Helping Athletes With Acute Injuries: Key Rehab Strategies with Dan Pope

Join The Champion Sports PT Mentorship!
https://mikereinold.com/champion-sports-physical-therapy-mentorship-online-course/

Unlock the secrets to effective acute sports injury management with our special guest, Dan Pope. Whether you're a clinician, physical therapist, or athletic trainer, this episode is packed with key strategies for navigating the first month post-injury. Learn how to reduce pain and swelling while safely guiding athletes back to their game, and discover how mentorship programs can sharpen your skills for providing top-notch care during the acute phase.

In a world where every injury is unique, understanding the rehabilitation journey from acute to subacute phases is crucial. We share a compelling case study of a 15-year-old athlete with a lateral ankle sprain, highlighting the power of proper diagnosis, patient education, and movement in recovery. Dive into the psychological aspects of injury rehabilitation, exploring how tailored communication can empower patients and their families to feel in control and reassured throughout the process.

Navigating long-term rehabilitation requires a delicate balance between immediate athletic desires and future well-being. We delve into the importance of educating athletes on the risks of returning to competition too soon and discuss the strategic approach needed for post-operative shoulder and ACL rehab. From understanding surgical protocols to integrating strength and conditioning principles, this episode provides a comprehensive guide for clinicians aiming to support athletes in achieving long-term success and health.

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Episode Transcript

Speaker 1 (00:13):
Hello everyone and welcome back to another episode
of the shift show, where mynumber one goal is to make it
the tools, ideas and the latestscience to help you change
gymnast lives.
My name is Dave Tilley.
Today in the podcast, myselfand my good friend Dan Pope are
talking about what do you do inthe first maybe you know, one
day to one month of a very acuteinjury?
I think this is an area of thesport and kind of all of sports

(00:34):
which is really overwhelming,because as soon as you get an
injury or somebody that you'reworking with gets an injury, you
guys just both want to go awayas fast as possible, right?
So what can you do as a newclinician, maybe a physical
therapist, athletic trainer, achiropractor?
What can you do in the firstcouple days to couple weeks to
help reduce the swelling, thepain, get so much strength back
and get somebody back on theirfeet and back into their sport
as quickly as possible but assafely as possible?

(00:55):
Okay, so Dan and I talked aboutsome really good examples of
kind of generalized care, butalso, you know, post operative
care, of how do you helpsomebody when it's really
overwhelming for a new grad andreally all this is wrapped up
into one of our big mentorshipgroups that's actually starting
right now.
Huge module that people ask usfor is what can we do to help
these people right away and getout of pain, get their strength
back up, get off the crutches orhelp somebody get back to their

(01:15):
sport as fast as we can?
So, inside the mentorship groupwhich is actually launching
right now, if you guys want tojoin that cohort you're a PT, at
chiropractor or someone whojust wants to learn about
clinical care head down to theshow notes and jump in.
It starts January 6th.
Myself, mike Ronald and DanPope are doing the Champion PT
Mentorship.
Pretty much just like how wetreat, how we approach things,
all our exercises, our manualtherapy, tricks, all that kind
of stuff.
It's a six-week cohort.

(01:36):
Super successful in the firstone, so we're running another
one in January.
But this is one chunk of theentire mentorship.
We talk about the acute phase,the middle phase, the advanced
phase, the return to sport phase, and we figured that this
episode on the acute phase wasreally helpful because a lot of
people are going into theirseason now and they kind of want
some clinical pearls and someclinical wisdom.
So, again, if you want to jointhe mentorship at six weeks,
probably one of the best thingsyou can possibly do as a new

(01:56):
clinician.
Offer tons of episode Q and aright to us.
So head on down to the bottomshow notes and check that out
and, if not, just enjoy theepisode.
I'll see you guys.
Sweet, we're alive.
Dan, my man was shaking.
Not much man Pumped to be hereLong time.
No see, six hours.
Yep, it's been a while.

Speaker 2 (02:12):
I miss you tremendously Um reunited soon,
it is?

Speaker 1 (02:16):
Uh, I actually did think about this this morning.
It actually.
It has been a while since we'vetruly been on each other's
podcast, minus like Mike's so itbrought me back to the glory
days of a pre power monkey in2014, when we were doing morning
podcasts over like kipping,pull-ups and handstands.

