May 13, 2025 • 38 mins
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Rehabbing elbow injuries in young gymnasts requires a specific approach, especially when dealing with osteochondritis dissecans (OCD) lesions and other complex conditions that lack standardized return-to-sport protocols.
• Elbow OCD occurs when repetitive compression creates a "pothole" in the cartilage of the capitellum
• OATS procedure uses a bone plug from the knee to replace damaged elbow cartilage
• Young patients who are casted post-surgery develop significant stiffness issues
• Creative approaches like using heat while allowing distractions help children tolerate stretching
• Weight-bearing should typically be delayed until 12 weeks post-surgery, unlike knee/ankle protocols
• Strength training with BFR can help maintain muscle mass during non-weight-bearing phases
• Handstand progressions should begin with sideways walking against a wall to control loading
• Return-to-sport protocols should follow 2-week phases with progressive increases in repetitions and surface hardness
• Hand position during skills affects injury risk—neutral or slightly turned in positions distribute forces better
• Strength testing should assess shoulder, elbow, and grip symmetry before return to full gymnastics
We're finalizing a comprehensive paper for the Journal of Sports Physical Therapy that will provide detailed rehab protocols from day one post-surgery through six months of recovery, creating a resource for clinicians who don't regularly work with gymnasts.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 2 (00:05):
every day.
You essentially pay your duesby doing the harder thing when
it's the right thing to do.
Alia, welcome to the podcast.
How was your week in the clinic?
Speaker 1 (00:15):
it was great busy, yeah, very busy, yeah, long week
.
Speaker 2 (00:18):
I'm ironically wearing the same shirt that I
was the last time we recorded Iwashed it just for this podcast
I'm just kidding everyone, justto catch out of the bag.
We were going to record a bunchof episodes in a row, so, yeah,
a couple of weeks in a row withthe same, uh, same outfit.
But, um, okay, first one was inworkloads and the way we're
going to try to put thesetogether is literally it's just
like a brain dump of everythingthat Aaliyah and I are thinking
(00:40):
of or working on, and we taketopics based on this Google
sheet that we have.
Where I was, literally you knownot that I text and drive, but
I was in traffic staticallysitting.
Still, I actually turned my caroff on 93 because there was an
accident.
I literally turned my car offand I had five minutes to go and
I was like wrote down a bunchof stuff that I was thinking
(01:01):
about.
Like you know, uh, I forgetwhat it was like elbow OCD,
which we'll explain what that is, but essentially, um, we are in
the final stages of submittinga paper that is an entire start
to finish of rehab for elbow OCD, and we'll explain what that is
.
But, um, mike and Lenny madethe same thing for Tommy John
UCL repairs back in the day,which helps a lot of people and
(01:24):
I see a lot of elbow OCDs butalso things you know, media
epicondyle fracture I think youwere talking about.
You have a lot of those UCL, uh, tommy John's and female
gymnasts as well OCD paper.
So essentially there's noconsensus on how to get somebody
back to gymnastics after theydo any of these surgeries.
Sometimes, like, the rehabprocess is very murky and I have
a lot of people reach out to meand like don't see as many
(01:45):
gymnasts for, uh, these issues,and they get to like three
months and their elbow motion isokay or their strength is back
and they're just like okay, likewell, how do we do gymnastics?
Like how do we get you backsafely?
Throwing program is reallybasic, you know.
You just like throw it 30, then45, then 60 and it slowly goes
up um, not so much forgymnastics.
And so that's where the papercame from, was that?
At the time it was Jen King, um, and her and I, and then a
(02:06):
surgeon and his fellowessentially just wrote this
monster rehab protocol for likehere's how we rehab them, here's
how we get them back to weightbearing, here's how we start the
advanced power phase, here'show we get them back to
gymnastics and we put that intoa paper, but there's not a lot
of consensus on uh precautionsfor OCD, so that's kind of where
I want to chat about this.
But yeah, do you have any broadarching thoughts about like
(02:29):
elbows, ucl, ocd, before we gointo some of the stuff?
Speaker 1 (02:33):
I don't like when people get casted.
Speaker 2 (02:36):
Yeah, that was an off air conversation.
I don't yeah, I am not to upsetany surgeons who might listen,
but I don't.
With younger patients, I thinkthe thought is that if we cast
them they won't hurt themselves,and so I understand that
perspective, right,eight-year-olds, nine-year-olds,
they fall, they break theirelbow.
But like from the pt side, Ican just say from what we
experience, like if someone iscasted for four weeks or braced,
(02:57):
locked in extension for fourweeks or something like that,
bro, it is a nightmare to rehabthat person because they're so
stiff and they're so painful andthey're so sore.
So this fell out of fashionwhere, like you know, acls used
to be non-weight bearing andlocked in extension for four
weeks.
Then you go to PT at four weeksand Mike and Lenny are, you know
, telling the surgeons that,like, this person's not bending
at all.
And the surgeon's like, well,just bend them more.
And it's like, yeah, but thisperson's crying on the table.
(03:19):
This is not okay.
And when you have an eight yearold or a nine year old who's
casted, um man, getting thatthat little kid to do rehab or
getting their mom to bend theirelbow or their dad to bend their
elbow when they're, whenthey're not happy is really,
really hard.
Um so I understand that, but Ialso see the other side of the
side of the fence that a lot ofplaces are really busy
outpatient clinics where theydon't have a lot of time with
the therapist, and you knowthey're not, they're not,
(03:45):
they're not really getting greathands on quality motion, and so
that person maybe gets bent oris pushed too hard, too fast
early, maybe they get hurt.
Maybe it's a surgeon's thought,as they, their elbow is is
getting cranky from the rehaband they're not doing well, I
don't know.
I don't know.
Speaker 1 (03:57):
Yeah, it's tough.
Speaker 2 (03:58):
You have some stiff elbows.
Speaker 1 (04:00):
I have so many stiff elbows right now.
They're just particularly whenthey're younger.
They just get so stiff Like Idon't know what it is, but like
when I get older kid elbows,like in high school they're
they're honestly fine, even ifthey get past it, like there'll
be a little stiff but we'll getthrough it.
But the kids that are likeeight, nine, 10, their elbows
don't move, like if they getcasted or stuck in a position
(04:21):
for a while.
They are so stiff and it's sohard to get their emotion back
and it hurts so much.
So just it's not?
Speaker 2 (04:27):
Yeah, I think there's .
There's two pieces.
One is that younger kids havethe attention span oftentimes of
like a goldfish.
All right, so like.
Like when I was eight, bro, Iwas like playing video games and
running around and playing withmy brother and if I hurt my
ankle or something like that,like I did not even think about
it.
Like my mom tried so hard toget me to do rehab.
There's no way it's happening.
So like to get a kid to bendtheir elbow every hour on the
(04:50):
hour to end range instead ofgoing to play whatever, um is
really hard to do, you know.
So like, younger kids arehaving a tougher time with
adherence to exercise.
And parents are busy, man,they're working, they have stuff
going on, they can't be ontheir kid all the time.
So I I'm empathetic to that.
The other piece of it,unfortunately, is that it's grow
like weeds, right.
So when you get a stiff elbowand you know you cast somebody
for four weeks or like threemonths go by.
(05:11):
Their humerus is growing, theirform is growing, right, so like
their biceps.
Tricep is trying to keep up, butit's it's very stiff relative
to the rest of them.
So that's like a double whammythat they're growing as you're
trying to get motion back andthen they just don't have the
attention span.
Speaker 1 (05:25):
Definitely yeah, I see that all the time, and
especially if it's painful, thentrying to get an eight-year-old
to push, put themselves intopain, is not going to work.
Speaker 2 (05:33):
Yeah, and a practical advice I would say is that for
those people that are really,really stiff and or not can hear
, uh, add what's the word I'mlooking for?
Coherent, no, compliant,compliant, coherent, no,
compliant, compliant.
Um, like, sometimes like heatpack on their elbow for like
five minutes, just like lettingit droop, and like pass the time
of like put their elbow overedge, put a heat pack on their
edge of their front, of theirbicep, and maybe even like a
(05:54):
light band pulling them down ifthey're cleared by a pt, and
like let them scroll on tiktokfor 10 minutes while they, while
they just sit there with theheat pack and like melt their
elbow straight, like more active, focused, focus, like they have
to be doing the thing staringat it, the board they're going
to get.
So find other ways to to keepthem distracted.
Like you know, play cards withthem or, like you know, do
something else while they justlet their heat do the work for
(06:15):
them.
I think that's probably abetter uh approach than you know
.
Let's do this soft tissue whereit goes bend every hour on the
hour, like I don't think it'sgoing to work.
So, yeah, that'd be my one tipof practical advice.
Yeah, got to get creative anddon't cast them, if we can.
Um, okay, so elbow OCD longstory short is a uh injury to
(06:35):
the cartilage of the uh forearmarea.
So let me see if I can zoom ina little bit.
So, essentially, when you dogymnastics this happens in
baseball too, but when you dogymnastics over and over again,
your arm is not a leg and soyour knee joint can take a lot
of high force, but your elbowjoint cannot.
So in a young, growing athlete,that little bump you see there
is essentially like a potholedeficit, that's that's
(06:58):
developing.
Um, on what's called thecapitellum.
So the elbow side gets a bigold pothole in it and because
maybe the, maybe the bone downhere is harder than up top, so
radius is stiffer relative tothe capitellum, that's one
theory, but essentially you hitthe same spot over and over
again and it causes a bruising.
Bruising becomes damaged,damage becomes, cartilage gets
kind of like again hollowed outin a pothole, and that is
(07:19):
obviously not good.
So they have to fix it.
The procedure that tends to havethe best outcomes is an oats
procedure.
So, um, they take a small graftfrom your knee, where it's not
weight bearing, and theyessentially form into a bone
plug, they put it inside theelbow joint and they stick it in
there and then, um, they letthat heal, they suture it down,
uh, or they suture down, they,they fixate it down and then
(07:40):
slowly over time the bone plugfrom your knee becomes a new
like covered over area of yourelbow.
That's what an Oates procedureis.
There's a lot more dorkyexplanations for that, but in a
nutshell, you know, gymnasts areyoung, their elbows are not
knees.
They're doing probably too much, too fast, they're not that
strong yet relative to how hardgymnastics is, and so this
happens when high amounts ofupper body impacts are going on
(08:01):
slowly but surely and thenunfortunately sometimes need a
surgery.
