise, can't tolerate.
What's the next thing in theclinical guideline?
You're trying everything, can'texercise, can't tolerate.
What's the next thing in theclinical guideline?
Yeah, so what needs to happen?

(01:21:01):
Yeah, refer him.
Refer him to a doctor becausemaybe he needs an MRI, right,
maybe he does have a huge-assdisc bulge and or like an
excursion of his back and heneeds some extra attention.
The algorithm is PT right.
After four weeks I usually tryto send somebody back and then
it's usually going to be somesort of uh, increased
pharmacologically of like anoral dose pack, right and or MRI
to see exactly where it maybeis a lateral bulge, and I missed

(01:21:22):
the boat completely.
And he's not posterior lateralright, maybe he needs more
lateral work and then from theremaybe an injection right.
Maybe he needs more lateralwork and then from there, maybe
an injection right, maybe acorticosteroid injection
directly to the nerve root spaceto help calm that area down.
And then if somebody has, youknow, that rare five to 10% case
so they have a huge disc bulgeextrusion, they might need a
surgical consult to get amicrodiscectomy.
Sports are hard man.
So yeah, I think sometimes PTsare like no, no surgery ever, no

(01:21:44):
drugs ever.
I can do it all, I can fix itall myself.
But if somebody comes back toyou in a month in and they're
still frigging, struggling man,think about you.
A month goes by, you're goingto PT once or twice a week and
your leg is still killing on youLike my guy, I need to see
somebody else right.
Like something is definitelyoff here.
It's just pending that homie isdoing everything that he's
asked and is not getting drunkand going to a party and like
jumping off a stair, which youwould believe happens a lot more

(01:22:06):
than you think.
People tear their ACL and saylike, oh, he's like no, no, he's
like fell, fell.
No wine involved at all Okay.
So leg zero, back three out of10, feeling pretty good, more or
less feeling good.
He has a little bit of hopehere.
He's like when can I play?
I got to play.
What's the next phase for thisgent?
We're probably in phase two-ish, three, if we're thinking about

(01:22:28):
one, two, three, four.
So he's got daily life, feelsfine, can go to school class.
Those are all okay.
But he's a little nervous aboutthe weight room and or catching
.
So what's the next thing wehave to do?
There we go.
Now we're starting to get inthere, right.
So this is actually where I'llstart to add back in the other
exercises.
We would avoid it previously.
So I'm actually going to havehim quad rock.

(01:22:50):
I'm going to have him do alittle bit of light rocking back
and forth through exposedflexion a bit I'm a big fan of
that.
Maybe do a little bit of toetouch just to test the water,
see how we're going.
So that's good.
The strength stuff, just allincreased load.
So all the exercises that wedid split, squat, step up, sled,
whatever we're going to addharder degrees, okay.
The other thing that I think Ilike to add in here too, one is

(01:23:10):
I do want to try to add somepower work and that's typically
done via med balls.
So a med ball slam or a throwor rotational shot put right,
that starts to stress the back alot more and you have to use
the hip mobility that youhopefully got over the last
month right.
So med ball slams are flexion,med ball reverse throws, our
extension, med ball shot putsideways is rotation.

(01:23:31):
So, whatever the categoriesthat they have, carefully start
with the other ones and thenwork your way back into those.
Then we're doing, you know,this is where box jumps come in,
this is where broad jumps comein, double leg, this is where
we're doing some running drillsright.
Obviously, just force overloadis kind of what we're working on
.
So we have the actual flexionexercises a little bit, we have

(01:23:52):
some power right Work and thenalso, uh, I think this is a good
time to start adding in somedirect low back loading.
I think sometimes people arescared to load anti-flexion uh,
reverse sled drags.
So reverse sled drags, um, ghdholds, hyper holds you could
argue, suitcase carries orunilateral for QL, d-ball holds

(01:24:17):
and carries.
That's why I do a ton of them,because it helps my back a lot.
D-ball carries those are alldirectly going to pull somebody
into flexion if they don't do it.
So they're working their lowback quite a bit.
That makes sense.
So I actually think that'sreally important to add in stuff
in this third phase, becausegoodness knows that, uh, they're

(01:24:37):
going to get rocked when theygo back to sports.
They have those forces arereally high.
So there's the next month.
Right, this is probably themajority of the next month is
just scaling these things up.
Uh, and again, they're probablynot going to be in a ton of
pain.
They might be a little stiff,but nothing too crazy.
So that's the third phase.
And then what about the fourthphase?
Got to catch man, I got tocatch a game, yeah, exactly.