The first uh approach is a sixmonth rest period, because I'd
rather not do surgery.
But if surgery uh is indicatedthey, they base it on how big
the lesion is and how deep thelesion is.
So grade one, two, three, fouris deeper down the bone itself,
whereas wider is, like you know,eight versus six versus 12
millimeters wide.
(08:22):
They make a bone plug.
So obviously the deeper thelesion with the more width, and
if there's like bone fragments,the more severe the surgery is
and the rehab is um versus not.
But yeah, there's no um,gymnastics and baseball, get
these, but there's no uh, reallyclear, I guess, guidelines on
how to rehab these people.
So the paper that we aresubmitting essentially is saying
(08:43):
that the first three months ismore or less the same for any
other.
You know surgery, you, you know, get their motion back, you let
the swelling come down, you tryto get their form stronger, you
try to protect the graft forthree months because it's a bone
, it's a bony graft, integration, and so we're trying to protect
that area, the same way that ifyou fractured your leg, you
wouldn't really want to walk onit for the first couple of weeks
.
So we put you in a immobilizedand we get your emotion back and
(09:05):
stuff.
But then around three months itstarts to become a large, I'd
say maybe debate or point ofdiscussion in the in the
academic world of like, when dowe start putting weight on the
elbow that has this bone plug?
And generally speaking, I wouldsay my thought is 12 weeks for
most stuff.
If someone has a really biglesion or a really deep lesion,
(09:27):
or there was an issue with thesurgery where they had to do
more work than they thought,maybe you push it out more.
But I think 12 weeks isprobably good because the bone
is probably fixated.
And the debate that I had withsome other surgeons is that
other research shows the kneeand the elbow, or the knee and
the ankle, when it has elbow OCD, they start weight bearing,
(09:47):
these people, at like six weeksor eight weeks because the
thought is that early partialweight bearing helps to secure
the plug in the pothole graft.
So the thought is that ifyou're, if you're fixating the
graft in via some partial weightbearing, it's allowing the
graft to more um, you know, tohave a better fit, be more
congruent.
I would sort of speak.
(10:07):
And my uh contrary to that isthat oftentimes the ankle has
like an evolutionary mileage oflike 10,000 years that it's been
built for this.
The talar dome is like this wide, flat, very supportive
structure, tons of cuboid bonesaround it, tons of ligaments
around it, and the knee is thisgiant like spherical shape joint
(10:27):
that's made for weight bearing.
Right your elbow is like so notthe same, and also it's all
these OCDs are in kids that areyoung and that are growing and
are not that strong.
So I think the elbow OCD tendsto be younger and kids that are
not as strong and they're doinga lot more activity on their
elbows, which makes it harderversus typically an OCD and like
a knee or an ankle.
(10:48):
That's like.
That's like an adult injury.
Right, that's a college, that'sa lacrosse field, hockey,
jumping, running, end stagecareer, someone who's been
running and jumping and playinga sport for their whole life,
professional athletes knee andankle stuff is almost always
college and above level.
Uh, athletes and status, notelbow, which is like the
youngest amateur athlete.
(11:09):
So yeah, big picture, those aremy thoughts, but what do you
think?
Speaker 1 (11:14):
yeah, I agree.
I mean I don't really see anyocds, like post-op ocds, that
are like cleared at eight weeks.
They're almost always all weeksand up.
Um, if it's a big one, they'reusually wait until about four
but or four months.
But I think it's interestingwith the eight weeks because,
because the elbow is such acongruent joint, sometimes I
feel like giving it a little bitof weight bearing, like just
(11:36):
very low level, like even justlike you know, like putting your
hands like go on hands andknees, like rocking forward,
backwards, side to side, just toget a little bit more motion.
I have a hard time with elbowstrying to get all of my
extension back actively withoutdoing any weight bearing.
It's really hard for me likethey can get almost there, but
that like active without doingweight bearing gets really hard.
(11:58):
So it'd be nice if I was ableto do a little bit more weight
bearing, like closer to likeeight to eight, maybe 10 weeks,
where you're just working onlike very low level, just being
able to like push againstsomething and get your elbow
straight to like start workingon strength in that position,
rather than like actual loadingor like impact.
Speaker 2 (12:18):
I'm totally down with that.
So I think that when we madethis protocol, we were looking
at research on like, whatpercentage of weight bearing
certain positions are Right, solike, uh, I think a quadruped
rock and a bird dog is like 17%upper extremity weight bearing
Right.
So you could argue that that'slike one sixth of their body
weight, right, it's like sosmall, and I actually I agree
(12:41):
with you, though, that like onesixth of their body weight,
right, it's like so small, and Iactually, I, I agree with you,
though that like, I think, I, Ithink a lot about acls too is I
have one case right now likejust a bit stiffer, she had an
lat, so the swelling was more,and like she has passively, when
I do it like eight degrees ofhyperextension in her knee, but
she cannot lift her own heel offto get to eight degrees.
Eight degrees of hyperextension, it's just a zero, and that
tells you that, like her quad isthe reason why she can't get
her legs super, super straight.
I think, the same is true forelbows right Like you have
(13:01):
somebody who passively isgetting to like zero after an
OCD or UCL or whatever or amedial epicondyle fracture, but
then like actively it's likenegative 10.
That means their tricep is notable to overcome its relative
strength right, their tricep isnot as strong to overcome the
stiffness of the front of theirelbow.
So in that situation I agreewith you, I think it's good to
get somebody quadruped and dolike the version of tkes.
(13:22):
But for their elbow right, justhave them do hyper, like uh,
tricep firing in neutral onmaybe a dumbbell with neutral
wrist, just to get their wristsuper duper straight and their
elbow super duper straight.
And then you add someresistance around and maybe that
closes the gap between, likewhat they passively have and
what they actively have.
So yeah, I think I'm okay withthat.
You know, I think at 10 weeksI'm down to do some like
quadruped rocking and some likeput them on dumbbells with their
(13:44):
wrists are neutral and havethem rock forward, backward,
side to side more.
So maybe for the strength pieceof end range, like active range
of motion, before you startprogressing somebody into like
the strengthening side of weightbearing, yeah, Sure, yeah, I
mean, even when we're in like adumbbell program.
Speaker 1 (13:58):
It's like when you add the addition of the dumbbell
and then you're like musclesfiring, like how much force is
going between the joint anyways,does it really make that much
of a difference, right?
That's something that's lowlevel weight bearing versus like
lifting a 10 pound dumbbellover your head and having the
impact forces of that.
And I think, too, like I haven'thad a lot of these where I've
had issues where it feels likethe joint isn't as smooth when
(14:20):
you're doing motion.
But I've had a couple where I'mlike I wanted to do weight
bearing because I'm like itdoesn't feel totally smooth.
It feels like there's a littlelike I don't want to say the
word crunch, but like a littlesticky you can just feel it a
little bit and you're like alittle bit more than you want
and I feel like early on, whenit's still trying to like get
integrated into the bone andkind of shape itself out like
(14:41):
remodeling of that bone, itmight be I don't, I don't know
if that would be beneficial tolike have a little bit of weight
bearing.
That way it can start to likeshape, go like, get the correct
shape.
That way you're not feelinglike this stickiness or losing
motion because it's not thecorrect shape that it needs to
be.
Speaker 2 (14:58):
Yeah, no, I agree with that for sure.
I think I think part of thebenefit of dumbbell programming
is to give somebody like a verysmall dosage of axial loading,
right.
So if someone's around 10 weeksand you're feeling a bit iffy,
maybe instead of going toquadruped and then like bird
dogs and like crawling and stuff, maybe you do like a floor
press overhead, dumbbell pressweek where you're just saying
like all right, let's do likefive, 10 pounds, try to get your
(15:20):
elbow fully locked out so it'sless weight.
But you're doing active rangeof motion and that's kind of an
indicator of like whether thenext phase is going to go really
well.
Right.
Like if you're going to havesomebody who's able to um press
overhead to full end range andthen also do a floor press to
end range, you're getting twovectors there of overhead and
floor press.
That sets somebody up to dowell on a quad rocking or
something like that.
Speaker 1 (15:39):
Sure, yeah, do you have.
I'm curious with your motion,like when you're getting elbow
extension back, are you?
Are you pushing, like, say,I've had a couple of kids that
have like close to 20, 25degrees of hyper extension,
which is a lot.
Do they need all of that?
Not necessarily, but ingymnastics they're, if they're
(16:00):
locking their elbow out in anyway, like they're going to be
off center if they can't gettheir other elbow, the other
like the same amount.
But you know what's?
What are the limits?
Speaker 2 (16:08):
yeah, I treat it all the way back to that, or yeah, I
treat it like like the knee,whereas like if somebody's hyper
11 or 10 on one side, you canargue that you don't want hyper
10 on the graph side becauseyou're going to stress the graph
Right If you push really,really hard, probably within a
couple of degrees, like withinfive is probably doable.
You know, like I think I'veseen a lot of people either
(16:30):
elbow like OCD or Tommy John ormedia up condyle, who get like
five and 10.
Right, or like or like sevenand 10 or like, you know, six
and five or whatever.
I think within within a likefive to 10% of the other side is
probably okay Because I amwilling to bet that naturally,
over time as they go back tofull gymnastics it's going to
kind of slowly get a bit more.
You know they're oftentimes laxand very loose, so I don't want
(16:51):
to let somebody get away withlike missing five degrees on one
side and having plus 10 on theother, because that's a 15
degree swing.
But if someone only gets toneutral when they had, you know,
plus five or plus 10 after asurgery, that's probably okay.
I think particularly in like UCLrehab end range, hyperextension
stresses the anterior bundlequite a bit which is where their
(17:11):
you know their job graft was.
And then you have a lot ofdynamic restraints of like the
flexor digital rooms and stufflike that.
They're overlying the tendon.
So I don't know if I want toget somebody all the way to
hyper end range, where we'restressing a graft and then
asking the dynamic stabilizersto do extra double duty.
Sure, I think.
Personally, I think they'reprobably going to be okay if we
just get them to like a littleabove or neutral and their body
(17:32):
will probably figure it out.
Speaker 1 (17:32):
For the rest, yeah, and it's hard because, like with
a throwing sport, I mean youwant, you want motion like
within near symmetrical ranges,for sure, but from like a, you
don't necessarily need all ofyour hyperextension to like
throw a baseball, like yeah youknow, like gymnastics.
You're like you have to besymmetrical, like if you can't
be on a bar, and like one elbowis over extended 20 degrees, the
(17:54):
other one's only five, likeyou're going to be off center
and you're going to feel thatyeah, to that point.
Speaker 2 (17:58):
I mean a lot of elbow player or elbow, uh, elbow in
baseball players is is like verystiff and bent from years of
throwing from a bony point to do, right.
But the same could be said isthat, like the shoulder is the
equivalent of the elbow forgymnastics.
Like you can't not ish degreesof risk, right, but like your
(18:25):
elbow needs to be really, reallyclose and then maximize the
rest from your shouldersoverhead, right, yeah, yeah, I
would say that close enough isprobably good in a young
pediatric elbow for sure.
Speaker 1 (18:32):
Yeah, yeah, I've had, I think with extension their
motion usually isn't too bad,like we can usually get it back,
get it pretty close.
But it's that active and rangeextension that we always have a
hard time with, especially oncewe start getting into like like
true weight bearing, likeenhancing positions or L holds
or whatever we're doing workingon like pushup positions.
They just have a really hardtime getting their elbow to
(18:53):
maintain like their fullextension.
Speaker 2 (18:56):
For sure.
Speaker 1 (18:58):
I'd be curious to know your thoughts too on like a
.
A lot anecdotally I have seen Idon't know how true this is or
you can you've seen a lot morethan me so you'll be able to
like comment on this but I see alot of the kids that I've seen
with ocds are ones that willlike literally like turn their
hand out and like hyper,although out completely, when
they do skills which you don'treally see much at the high
(19:19):
level, because their coaches arenot.
They're going to fix that.
Speaker 2 (19:21):
They don't want to see kids with their hands all
the way out I think uh, uh, Iknow this, I saw this paper the?
yeah, I think I know what you'retalking about yeah, the t
position round off yeah so yeah,essentially this paper was just
showing that you know it's in around off, but doing a T
(19:42):
position is probably a littlebit better versus like rotating
all the way in or all the wayout.
I don't get to pull it up, butessentially when you fully
rotate all the way out, likethat, you're asking the joints
to do all the work right.
Your tricep can't help out aton.
When that maximally externallyrotated position is versus if
you're really all the way in,you're just like really all
muscles, no bones, and so you'rekind of asking the opposite
(20:02):
side.
So I think that you know,neutral or slightly turned in is
probably good and even slightlyturned out because of like
wrist or shoulder mobility, butI think anything beyond like the
basic, you know what would thatbe like?
10 to two position on, like aclock.
I think, when you dance too faroutside of 10 to two, you're
asking one or the other to do alot of work.
Really far outside.
It's a lot of joints, reallyfar insides, a lot of muscles.
(20:23):
You're probably gonna haveperformance issues here and
ouchy issues on the other side.
So I like how I'm trying to fitit in frame, so yeah.
So I think that, uh, if someoneis really far out, they're
oftentimes trying to make up foran overhead flexibility
position.
They don't have enoughflexibility or shoulder
flexibility or thoracic spinemobility to go overhead.
(20:45):
So I would probably spend moretime addressing that If
someone's really far in.
I think it's more of a coaching, technical correction than it
is um.
You know a you know performancebased PT issue.
So yeah, I would try to figurethat out in the rehab process or
ideally before Um.
But you definitely don't wantto be hanging your hand Like you
don't want to rotate your handsout too far or too in, uh, or
(21:05):
either sides of the issues.
Speaker 1 (21:06):
but yeah, yeah, yeah, I try to honestly any of the
elbows that I have or shoulders,really any gymnast that comes
in if they're doing gymnasticskills and they look like their
hands look funky, I'll alwaystry to get them at least neutral
or in a little bit that waythey don't have to use their
muscles and can't like just relyon hyper extending all the way
out and like using their jointsas their stability.
Speaker 2 (21:27):
Exactly, exactly and to that point I think, like
early on in the rehab processyou have to.
There's two pieces.
One is that you have to do alot of early um strength
maintenance, I should say, orlike reducing atrophy when
they're in the uh, the brace orthe cast or they're like
whatever Um and so doing, uh,early isometrics.
Doing early like active motion,concentric, more consistently,
(21:51):
and then like using BFR onsomeone who's probably
appropriate, who's a littleolder, like upper body BFR, when
you can't lift a, a lot ofweights but maintain metabolic
capacity or strength training,is the same as like acl bfr,
right, like.
I don't think we're gettingsomeone's quad stronger with bfr
in the first eight weeks.
I think we're minimizing lossby making it a lot harder.
Same can be true for the upperbody.
Maybe bfr can help us in thefirst couple months to minimize
(22:12):
tricep and bicep loss so thatwhen they do eventually get the
12 weeks, you know.
The second piece is, you know,quadruped rocking becomes bird
dogs, which becomes like astatic bear crawl position,
which becomes crawling, whichbecomes a tall plank, which
becomes a pike, which becomes ahandstand.
That progression over, you know, whatever it is, eight weeks of
weight bearing reintroductionis good because it allows us to
(22:32):
slowly add more to the tricepload and maybe get off BFR.
But you know you also got to bedoing like high, high load,
high volume, hypertrophy work ofthe tricep right.
That thing's been really likenot worked quite a bit if
they're pre-op and then post-op.
So just doing like good oldfashioned you know four by
eights or like three by tenswith moderate to heavyweight
skull crushers, likebodybuilding stuff, like really
(22:53):
important for like the youngerpost-op people to do because
they're going to eventually needjust raw tricep cross-sectional
area to support the progressionof whatever they're doing.
Speaker 1 (23:04):
Sure, when they're returning to sport after like
post-op well, any post-op elbow,I guess.
But for OCDs are you doing likehandheld strength testing?
Speaker 2 (23:10):
Yeah, yeah, yeah, for sure.
Um, I think we definitely doshoulder and uh, shoulder and
elbow together and then maybegrip.
So shoulder and grip is morelike what's above and below,
helping to buffer.
So I want their shoulderstrength side to side to be kind
of close because their cuff andtheir upper body is going to
handle a lot of that force.
Um, grip strength side to sideshows me the dynamic stabilizers
are supporting the elbow right.
(23:31):
So like there's one piece whichis that, yeah, if you have a
UCL, the flexor pronator mass isvery much needed to protect
that.
If you have an elbow OCD, um,your forearm and your grip
strength is uber important toprotect you during bars and
weight bearing.
So I want to make sure you'renot going to peel off right on
bars but also have enoughforearm strength to handle
handstands and handle backhandsprings and stuff.
And then you can also do like adynamometry of like tricep and
(23:53):
bicep, just to make sure we'reside to side strength.
That's probably like thesurgical uh uh issues themselves
.
The same way, like I want tosee torque in an acl be whatever
above their uh.
I think it's like two pointsomething for girls or guys but
I want their torque side to side, to be high in their leg, in
the same way that I want theirbicep tricep to be symmetrical
in their upper body, becausethat's like do not pass, go
(24:14):
unless you, you know, move on tothe next one sure, yeah, we've
been playing around with somelike upper extremity functional
test stuff, um, creating like aformal, I guess, test similar to
what we do for acls to clearpatients for sports.
Speaker 1 (24:28):
We've been kind of messing around with the like
elbow, like flexion extension,with handheld, and it's kind of
a tricky one to isolate.
Like I have a hard time withtriceps, particularly because
I've been doing it supine, wheretheir arms kind of like up this
way, and then I'm like here andit's just it's so hard for them
not to like go this way, likein or out or like push the whole
shoulder up.
(24:48):
So yeah, that one's not.
Speaker 2 (24:50):
That's been a little bit trickier to test the hard
thing to figure out is like toget a setup that's equivalent to
sitting, with like a chainlocked in extension for ACR
right, like there's a setup thatwe use the gym that many people
do which is like a chain from astatic point.
You're stuck at 90 degrees,you're belted down and you're
sitting up tall and you have atrue extension.
Like getting to the point whereyou can set up somebody on a
chain to be isolated, like ithas to be, like sitting with a
(25:13):
chain over their shoulder andjust like literally at 90
degrees going straight.
Like that.
Like that's a very unrealisticsetup that's what I'm trying to
accomplish.
Speaker 1 (25:21):
Yeah, but it hasn't been going yeah, I mean you
could really, but it hasn't beengoing like.
I'm not looking at that beinglike oh yeah, that's truly just
a triceps measurement, like Imean you totally could.
Speaker 2 (25:29):
You could have someone just like kneel down
next to the same box you woulduse for acl and put the chain
with a wrist cuff and put themat 90 degrees and curl as hard
as you can and then flip themaround the other way and just
extend as hard as you can.
I'd be down with that.
You probably just need asmaller chain to make sure that
it's not awkward.
Uh, on top of them, but yeah,that's a.
The only other way I think islying prone, but that's kind of
awkward too.
Um um, yeah, so this paper thatwe're trying to put out, uh, I
(25:52):
think 12 weeks is probably good.
I think 10 weeks I canunderstand maybe doing a little
bit on the way on the front end,um, weight bearing progressions
probably take like four weeksto go all the way from quad
rocking to doing a tall staticpush-up position, shoulder taps,
and then going from static totucked to piked, to one-legged
handstand, to handstand, tohandstand walking on the wall.
That's probably another fourweeks and I think that that
(26:14):
probably is the whole process ofweight bearing progressions is,
at the same time you're doing astrength training program of
like floor presses, um, to, yeah, floor presses, to like knee
elevated pushups to regularpushups.
Right, it's the same as likegoing from um half kneeling
cable pull downs to a statichang, to a pull up with the body
(26:34):
assistance of of a pull up band, then to a full pull up, like
those are all a parallel-up withthe body assistance of a
pull-up band, then to a fullpull-up, like those are all a
parallel track of like thehanging pull-up progression is
also the pushup progression,which is also the weight bearing
overhead progression, andeventually you get to the point
where somebody should be able todo, you know, a couple sets of
good pushups, couple sets ofgood pull-ups.
They should be able to hold thestatic handstand and walk
sideways on a wall.