(01:25:00):
So what do we do with throwersafter Tommy John Throwing
program, right.
So what would you do with acatcher after a disc injury?
A catching program, right.
So what would you do with acatcher after a disc injury?
A catching program, right.
So let's have you sit first andsit on a bucket and just catch,
play in light toss, roll theballs back.
Next phase you know 30 of those.
And then we'll have you squatfor 30, hop up on your knees,

(01:25:22):
light toss back.
Things progress more and moreand more.
You know hitting as well, allthat kind of stuff.
But yeah, just do a good oldfashion and return to throwing
and hitting program.
I would say, in here you canprobably start exposing deep
goblet squats, some of thethings that will put him in a
similar position.
I think this is actually whereI like front foot elevated foot
squats for these people becauseit puts them in a really low
flex position, but on one leg.
So you want to add the thingsin that at first you would not

(01:25:44):
want to use at all.
Yep, there you go.
So that's one.
Let's do one more.
For the other direction, let'spick like extension, compression
.
What do you guys think?
What do you want to do?
You want to do a baseballperson?
You want to do a gymnast?
You want to do a regular human.
Again, if it walked in the door, what would scare the shit out
of you?
Let's go.

(01:26:07):
You guys want to use kylie's.
Can we use yours?
Kylie was 14 when I met her, soif kylie walked in the door,
shit your pants.
Right, I'm kylie.
Makes me nervous still so, 14year old gymnast, level 10.
You guys don't know what thatis, but, um, bilateral back pain
, sharp, it's about, uh, eightyears in duration, I'm just

(01:26:30):
kidding.
Bilateral back pain Sharp, it'sabout eight years in duration,
I'm just kidding.
Probably like I don't know.
Two months, three months, twomonths, three months, maybe in
season Slowly over, worse inseason.
Now it's like I think this isright, but like states and
regionals Trying to go out, andthen NCAA is the goal.

(01:26:53):
So what are you going to ask?
Yep, my daily routine isgymnastics, school gymnastics,
said with love, Nothing butgymnastics.
These people train all day,every day, four hours a day, six
days a week.
So goes to school, goes to gym,does homework, wakes up and

(01:27:18):
does more of the same.
Good question, right?
So this is gymnastics.
Diving, baseball gets this too.
So it's like a little bit of aslow burn and then like one
thing, like blows them up.
So in gymnastics sometimes it'slike landing on floor.
A skill called the one and ahalf is a lot of extension,
compression, load, um, theirbeam series, uh, and there's

(01:27:40):
sometimes these.
They're called releases, butyou guys don't need to know
about that, but they're justviolent extension, they're like
hardcore extension, um, and sousually they're doing lots and
lots and lots of repetitions.
And then something happenswhere we had two consults last
week One girl she did one and ahalf punch felt something go,
couldn't breathe after.
Another girl was doing a drillpunch, front tuck landed on her
butt and it hit her back reallyhard.

(01:28:01):
So she got like this huge axialloading force.
But it's almost always hurts.
They keep going, something goes, not allowed to keep going
because it hurts so bad.
So, yep, that's good questions.
What else?
Yeah, sitting being in class sowhen I'm not up walking around,

(01:28:22):
makes it worse.
There's a heavy backpack.
These folks usually wear aheavy backpack and it feels
really bad.
So long walks in Boston with myfriends being up walking around
makes it worse.
There's a heavy backpack.
These folks usually wear aheavy backpack and it feels
really bad.
So long walks in Boston with myfriends being up walking around
.
But I feel better sitting inclass.
I feel better on my couch athome.
That's where I want to live.
Yep, I think the only thing toask here is how you describe the

(01:28:44):
pain.
It's almost always very sharp.
It's like this like takes yourbreath away, like right and
speed.
Run this um so positive, stork,positive pronon, elbows,
rotation, positive pa andunilateral camera.
I can't believe.
I remember this a long time ago.

(01:29:05):
Um, so that's all the thingsthat were positive.
What other things do you wantto ask about above and below?
Leg pain no, leg pain.
I think the other dude was likeso cripplingly side bent we

(01:29:28):
couldn't test his hip andthoracic.
But like, what else do we needfor this population?
Yeah, right, so t-spineextension, that's actually
pretty good.
But overhead mobility this iswhere we got sticky, like 165
maybe so of lats and terries,super duper flexible, lots of

(01:29:50):
laxity, but but very, very stiff.
We tested this with a back towall shoulder flexion, sit down,
reverse grip on a dumbbell or aPVC pipe.
Couldn't get her arms overhead.
Most gymnasts are like that.
So very stiff.
And then no hip extension.
So positive favor adductorssuper stiff.
And then positive, two-jointThomas.
Okay, I think we're getting thehang of this.