That's how you you're doingwell and you're probably going
(26:56):
to get cleared at six months andgo back to a return to sport
program which has to have tumbletrack for two weeks, three days
per week, and then rod strip,and then rod strip goes to hard
tumbling and hard bars, stufflike that, but adding in the
less intense stuff first yeah, Ihaven't tried a lot of sideways
handstand walking it's good yougo to a lot of forward
backwards, but I haven't reallytried that I'll do like shoulder
(27:16):
taps or hand taps yeah, it'sgood because you can move
more of the handstand yeah, youcan take away the, the balance
skill of handstand walking andjust do like the loading of the
joint.
So we'll have someone go liketuck, tuck walks on a box, then
pike walks on a box sideways andthen do like a 45 degree wall
hold and just do taps and thenwhen they get the full handstand
here, you just pivot them andyou walk like side to side down
(27:37):
the wall.
It's a better way to do itversus front to back.
Speaker 1 (27:39):
Front to back.
Yeah, yeah, then they're notfalling all over the place.
Speaker 2 (27:42):
Correct Into their bridge, or yeah, they can work
on that handstand holding alittle later.
Speaker 1 (27:47):
Yeah, that's fair.
I'll have to try that one.
Speaker 2 (27:50):
Yeah, yeah.
So that's just this little one.
I think that hopefully thepaper will get submitted soon in
a month we're like literally inthe final editing process to
submit it to the journal andsports PT and then hopefully
it's accepted and it has like anappendix.
That's literally like sevenpages of like from the day they
come from you from the surgeonday, post-op one to six months
when they're going back to likethe hardest gymnastic skills
(28:12):
ever.
But hopefully it's a bit of aguide for people who maybe
aren't like I.
I just think about like when Ihad a baseball player and I was
like I don't know how to cheerbaseball player um mike and
lenny's papers were so helpful.
So our hope is that we can makesomething similar to that for,
like, the average everydaysports clinician who doesn't see
a lot of elbow ocd and they canjust like look on the journal
sports pt and see a wholeprotocol rehab that cause like.
Unfortunately a lot of peoplehave career ending OCD lesions
(28:34):
because a lot of reasons, butunfortunately one of them is
that they don't have a greatprogression back to sports and
they get like a good intentionfrom their PTs or doctors but
nobody really knows gymnasticsso they go back too fast, it
starts to flare up again.
The parents are like, yeah,we're not doing this again.
They just you know they're done, so hopefully that stops
happening.
Speaker 1 (28:51):
Yeah, do you have a progression that you're you
follow for upper extremity, likea specific, like I don't know.
I tend to make mine by hand,based on the kid, or I'll follow
like Emily Sweeney's, likeupper extremity, she's got like
shoulder wrist, elbow, likedifferent protocols for like a
return progression.
Do you use any of those or youjust kind of make them?
Speaker 2 (29:11):
Yeah, emily's is great.
I think Emily's is awesome andshe has a lot of good stuff.
Let me try to find.
I think I have I don't know ifit's an elbow ocd um, I get a
lot of questions about that frommy co-workers.
Speaker 1 (29:26):
They'll like reach out and say like, hey, like, how
should I progress this kid backto sport, like from.
Uh, it's so hard because everykid's a little bit different,
especially when you're gettinginto, like, optional levels
where they have different skillsyeah, for general advice and be
like they should do this andthen that.
So I usually provide theprotocol by emily sweeney
because I like how it separatesit by joint yeah, I think those
(29:47):
are.
Speaker 2 (29:47):
Those are probably really good to do as a.
Um, yeah, if you're notfamiliar with gymnastics, I
think emily does a great job ofhelping to just like I don't
know, do it for you.
I don't want to say, but likeshe gives you a really good
guide when you're not someonewho's as skilled at making those
programs.
Um, I will just pull up, notthis one, but this is, uh, this
is an Achilles, but whatever,this is going to be good enough
(30:08):
just to show the principle.
But essentially I think you can,can you can take the basis of
those.
I think the hard problem comesup to when they have optional
level skills and they're doingnot as many events so they have
kind of stuff going on um,that's not only compulsory,
compulsory, it's easy, right,compulsory.
Like, have the same plug andchug program but um, window boop
, boop, uh, is that up?
(30:31):
Yeah, oh no, it's not there wego.
Um, add to stage, it's notworking.
Hold on pause for dramaticeffect oh, there we go.
So yeah, I think I take theirum.
This girl had an achilles repairum, and so it's obviously not
the same, but essentially liketaking her skills that she does
for level 10 gymnastics.
You take those and then I makethe first two weeks is always
(30:53):
like one of the events is notthe thing.
So you're not doing um vaultbars being for one day per week.
She happened to not vault, sothat was actually very
convenient.
Um, but the first weeks aregoing to be her skills on softer
surfaces, about three to fiverepetitions of low level stuff.
So drills, basic tumbling, youknow not her full hardcore um
(31:16):
tumbling uh all the way on ontumble track, but just basic
level stuff.
And so we do this for two weekswhere she's doing three to five
on softer surfaces four daysper week, with a built-in off
day in between to kind of giveher her arrest.
This would be the same thing.
It'd be three days per week orfour days per week of like upper
body loading, three to fiveskills, softer surfaces, um,
with basic drills andconditioning.
(31:36):
Then the second two um weeks,weeks three and week four.
We uh, we'll add in morerepetitions of harder skills.
So now, instead of maybe justdoing singular roundoffs or
singular back handsprings ontumble track, you're doing round
off by can't bring back tuckfor a low level athlete or for
an older level athlete, it'syou're doing.
Instead of just like layout,you're doing double backs or
(31:57):
double pikes or fulls on tumbletrack and then you'd spend half
the time on a harder surface.
So, tumble track, you would doharder skills of like full, full
tumbling, and then, after youdo five or seven of those, you
go to floor and you would doyour basics on the harder
surface.
So you do static, you knowroundoffs or back handsprings or
(32:20):
single level skills, try to goback and forth, and then the
same thing happens.
Down here is that weeks fiveand week six, you do your
hardest skills on rod strip andyour less intense skills on
floor.
So, like rod strip to a resiwould have double backs, double
pikes, um, or full tumbling, andthen you'd go over to your
floor and just do layouts frontand back or full front and back.
So it's like you're alwaysstepping up half the time on the
harder surface with lessintense skills, but they're
(32:41):
always around like five to sevenrepetitions.
And then the last bit is you doseven repetitions, um, of any
skill you want on hardersurfaces, but that's like your
skill cap.
So, yeah, I think almosteverybody I read a program for
has some flavor of that.
What are your skills?
We're doing three days per weektaking one event off to your
home program three to five repsto start, easier skills.
(33:01):
The second week bumps up thesurface half the time, a little
harder skills, maybe five reps.
The third phase of those twoweeks is seven reps on harder
surfaces, but we're we're justbeing careful about total volume
.
And then, lastly, they kind ofexpand.
So, yeah, whether it's OCD,whether it's ankle, whether it's
Achilles, whether it's back,tends to be the thing I do which
is based on how they got hurtfor their back.
It might be hyperextensions fortheir legs.
(33:21):
It might be impact.
Upper body.
Elbow might be impact too aswell.
Speaker 1 (33:27):
Are you letting kids go back?
I know this depends a littlebit on, like, the kid and the
age that they are but are you,during the three month period
where they're not weight bearing, are you letting them go to
practice at all and do?
Speaker 2 (33:38):
Oh yeah, that's so child dependent.
So, like you know, I have some,uh some kids that for their
mental health it's better ifthey're just at the PT.
You know they're just rehabbingPT.
They're doing a strengthprogram with us maybe one day
per week Because if they go tothe gym they get bummed that all
their friends are doing skillsand upgrades and they're pissed.
Older athletes that are morelike, you know, high school
whatever they can go, they wantto be there.
(34:00):
It's better for their mentalhealth to be there because
they're with their friends, theycan help coach the little ones,
they can do some drills, sothey go home early.
Um, younger ones, especiallywith their parents.
It's like they're worried thatif they go there they're like
going to just like do a coupleof things here and there and oh,
it feels pretty good.
I'll try this.
So I would say it's almostalways dependent on, like the
(34:22):
kid, their parents and theircoaching situation.
If the coaching situation isgreat and they know that, like
you know, we'll see you in threemonths.
And I have situations too,where not to go down the weed on
who or where or what, but likethe coach that is working with
(34:42):
the athlete is like I'm a coachand I love it, but I don't want
them here if they're not readyto go fully.
So like it's like elite, highlevel, whatever.
And like they were like yeah,yeah, I have a bunch of tens and
a bunch of elite girls we'recoaching whatever.
Like I love that you come andbuy and you swing and you hang
out once in a while, but likedon't come back to the gym till
you're fully cleared.
You can do all the assignmentsthat we want you to do and I'm
not worried about you gettinghurt, which is fine.
(35:02):
That's one way to coach.
But like essentially it's likeI kept them for way longer, like
I did like lily didn't textthat coach until six months and
be like all right, and theyhadn't done like the hardest of
hard stuff in the PT room that Icould possibly give them and
then I feel pretty safe.
They're going back to a goodenvironment, but that was their
choice.
You know, other peopleliterally are in there with
their brace on week one doingleg conditioning and, like you
know, trying to people.
Speaker 1 (35:23):
Yeah, I got one more question.
Yeah, do you do?
When do you start doingtraction like hangs and and
stuff?
Are you pretty lenient on thatone early on, or are you waiting
until, like yeah, so it's basedon.
Speaker 2 (35:37):
With elbow ocd, because the injury mechanism is
compression, um traction comesfirst.
So we progress the hangprogression a bit earlier, maybe
around four months I would sayum versus the compression hard
stuff I would say it's a littlefarther on.
So like yeah, we're doingquadruped and rocking and you
know tabletop type stuff, butlike true plyos or like
(35:58):
handstand type work doesn't comefor later but traction earlier
because the traction on thejoint is not that dangerous and
we want to develop the forearm.
The flip is true for TJs andfor so Tammy James we call them
the gymnasts that come femalesbut um, compression is good for
the TJ earlier because that'snot how they got hurt right,
they got hurt from a hyperextension and probably a
(36:18):
dislocation.
So traction and and uh,traction and um compression are
not inherently the bad thing,but traction is a lot of stress
on the flexor pronator mass,which is a lot of stress
probably around the elbow joint.
So I tend to progress thecompression side of Tommy John
UCL rehabs a bit faster thanearlier, than traction, whereas
an OCD it's traction notcompression.
(36:41):
Okay, yeah, so probably aroundfour months.
I would say they're both insome way shape or form going for
it.
Okay, sounds good.
All right, we'll leave it at 30something minutes.
We're close.
We're close.
Speaker 1 (36:55):
Yeah.
Speaker 2 (36:57):
So this is the second one.
So, people, if you enjoy this,let us know if there's topics
you want us to cover, like chatabout.
That might be.
A cool thing too is to not onlybe a brain dump from Aaliyah
and I what we have going on, butif there's stuff that's on your
mind that you want us to chatabout, we can do that.
So we'll see you guys.
I don't know what the next onewill be, but whenever we do it,
(37:17):
we'll see you guys.
Then See ya.
every day.
You essentially pay your duesby doing the harder thing when
it's the right thing to do.
Alia, welcome to the podcast.
How was your week in the clinic?
Speaker 1 (00:15):
it was great busy, yeah, very busy, yeah, long week
.
Speaker 2 (00:18):
I'm ironically wearing the same shirt that I
was the last time we recorded Iwashed it just for this podcast
I'm just kidding everyone, justto catch out of the bag.
We were going to record a bunchof episodes in a row, so, yeah,
a couple of weeks in a row withthe same, uh, same outfit.
But, um, okay, first one was inworkloads and the way we're
going to try to put thesetogether is literally it's just
like a brain dump of everythingthat Aaliyah and I are thinking
(00:40):
of or working on, and we taketopics based on this Google
sheet that we have.
Where I was, literally you knownot that I text and drive, but
I was in traffic staticallysitting.
Still, I actually turned my caroff on 93 because there was an
accident.
I literally turned my car offand I had five minutes to go and
I was like wrote down a bunchof stuff that I was thinking
(01:01):
about.
Like you know, uh, I forgetwhat it was like elbow OCD,
which we'll explain what that is, but essentially, um, we are in
the final stages of submittinga paper that is an entire start
to finish of rehab for elbow OCD, and we'll explain what that is
.
But, um, mike and Lenny madethe same thing for Tommy John
UCL repairs back in the day,which helps a lot of people and
(01:24):
I see a lot of elbow OCDs butalso things you know, media
epicondyle fracture I think youwere talking about.
You have a lot of those UCL, uh, tommy John's and female
gymnasts as well OCD paper.
So essentially there's noconsensus on how to get somebody
back to gymnastics after theydo any of these surgeries.
Sometimes, like, the rehabprocess is very murky and I have
a lot of people reach out to meand like don't see as many
(01:45):
gymnasts for, uh, these issues,and they get to like three
months and their elbow motion isokay or their strength is back
and they're just like okay, likewell, how do we do gymnastics?
Like how do we get you backsafely?
Throwing program is reallybasic, you know.
You just like throw it 30, then45, then 60 and it slowly goes
up um, not so much forgymnastics.
And so that's where the papercame from, was that?
At the time it was Jen King, um, and her and I, and then a
(02:06):
surgeon and his fellowessentially just wrote this
monster rehab protocol for likehere's how we rehab them, here's
how we get them back to weightbearing, here's how we start the
advanced power phase, here'show we get them back to
gymnastics and we put that intoa paper, but there's not a lot
of consensus on uh precautionsfor OCD, so that's kind of where
I want to chat about this.
But yeah, do you have any broadarching thoughts about like
(02:29):
elbows, ucl, ocd, before we gointo some of the stuff?
Speaker 1 (02:33):
I don't like when people get casted.
Speaker 2 (02:36):
Yeah, that was an off air conversation.
I don't yeah, I am not to upsetany surgeons who might listen,
but I don't.
With younger patients, I thinkthe thought is that if we cast
them they won't hurt themselves,and so I understand that
perspective, right,eight-year-olds, nine-year-olds,
they fall, they break theirelbow.
But like from the pt side, Ican just say from what we
experience, like if someone iscasted for four weeks or braced,
(02:57):
locked in extension for fourweeks or something like that,
bro, it is a nightmare to rehabthat person because they're so
stiff and they're so painful andthey're so sore.
So this fell out of fashionwhere, like you know, acls used
to be non-weight bearing andlocked in extension for four
weeks.
Then you go to PT at four weeksand Mike and Lenny are, you know
, telling the surgeons that,like, this person's not bending
at all.
And the surgeon's like, well,just bend them more.
And it's like, yeah, but thisperson's crying on the table.
(03:19):
This is not okay.
And when you have an eight yearold or a nine year old who's
casted, um man, getting thatthat little kid to do rehab or
getting their mom to bend theirelbow or their dad to bend their
elbow when they're, whenthey're not happy is really,
really hard.
Um so I understand that, but Ialso see the other side of the
side of the fence that a lot ofplaces are really busy
outpatient clinics where theydon't have a lot of time with
the therapist, and you knowthey're not, they're not,
(03:45):
they're not really getting greathands on quality motion, and so
that person maybe gets bent oris pushed too hard, too fast
early, maybe they get hurt.
Maybe it's a surgeon's thought,as they, their elbow is is
getting cranky from the rehaband they're not doing well, I
don't know.
I don't know.
Speaker 1 (03:57):
Yeah, it's tough.
Speaker 2 (03:58):
You have some stiff elbows.
Speaker 1 (04:00):
I have so many stiff elbows right now.
They're just particularly whenthey're younger.
They just get so stiff Like Idon't know what it is, but like
when I get older kid elbows,like in high school they're
they're honestly fine, even ifthey get past it, like there'll
be a little stiff but we'll getthrough it.
But the kids that are likeeight, nine, 10, their elbows
don't move, like if they getcasted or stuck in a position
(04:21):
for a while.
They are so stiff and it's sohard to get their emotion back
and it hurts so much.
So just it's not?
Speaker 2 (04:27):
Yeah, I think there's .
There's two pieces.
One is that younger kids havethe attention span oftentimes of
like a goldfish.
All right, so like.
Like when I was eight, bro, Iwas like playing video games and
running around and playing withmy brother and if I hurt my
ankle or something like that,like I did not even think about
it.
Like my mom tried so hard toget me to do rehab.
There's no way it's happening.
So like to get a kid to bendtheir elbow every hour on the
(04:50):
hour to end range instead ofgoing to play whatever, um is
really hard to do, you know.
So like, younger kids arehaving a tougher time with
adherence to exercise.
And parents are busy, man,they're working, they have stuff
going on, they can't be ontheir kid all the time.
So I I'm empathetic to that.
The other piece of it,unfortunately, is that it's grow
like weeds, right.
So when you get a stiff elbowand you know you cast somebody
for four weeks or like threemonths go by.
(05:11):
Their humerus is growing, theirform is growing, right, so like
their biceps.
Tricep is trying to keep up, butit's it's very stiff relative
to the rest of them.
So that's like a double whammythat they're growing as you're
trying to get motion back andthen they just don't have the
attention span.
Speaker 1 (05:25):
Definitely yeah, I see that all the time, and
especially if it's painful, thentrying to get an eight-year-old
to push, put themselves intopain, is not going to work.
Speaker 2 (05:33):
Yeah, and a practical advice I would say is that for
those people that are really,really stiff and or not can hear
, uh, add what's the word I'mlooking for?
Coherent, no, compliant,compliant, coherent, no,
compliant, compliant.
Um, like, sometimes like heatpack on their elbow for like
five minutes, just like lettingit droop, and like pass the time
of like put their elbow overedge, put a heat pack on their
edge of their front, of theirbicep, and maybe even like a
(05:54):
light band pulling them down ifthey're cleared by a pt, and
like let them scroll on tiktokfor 10 minutes while they, while
they just sit there with theheat pack and like melt their
elbow straight, like more active, focused, focus, like they have
to be doing the thing staringat it, the board they're going
to get.
So find other ways to to keepthem distracted.
Like you know, play cards withthem or, like you know, do
something else while they justlet their heat do the work for
(06:15):
them.
I think that's probably abetter uh approach than you know
.
Let's do this soft tissue whereit goes bend every hour on the
hour, like I don't think it'sgoing to work.
So, yeah, that'd be my one tipof practical advice.
Yeah, got to get creative anddon't cast them, if we can.
Um, okay, so elbow OCD longstory short is a uh injury to
(06:35):
the cartilage of the uh forearmarea.
So let me see if I can zoom ina little bit.
So, essentially, when you dogymnastics this happens in
baseball too, but when you dogymnastics over and over again,
your arm is not a leg and soyour knee joint can take a lot
of high force, but your elbowjoint cannot.
So in a young, growing athlete,that little bump you see there
is essentially like a potholedeficit, that's that's
(06:58):
developing.
Um, on what's called thecapitellum.
So the elbow side gets a bigold pothole in it and because
maybe the, maybe the bone downhere is harder than up top, so
radius is stiffer relative tothe capitellum, that's one
theory, but essentially you hitthe same spot over and over
again and it causes a bruising.
Bruising becomes damaged,damage becomes, cartilage gets
kind of like again hollowed outin a pothole, and that is
(07:19):
obviously not good.
So they have to fix it.
The procedure that tends to havethe best outcomes is an oats
procedure.
So, um, they take a small graftfrom your knee, where it's not
weight bearing, and theyessentially form into a bone
plug, they put it inside theelbow joint and they stick it in
there and then, um, they letthat heal, they suture it down,
uh, or they suture down, they,they fixate it down and then
(07:40):
slowly over time the bone plugfrom your knee becomes a new
like covered over area of yourelbow.
That's what an Oates procedureis.
There's a lot more dorkyexplanations for that, but in a
nutshell, you know, gymnasts areyoung, their elbows are not
knees.
They're doing probably too much, too fast, they're not that
strong yet relative to how hardgymnastics is, and so this
happens when high amounts ofupper body impacts are going on
(08:01):
slowly but surely and thenunfortunately sometimes need a
surgery.
The first uh approach is a sixmonth rest period, because I'd
rather not do surgery.
But if surgery uh is indicatedthey, they base it on how big
the lesion is and how deep thelesion is.
So grade one, two, three, fouris deeper down the bone itself,
whereas wider is, like you know,eight versus six versus 12
millimeters wide.
(08:22):
They make a bone plug.
So obviously the deeper thelesion with the more width, and
if there's like bone fragments,the more severe the surgery is
and the rehab is um versus not.
But yeah, there's no um,gymnastics and baseball, get
these, but there's no uh, reallyclear, I guess, guidelines on
how to rehab these people.