(01:30:18):
What's the first thing we'regoing to give to make her feel
better?
Yeah, bilateral quads,bilateral adductors.
I'll be stiff just because thisis not just gymnastics, but
just so much adductor, so muchquad work.
It's a whole nother discussionabout strength programs and they
do like a thousand jump squatsbut never any hinging work.

(01:30:39):
So just super roped up quadsand a lot of the lat terry stuff
is.
People who are good atgymnastics, are very strong that
area because of how hard theytap, just like when you throw
hard.
Your lat has to be very strongto throw very hard, but if it
gets so stiff you can't raiseyour arm overhead, you lose lay
back and you get elbow issues.
So, yep, that's all positive.
How do we treat yep?

(01:31:00):
So cat cows rock backs and thendeep exhales, and then deep
exhales.
I think sometimes people likethe deep exhale rock back on a
TRX.
So you hold the TRX and sit allthe way really, really low
breathe.
That one's pretty good.
You could sit, reach forwardtoo.
That's a PRI one.
It's pretty good, I will say.

(01:31:21):
There's a couple of PRI courseswhere these bilateral extension
people actually I use a lot ofthose drills.
So, yep, I'm going to do thatagain 10 times about every two
hours.
What are we not going to do?
What are we going to take awayin your daily life?
Yeah, so don't wear yourbackpack.
Try to carry your books betweenclasses, try to not lay on your

(01:31:44):
stomach or sleep on yourstomach.
Let's not go for long.
Two hour Boston walks.
Let's try to break it up andsit on a bench throughout it or
whatever else it is.
And then, of course, the thingsin gymnastics.
We're not going to do anyextension or compression, but
there's many other things theycan do.
So there's still plenty to do.

(01:32:04):
But yeah, that's the firstmonth, right?
Just take away the things thathurt, add the things that are
better.
Got it, okay, that feels better.
Two weeks go by, more or lessbetter, but still sore.
What's the first thing we'rewriting back in for strength
programming?
More of the same, the exactsame thing as the other person

(01:32:27):
all the midline stuff, split,squat, step up, uh, dead, bug,
bird, dog, side plank, like it'sthe whole program, right, the
whole thing.
And then when you get back tothe third phase, you would not
do reverse med ball first, youwould do slams first and
rotational stuff first.
You probably still do broadjumps, but box jumps might be a
little bit too much because theaxial load.
So you'd start with like singleleg versions, maybe like low

(01:32:48):
pogo hops, low banded hops, andthen eventually add in med ball,
reverse throws, um, standingreverse throws are the most
force, uh, depth drops, and thenit would be like the reverse
sled drags, maybe the d-ballstuff.
It would be all that jazz.
So, um, yeah, I don't want tobore you with the exact same
answer, but 80 of them or 70 ofthem, I would say the same.

(01:33:08):
Once you have like thistreatment system down, most
athletes fall into some of thatcategory.
The last 30% is where catchingprogram, return to gymnastics
program, which you're not goingto go into a throwing program, a
hitting program, a walking mydog program, whatever they want
to get back to.
But yeah, that's more or lessthe nuts and bolts of it.
So any questions Last fiveminutes I know it's a lot of

(01:33:33):
information in 90 minutes.
Going back to the baseball guyin the beginning, you're
obviously telling him to nottouch the ball.
Yeah, none, he can hit, maybeEven that you know when they're
that painful I would sayprobably no baseball at all and
they know it.
They're like, yeah, I can'treally do much.
These people can't walk, youknow, let alone hit.
But if I was going to go backat the end, I'd actually
probably want to have thatperson do some light swings

(01:33:54):
first before we do like reallydeep squatting and heavy flexion
based stuff.
So, yeah, um, just like the uhTJ people can hit before they
throw.
The catching people and theback people could probably throw
or could hit before they throwas well, hit and throw before
they squat.
I think that's the right way tosay that.
Yeah, people who have hipinjuries, fai injuries, like big

(01:34:15):
hitters.
They want to throw before theyhit.
If they have a labor repair andthey like have a huge bat,
they'd want to go the other way.
Yep, cool, all right, that's it, no problem, it's my entire
career in an hour and a half.

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