So the paper that we aresubmitting essentially is saying
(08:43):
that the first three months ismore or less the same for any
other.
You know surgery, you, you know, get their motion back, you let
the swelling come down, you tryto get their form stronger, you
try to protect the graft forthree months because it's a bone
, it's a bony graft, integration, and so we're trying to protect
that area, the same way that ifyou fractured your leg, you
wouldn't really want to walk onit for the first couple of weeks
.
So we put you in a immobilizedand we get your emotion back and
(09:05):
stuff.
But then around three months itstarts to become a large, I'd
say maybe debate or point ofdiscussion in the in the
academic world of like, when dowe start putting weight on the
elbow that has this bone plug?
And generally speaking, I wouldsay my thought is 12 weeks for
most stuff.
If someone has a really biglesion or a really deep lesion,
(09:27):
or there was an issue with thesurgery where they had to do
more work than they thought,maybe you push it out more.
But I think 12 weeks isprobably good because the bone
is probably fixated.
And the debate that I had withsome other surgeons is that
other research shows the kneeand the elbow, or the knee and
the ankle, when it has elbow OCD, they start weight bearing,
(09:47):
these people, at like six weeksor eight weeks because the
thought is that early partialweight bearing helps to secure
the plug in the pothole graft.
So the thought is that ifyou're, if you're fixating the
graft in via some partial weightbearing, it's allowing the
graft to more um, you know, tohave a better fit, be more
congruent.
I would sort of speak.
(10:07):
And my uh contrary to that isthat oftentimes the ankle has
like an evolutionary mileage oflike 10,000 years that it's been
built for this.
The talar dome is like this wide, flat, very supportive
structure, tons of cuboid bonesaround it, tons of ligaments
around it, and the knee is thisgiant like spherical shape joint
(10:27):
that's made for weight bearing.
Right your elbow is like so notthe same, and also it's all
these OCDs are in kids that areyoung and that are growing and
are not that strong.
So I think the elbow OCD tendsto be younger and kids that are
not as strong and they're doinga lot more activity on their
elbows, which makes it harderversus typically an OCD and like
a knee or an ankle.
(10:48):
That's like.
That's like an adult injury.
Right, that's a college, that'sa lacrosse field, hockey,
jumping, running, end stagecareer, someone who's been
running and jumping and playinga sport for their whole life,
professional athletes knee andankle stuff is almost always
college and above level.
Uh, athletes and status, notelbow, which is like the
youngest amateur athlete.
(11:09):
So yeah, big picture, those aremy thoughts, but what do you
think?
Speaker 1 (11:14):
yeah, I agree.
I mean I don't really see anyocds, like post-op ocds, that
are like cleared at eight weeks.
They're almost always all weeksand up.
Um, if it's a big one, they'reusually wait until about four
but or four months.
But I think it's interestingwith the eight weeks because,
because the elbow is such acongruent joint, sometimes I
feel like giving it a little bitof weight bearing, like just
(11:36):
very low level, like even justlike you know, like putting your
hands like go on hands andknees, like rocking forward,
backwards, side to side, just toget a little bit more motion.
I have a hard time with elbowstrying to get all of my
extension back actively withoutdoing any weight bearing.
It's really hard for me likethey can get almost there, but
that like active without doingweight bearing gets really hard.
(11:58):
So it'd be nice if I was ableto do a little bit more weight
bearing, like closer to likeeight to eight, maybe 10 weeks,
where you're just working onlike very low level, just being
able to like push againstsomething and get your elbow
straight to like start workingon strength in that position,
rather than like actual loadingor like impact.
Speaker 2 (12:18):
I'm totally down with that.
So I think that when we madethis protocol, we were looking
at research on like, whatpercentage of weight bearing
certain positions are Right, solike, uh, I think a quadruped
rock and a bird dog is like 17%upper extremity weight bearing
Right.
So you could argue that that'slike one sixth of their body
weight, right, it's like sosmall, and I actually I agree
(12:41):
with you, though, that like onesixth of their body weight,
right, it's like so small, and Iactually, I, I agree with you,
though that like, I think, I, Ithink a lot about acls too is I
have one case right now likejust a bit stiffer, she had an
lat, so the swelling was more,and like she has passively, when
I do it like eight degrees ofhyperextension in her knee, but
she cannot lift her own heel offto get to eight degrees.
Eight degrees of hyperextension, it's just a zero, and that
tells you that, like her quad isthe reason why she can't get
her legs super, super straight.
I think, the same is true forelbows right Like you have
(13:01):
somebody who passively isgetting to like zero after an
OCD or UCL or whatever or amedial epicondyle fracture, but
then like actively it's likenegative 10.
That means their tricep is notable to overcome its relative
strength right, their tricep isnot as strong to overcome the
stiffness of the front of theirelbow.
So in that situation I agreewith you, I think it's good to
get somebody quadruped and dolike the version of tkes.
(13:22):
But for their elbow right, justhave them do hyper, like uh,
tricep firing in neutral onmaybe a dumbbell with neutral
wrist, just to get their wristsuper duper straight and their
elbow super duper straight.
And then you add someresistance around and maybe that
closes the gap between, likewhat they passively have and
what they actively have.
So yeah, I think I'm okay withthat.
You know, I think at 10 weeksI'm down to do some like
quadruped rocking and some likeput them on dumbbells with their
(13:44):
wrists are neutral and havethem rock forward, backward,
side to side more.
So maybe for the strength pieceof end range, like active range
of motion, before you startprogressing somebody into like
the strengthening side of weightbearing, yeah, Sure, yeah, I
mean, even when we're in like adumbbell program.
Speaker 1 (13:58):
It's like when you add the addition of the dumbbell
and then you're like musclesfiring, like how much force is
going between the joint anyways,does it really make that much
of a difference, right?
That's something that's lowlevel weight bearing versus like
lifting a 10 pound dumbbellover your head and having the
impact forces of that.
And I think, too, like I haven'thad a lot of these where I've
had issues where it feels likethe joint isn't as smooth when
(14:20):
you're doing motion.
But I've had a couple where I'mlike I wanted to do weight
bearing because I'm like itdoesn't feel totally smooth.
It feels like there's a littlelike I don't want to say the
word crunch, but like a littlesticky you can just feel it a
little bit and you're like alittle bit more than you want
and I feel like early on, whenit's still trying to like get
integrated into the bone andkind of shape itself out like
(14:41):
remodeling of that bone, itmight be I don't, I don't know
if that would be beneficial tolike have a little bit of weight
bearing.
That way it can start to likeshape, go like, get the correct
shape.
That way you're not feelinglike this stickiness or losing
motion because it's not thecorrect shape that it needs to
be.
Speaker 2 (14:58):
Yeah, no, I agree with that for sure.
I think I think part of thebenefit of dumbbell programming
is to give somebody like a verysmall dosage of axial loading,
right.
So if someone's around 10 weeksand you're feeling a bit iffy,
maybe instead of going toquadruped and then like bird
dogs and like crawling and stuff, maybe you do like a floor
press overhead, dumbbell pressweek where you're just saying
like all right, let's do likefive, 10 pounds, try to get your
(15:20):
elbow fully locked out so it'sless weight.
But you're doing active rangeof motion and that's kind of an
indicator of like whether thenext phase is going to go really
well.
Right.
Like if you're going to havesomebody who's able to um press
overhead to full end range andthen also do a floor press to
end range, you're getting twovectors there of overhead and
floor press.
That sets somebody up to dowell on a quad rocking or
something like that.
Speaker 1 (15:39):
Sure, yeah, do you have.
I'm curious with your motion,like when you're getting elbow
extension back, are you?
Are you pushing, like, say,I've had a couple of kids that
have like close to 20, 25degrees of hyper extension,
which is a lot.
Do they need all of that?
Not necessarily, but ingymnastics they're, if they're
(16:00):
locking their elbow out in anyway, like they're going to be
off center if they can't gettheir other elbow, the other
like the same amount.
But you know what's?
What are the limits?
Speaker 2 (16:08):
yeah, I treat it all the way back to that, or yeah, I
treat it like like the knee,whereas like if somebody's hyper
11 or 10 on one side, you canargue that you don't want hyper
10 on the graph side becauseyou're going to stress the graph
Right If you push really,really hard, probably within a
couple of degrees, like withinfive is probably doable.
You know, like I think I'veseen a lot of people either
(16:30):
elbow like OCD or Tommy John ormedia up condyle, who get like
five and 10.
Right, or like or like sevenand 10 or like, you know, six
and five or whatever.
I think within within a likefive to 10% of the other side is
probably okay Because I amwilling to bet that naturally,
over time as they go back tofull gymnastics it's going to
kind of slowly get a bit more.
You know they're oftentimes laxand very loose, so I don't want
(16:51):
to let somebody get away withlike missing five degrees on one
side and having plus 10 on theother, because that's a 15
degree swing.
But if someone only gets toneutral when they had, you know,
plus five or plus 10 after asurgery, that's probably okay.
I think particularly in like UCLrehab end range, hyperextension
stresses the anterior bundlequite a bit which is where their
(17:11):
you know their job graft was.
And then you have a lot ofdynamic restraints of like the
flexor digital rooms and stufflike that.
They're overlying the tendon.
So I don't know if I want toget somebody all the way to
hyper end range, where we'restressing a graft and then
asking the dynamic stabilizersto do extra double duty.
Sure, I think.
Personally, I think they'reprobably going to be okay if we
just get them to like a littleabove or neutral and their body
(17:32):
will probably figure it out.
Speaker 1 (17:32):
For the rest, yeah, and it's hard because, like with
a throwing sport, I mean youwant, you want motion like
within near symmetrical ranges,for sure, but from like a, you
don't necessarily need all ofyour hyperextension to like
throw a baseball, like yeah youknow, like gymnastics.
You're like you have to besymmetrical, like if you can't
be on a bar, and like one elbowis over extended 20 degrees, the
(17:54):
other one's only five, likeyou're going to be off center
and you're going to feel thatyeah, to that point.
Speaker 2 (17:58):
I mean a lot of elbow player or elbow, uh, elbow in
baseball players is is like verystiff and bent from years of
throwing from a bony point to do, right.
But the same could be said isthat, like the shoulder is the
equivalent of the elbow forgymnastics.
Like you can't not ish degreesof risk, right, but like your
(18:25):
elbow needs to be really, reallyclose and then maximize the
rest from your shouldersoverhead, right, yeah, yeah, I
would say that close enough isprobably good in a young
pediatric elbow for sure.
Speaker 1 (18:32):
Yeah, yeah, I've had, I think with extension their
motion usually isn't too bad,like we can usually get it back,
get it pretty close.
But it's that active and rangeextension that we always have a
hard time with, especially oncewe start getting into like like
true weight bearing, likeenhancing positions or L holds
or whatever we're doing workingon like pushup positions.
They just have a really hardtime getting their elbow to
(18:53):
maintain like their fullextension.
Speaker 2 (18:56):
For sure.
Speaker 1 (18:58):
I'd be curious to know your thoughts too on like a
.
A lot anecdotally I have seen Idon't know how true this is or
you can you've seen a lot morethan me so you'll be able to
like comment on this but I see alot of the kids that I've seen
with ocds are ones that willlike literally like turn their
hand out and like hyper,although out completely, when
they do skills which you don'treally see much at the high
(19:19):
level, because their coaches arenot.
They're going to fix that.
Speaker 2 (19:21):
They don't want to see kids with their hands all
the way out I think uh, uh, Iknow this, I saw this paper the?
yeah, I think I know what you'retalking about yeah, the t
position round off yeah so yeah,essentially this paper was just
showing that you know it's in around off, but doing a T
(19:42):
position is probably a littlebit better versus like rotating
all the way in or all the wayout.
I don't get to pull it up, butessentially when you fully
rotate all the way out, likethat, you're asking the joints
to do all the work right.
Your tricep can't help out aton.
When that maximally externallyrotated position is versus if
you're really all the way in,you're just like really all
muscles, no bones, and so you'rekind of asking the opposite
(20:02):
side.
So I think that you know,neutral or slightly turned in is
probably good and even slightlyturned out because of like
wrist or shoulder mobility, butI think anything beyond like the
basic, you know what would thatbe like?
10 to two position on, like aclock.
I think, when you dance too faroutside of 10 to two, you're
asking one or the other to do alot of work.
Really far outside.
It's a lot of joints, reallyfar insides, a lot of muscles.
(20:23):
You're probably gonna haveperformance issues here and
ouchy issues on the other side.
So I like how I'm trying to fitit in frame, so yeah.
So I think that, uh, if someoneis really far out, they're
oftentimes trying to make up foran overhead flexibility
position.
They don't have enoughflexibility or shoulder
flexibility or thoracic spinemobility to go overhead.
(20:45):
So I would probably spend moretime addressing that If
someone's really far in.
I think it's more of a coaching, technical correction than it
is um.
You know a you know performancebased PT issue.
So yeah, I would try to figurethat out in the rehab process or
ideally before Um.
But you definitely don't wantto be hanging your hand Like you
don't want to rotate your handsout too far or too in, uh, or
(21:05):
either sides of the issues.
Speaker 1 (21:06):
but yeah, yeah, yeah, I try to honestly any of the
elbows that I have or shoulders,really any gymnast that comes
in if they're doing gymnasticskills and they look like their
hands look funky, I'll alwaystry to get them at least neutral
or in a little bit that waythey don't have to use their
muscles and can't like just relyon hyper extending all the way
out and like using their jointsas their stability.
Speaker 2 (21:27):
Exactly, exactly and to that point I think, like
early on in the rehab processyou have to.
There's two pieces.
One is that you have to do alot of early um strength
maintenance, I should say, orlike reducing atrophy when
they're in the uh, the brace orthe cast or they're like
whatever Um and so doing, uh,early isometrics.
Doing early like active motion,concentric, more consistently,
(21:51):
and then like using BFR onsomeone who's probably
appropriate, who's a littleolder, like upper body BFR, when
you can't lift a, a lot ofweights but maintain metabolic
capacity or strength training,is the same as like acl bfr,
right, like.
I don't think we're gettingsomeone's quad stronger with bfr
in the first eight weeks.
I think we're minimizing lossby making it a lot harder.
Same can be true for the upperbody.
Maybe bfr can help us in thefirst couple months to minimize
(22:12):
tricep and bicep loss so thatwhen they do eventually get the
12 weeks, you know.
The second piece is, you know,quadruped rocking becomes bird
dogs, which becomes like astatic bear crawl position,
which becomes crawling, whichbecomes a tall plank, which
becomes a pike, which becomes ahandstand.
That progression over, you know, whatever it is, eight weeks of
weight bearing reintroductionis good because it allows us to
(22:32):
slowly add more to the tricepload and maybe get off BFR.
But you know you also got to bedoing like high, high load,
high volume, hypertrophy work ofthe tricep right.
That thing's been really likenot worked quite a bit if
they're pre-op and then post-op.
So just doing like good oldfashioned you know four by
eights or like three by tenswith moderate to heavyweight
skull crushers, likebodybuilding stuff, like really
(22:53):
important for like the youngerpost-op people to do because
they're going to eventually needjust raw tricep cross-sectional
area to support the progressionof whatever they're doing.
Speaker 1 (23:04):
Sure, when they're returning to sport after like
post-op well, any post-op elbow,I guess.
But for OCDs are you doing likehandheld strength testing?
Speaker 2 (23:10):
Yeah, yeah, yeah, for sure.
Um, I think we definitely doshoulder and uh, shoulder and
elbow together and then maybegrip.
So shoulder and grip is morelike what's above and below,
helping to buffer.
So I want their shoulderstrength side to side to be kind
of close because their cuff andtheir upper body is going to
handle a lot of that force.
Um, grip strength side to sideshows me the dynamic stabilizers
are supporting the elbow right.
(23:31):
So like there's one piece whichis that, yeah, if you have a
UCL, the flexor pronator mass isvery much needed to protect
that.
If you have an elbow OCD, um,your forearm and your grip
strength is uber important toprotect you during bars and
weight bearing.
So I want to make sure you'renot going to peel off right on
bars but also have enoughforearm strength to handle
handstands and handle backhandsprings and stuff.
And then you can also do like adynamometry of like tricep and
(23:53):
bicep, just to make sure we'reside to side strength.
That's probably like thesurgical uh uh issues themselves
.
The same way, like I want tosee torque in an acl be whatever
above their uh.
I think it's like two pointsomething for girls or guys but
I want their torque side to side, to be high in their leg, in
the same way that I want theirbicep tricep to be symmetrical
in their upper body, becausethat's like do not pass, go
(24:14):
unless you, you know, move on tothe next one sure, yeah, we've
been playing around with somelike upper extremity functional
test stuff, um, creating like aformal, I guess, test similar to
what we do for acls to clearpatients for sports.
Speaker 1 (24:28):
We've been kind of messing around with the like
elbow, like flexion extension,with handheld, and it's kind of
a tricky one to isolate.
Like I have a hard time withtriceps, particularly because
I've been doing it supine, wheretheir arms kind of like up this
way, and then I'm like here andit's just it's so hard for them
not to like go this way, likein or out or like push the whole
shoulder up.
(24:48):
So yeah, that one's not.
Speaker 2 (24:50):
That's been a little bit trickier to test the hard
thing to figure out is like toget a setup that's equivalent to
sitting, with like a chainlocked in extension for ACR
right, like there's a setup thatwe use the gym that many people
do which is like a chain from astatic point.
You're stuck at 90 degrees,you're belted down and you're
sitting up tall and you have atrue extension.
Like getting to the point whereyou can set up somebody on a
chain to be isolated, like ithas to be, like sitting with a
(25:13):
chain over their shoulder andjust like literally at 90
degrees going straight.
Like that.
Like that's a very unrealisticsetup that's what I'm trying to
accomplish.
Speaker 1 (25:21):
Yeah, but it hasn't been going yeah, I mean you
could really, but it hasn't beengoing like.
I'm not looking at that beinglike oh yeah, that's truly just
a triceps measurement, like Imean you totally could.
Speaker 2 (25:29):
You could have someone just like kneel down
next to the same box you woulduse for acl and put the chain
with a wrist cuff and put themat 90 degrees and curl as hard
as you can and then flip themaround the other way and just
extend as hard as you can.
I'd be down with that.
You probably just need asmaller chain to make sure that
it's not awkward.
Uh, on top of them, but yeah,that's a.
The only other way I think islying prone, but that's kind of
awkward too.
Um um, yeah, so this paper thatwe're trying to put out, uh, I
(25:52):
think 12 weeks is probably good.
I think 10 weeks I canunderstand maybe doing a little
bit on the way on the front end,um, weight bearing progressions
probably take like four weeksto go all the way from quad
rocking to doing a tall staticpush-up position, shoulder taps,
and then going from static totucked to piked, to one-legged
handstand, to handstand, tohandstand walking on the wall.
That's probably another fourweeks and I think that that
(26:14):
probably is the whole process ofweight bearing progressions is,
at the same time you're doing astrength training program of
like floor presses, um, to, yeah, floor presses, to like knee
elevated pushups to regularpushups.
Right, it's the same as likegoing from um half kneeling
cable pull downs to a statichang, to a pull up with the body
(26:34):
assistance of of a pull up band, then to a full pull up, like
those are all a parallel-up withthe body assistance of a
pull-up band, then to a fullpull-up, like those are all a
parallel track of like thehanging pull-up progression is
also the pushup progression,which is also the weight bearing
overhead progression, andeventually you get to the point
where somebody should be able todo, you know, a couple sets of
good pushups, couple sets ofgood pull-ups.
They should be able to hold thestatic handstand and walk
sideways on a wall.
That's how you you're doingwell and you're probably going
(26:56):
to get cleared at six months andgo back to a return to sport
program which has to have tumbletrack for two weeks, three days
per week, and then rod strip,and then rod strip goes to hard
tumbling and hard bars, stufflike that, but adding in the
less intense stuff first yeah, Ihaven't tried a lot of sideways
handstand walking it's good yougo to a lot of forward
backwards, but I haven't reallytried that I'll do like shoulder
(27:16):
taps or hand taps yeah, it'sgood because you can move
more of the handstand yeah, youcan take away the, the balance
skill of handstand walking andjust do like the loading of the
joint.
So we'll have someone go liketuck, tuck walks on a box, then
pike walks on a box sideways andthen do like a 45 degree wall
hold and just do taps and thenwhen they get the full handstand
here, you just pivot them andyou walk like side to side down
(27:37):
the wall.
It's a better way to do itversus front to back.
Speaker 1 (27:39):
Front to back.
Yeah, yeah, then they're notfalling all over the place.
Speaker 2 (27:42):
Correct Into their bridge, or yeah, they can work
on that handstand holding alittle later.
Speaker 1 (27:47):
Yeah, that's fair.
I'll have to try that one.
Speaker 2 (27:50):
Yeah, yeah.
So that's just this little one.
I think that hopefully thepaper will get submitted soon in
a month we're like literally inthe final editing process to
submit it to the journal andsports PT and then hopefully
it's accepted and it has like anappendix.
That's literally like sevenpages of like from the day they
come from you from the surgeonday, post-op one to six months
when they're going back to likethe hardest gymnastic skills
(28:12):
ever.
But hopefully it's a bit of aguide for people who maybe
aren't like I.
I just think about like when Ihad a baseball player and I was
like I don't know how to cheerbaseball player um mike and
lenny's papers were so helpful.
So our hope is that we can makesomething similar to that for,
like, the average everydaysports clinician who doesn't see
a lot of elbow ocd and they canjust like look on the journal
sports pt and see a wholeprotocol rehab that cause like.
Unfortunately a lot of peoplehave career ending OCD lesions
(28:34):
because a lot of reasons, butunfortunately one of them is
that they don't have a greatprogression back to sports and
they get like a good intentionfrom their PTs or doctors but
nobody really knows gymnasticsso they go back too fast, it
starts to flare up again.
The parents are like, yeah,we're not doing this again.
They just you know they're done, so hopefully that stops
happening.
Speaker 1 (28:51):
Yeah, do you have a progression that you're you
follow for upper extremity, likea specific, like I don't know.
I tend to make mine by hand,based on the kid, or I'll follow
like Emily Sweeney's, likeupper extremity, she's got like
shoulder wrist, elbow, likedifferent protocols for like a
return progression.
Do you use any of those or youjust kind of make them?
Speaker 2 (29:11):
Yeah, emily's is great.
I think Emily's is awesome andshe has a lot of good stuff.
Let me try to find.
I think I have I don't know ifit's an elbow ocd um, I get a
lot of questions about that frommy co-workers.
Speaker 1 (29:26):
They'll like reach out and say like, hey, like, how
should I progress this kid backto sport, like from.
Uh, it's so hard because everykid's a little bit different,
especially when you're gettinginto, like, optional levels
where they have different skillsyeah, for general advice and be
like they should do this andthen that.
So I usually provide theprotocol by emily sweeney
because I like how it separatesit by joint yeah, I think those
(29:47):
are.
Speaker 2 (29:47):
Those are probably really good to do as a.
Um, yeah, if you're notfamiliar with gymnastics, I
think emily does a great job ofhelping to just like I don't
know, do it for you.
I don't want to say, but likeshe gives you a really good
guide when you're not someonewho's as skilled at making those
programs.
Um, I will just pull up, notthis one, but this is, uh, this
is an Achilles, but whatever,this is going to be good enough
(30:08):
just to show the principle.
But essentially I think you can,can you can take the basis of
those.
I think the hard problem comesup to when they have optional
level skills and they're doingnot as many events so they have
kind of stuff going on um,that's not only compulsory,
compulsory, it's easy, right,compulsory.
Like, have the same plug andchug program but um, window boop
, boop, uh, is that up?
(30:31):
Yeah, oh no, it's not there wego.
Um, add to stage, it's notworking.
Hold on pause for dramaticeffect oh, there we go.
So yeah, I think I take theirum.
This girl had an achilles repairum, and so it's obviously not
the same, but essentially liketaking her skills that she does
for level 10 gymnastics.
You take those and then I makethe first two weeks is always
(30:53):
like one of the events is notthe thing.
So you're not doing um vaultbars being for one day per week.
She happened to not vault, sothat was actually very
convenient.
Um, but the first weeks aregoing to be her skills on softer
surfaces, about three to fiverepetitions of low level stuff.
So drills, basic tumbling, youknow not her full hardcore um
(31:16):
tumbling uh all the way on ontumble track, but just basic
level stuff.
And so we do this for two weekswhere she's doing three to five
on softer surfaces four daysper week, with a built-in off
day in between to kind of giveher her arrest.
This would be the same thing.
It'd be three days per week orfour days per week of like upper
body loading, three to fiveskills, softer surfaces, um,
with basic drills andconditioning.
(31:36):
Then the second two um weeks,weeks three and week four.
We uh, we'll add in morerepetitions of harder skills.
So now, instead of maybe justdoing singular roundoffs or
singular back handsprings ontumble track, you're doing round
off by can't bring back tuckfor a low level athlete or for
an older level athlete, it'syou're doing.
Instead of just like layout,you're doing double backs or
(31:57):
double pikes or fulls on tumbletrack and then you'd spend half
the time on a harder surface.
So, tumble track, you would doharder skills of like full, full
tumbling, and then, after youdo five or seven of those, you
go to floor and you would doyour basics on the harder
surface.
So you do static, you knowroundoffs or back handsprings or
(32:20):
single level skills, try to goback and forth, and then the
same thing happens.
Down here is that weeks fiveand week six, you do your
hardest skills on rod strip andyour less intense skills on
floor.
So, like rod strip to a resiwould have double backs, double
pikes, um, or full tumbling, andthen you'd go over to your
floor and just do layouts frontand back or full front and back.
So it's like you're alwaysstepping up half the time on the
harder surface with lessintense skills, but they're
(32:41):
always around like five to sevenrepetitions.
And then the last bit is you doseven repetitions, um, of any
skill you want on hardersurfaces, but that's like your
skill cap.
So, yeah, I think almosteverybody I read a program for
has some flavor of that.
What are your skills?
We're doing three days per weektaking one event off to your
home program three to five repsto start, easier skills.
(33:01):
The second week bumps up thesurface half the time, a little
harder skills, maybe five reps.
The third phase of those twoweeks is seven reps on harder
surfaces, but we're we're justbeing careful about total volume
.
And then, lastly, they kind ofexpand.
So, yeah, whether it's OCD,whether it's ankle, whether it's
Achilles, whether it's back,tends to be the thing I do which
is based on how they got hurtfor their back.
It might be hyperextensions fortheir legs.
(33:21):
It might be impact.
Upper body.
Elbow might be impact too aswell.
Speaker 1 (33:27):
Are you letting kids go back?
I know this depends a littlebit on, like, the kid and the
age that they are but are you,during the three month period
where they're not weight bearing, are you letting them go to
practice at all and do?
Speaker 2 (33:38):
Oh yeah, that's so child dependent.
So, like you know, I have some,uh some kids that for their
mental health it's better ifthey're just at the PT.
You know they're just rehabbingPT.
They're doing a strengthprogram with us maybe one day
per week Because if they go tothe gym they get bummed that all
their friends are doing skillsand upgrades and they're pissed.
Older athletes that are morelike, you know, high school
whatever they can go, they wantto be there.
(34:00):
It's better for their mentalhealth to be there because
they're with their friends, theycan help coach the little ones,
they can do some drills, sothey go home early.
Um, younger ones, especiallywith their parents.
It's like they're worried thatif they go there they're like
going to just like do a coupleof things here and there and oh,
it feels pretty good.
I'll try this.
So I would say it's almostalways dependent on, like the
(34:22):
kid, their parents and theircoaching situation.
If the coaching situation isgreat and they know that, like
you know, we'll see you in threemonths.
And I have situations too,where not to go down the weed on
who or where or what, but likethe coach that is working with
(34:42):
the athlete is like I'm a coachand I love it, but I don't want
them here if they're not readyto go fully.
So like it's like elite, highlevel, whatever.
And like they were like yeah,yeah, I have a bunch of tens and
a bunch of elite girls we'recoaching whatever.
Like I love that you come andbuy and you swing and you hang
out once in a while, but likedon't come back to the gym till
you're fully cleared.
You can do all the assignmentsthat we want you to do and I'm
not worried about you gettinghurt, which is fine.
(35:02):
That's one way to coach.
But like essentially it's likeI kept them for way longer, like
I did like lily didn't textthat coach until six months and
be like all right, and theyhadn't done like the hardest of
hard stuff in the PT room that Icould possibly give them and
then I feel pretty safe.
They're going back to a goodenvironment, but that was their
choice.
You know, other peopleliterally are in there with
their brace on week one doingleg conditioning and, like you
know, trying to people.
Speaker 1 (35:23):
Yeah, I got one more question.
Yeah, do you do?
When do you start doingtraction like hangs and and
stuff?
Are you pretty lenient on thatone early on, or are you waiting
until, like yeah, so it's basedon.
Speaker 2 (35:37):
With elbow ocd, because the injury mechanism is
compression, um traction comesfirst.
So we progress the hangprogression a bit earlier, maybe
around four months I would sayum versus the compression hard
stuff I would say it's a littlefarther on.
So like yeah, we're doingquadruped and rocking and you
know tabletop type stuff, butlike true plyos or like
(35:58):
handstand type work doesn't comefor later but traction earlier
because the traction on thejoint is not that dangerous and
we want to develop the forearm.
The flip is true for TJs andfor so Tammy James we call them
the gymnasts that come femalesbut um, compression is good for
the TJ earlier because that'snot how they got hurt right,
they got hurt from a hyperextension and probably a
(36:18):
dislocation.
So traction and and uh,traction and um compression are
not inherently the bad thing,but traction is a lot of stress
on the flexor pronator mass,which is a lot of stress
probably around the elbow joint.
So I tend to progress thecompression side of Tommy John
UCL rehabs a bit faster thanearlier, than traction, whereas
an OCD it's traction notcompression.
(36:41):
Okay, yeah, so probably aroundfour months.
I would say they're both insome way shape or form going for
it.
Okay, sounds good.
All right, we'll leave it at 30something minutes.
We're close.
We're close.
Speaker 1 (36:55):
Yeah.
Speaker 2 (36:57):
So this is the second one.
So, people, if you enjoy this,let us know if there's topics
you want us to cover, like chatabout.
That might be.
A cool thing too is to not onlybe a brain dump from Aaliyah
and I what we have going on, butif there's stuff that's on your
mind that you want us to chatabout, we can do that.
So we'll see you guys.
I don't know what the next onewill be, but whenever we do it,
(37:17):
we'll see you guys.
Then See ya.
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