Speaker 2 (02:32):
Yeah, it's kind of funny because we used to hang
out online a lot more and nowthat we were together, I feel
like we just forgot about that.

Speaker 1 (02:38):
I just see you at the treatment table next to me.
Other than that, never online.
Um, yeah, I think many peopleare familiar with you from your
podcast and a lot of our worktogether, but the very fast
summary is that Dan and I haveworked together for probably
like eight years now at Champion, I think.
We met online via podcastingand the kind of pre-dawn of
online education and PT, andthen Dan got me a job at Power

(03:01):
Monkey.
I got Dan a job at Champion andwe've been homies ever since,
so it works out well.
But now isn't it crazy to thinkthat eight years later, we're
doing the mentorship with Mikeand it's a regular thing In grad
school?
Dave would have thought thatwas pretty ridiculous.

Speaker 2 (03:14):
Yeah, it is kind of crazy.
It's cool to see how far we'veall come over the course of time
.
Yeah, a lot of my success isdirectly responsible to you,
dave.
Kind of crazy that is.

Speaker 1 (03:23):
That is very.
That's probably the mostinaccurate statement I've ever
heard, but I'm flat I don't knowman, I think it's true, not at
all.
Um.
So, on these lines of stuff, Ithink, uh, we have the the
mentorship is going on right now.
That's why the podcast is kindof being uh put out right now
around christmas.
But I think I actually wantedto do this podcast not only for
the mentorship kind of likeaspect, but also because I just
think a lot of people areentering seasons right.

(03:43):
So, like I know, gymnastics ispicking up is like, uh, winter
seasons are picking up, springseasons are picking up, and
pretty much the first thing thathappens when somebody gets an
injury and comes to champion ifit's, if it's bad enough, where
they need uh help the firstthing they ask is when can I
play again?
Like it's funny to think about.
Like I actually tweaked my backlast week and I was like, as
soon as my back hurt, I wantedmy back to not hurt and I wanted
to go back to lifting.
Like it instantly was like I'mover this and I want it to not

(04:04):
happen anymore.
So I feel like that's the themost common thing we get from
people.
They come to us, they, theyhave trust with us and they
essentially like, how do I getback?
Right now I can't walk or myfoot hurts like how do I get out
of this right now?
So I feel like a lot of peoplecould benefit from this podcast
people that are in the clinic,that are sports bts or ats
helping these athletes that arereally trying to get back on the
field fast, but also theathletes themselves.
It's probably good for them tounderstand you know this upfront

(04:26):
first maybe what six weeks ofan injury and why it's so
important to kind of nail this.
Would you agree?

Speaker 2 (04:31):
Oh, yeah, for sure.
Um, tremendously important.
It's going to vary a lot basedon the injury, so I know if
you're going to ask specificquestions, but I agree with you
Totally.
People are always freaked out.
I mean, I just kind of tweakedmy knee the other day and it's
funny because, like the, thepsychological tailspin the
athletes go into immediatelyafter an injury is terrible.
And like for someone like mewho's washed up right like I'm

(04:51):
not competing anything, I justlike my fitness a lot when I get
hurt, I still have the sameproblems, the same things going
on in my head.
And it's funny because you know, I'm logical, rational or at
least I believe so, and I haveall this information about how
to rehab these things, but Istill have that freak out.
You know, just kind of like anatural reaction that goes off
in my head and every otherathlete and it's probably way
worse because they probably havea lot more riding on their kind

(05:13):
of sports and athleticism thanI do at this point in my life.

Speaker 1 (05:16):
Yeah, exactly, and I think we dig into it.
I think that's a really goodplace to start is.
You know the cohort last timewe had we asked them or, I guess
, asked them but also justgathered information about like
what do you need the most helpwith?
We asked them and likeliterally 75% of the people were
on the very ends of thespectrum.
Right Half half these peoplesaid, um, I don't feel
comfortable with the last phasesof rehab when someone's like
not really in pain, they're,they're, you know, more or less

(05:37):
better, but they have no ideahow to safely get back to their
sport.
And we covered that on Mike'spodcast, which is out.
But I think the other large,overwhelming majority said like
you know, I don't really knowwhat to do with someone who's
super acute, who like literallyjust got hurt, and maybe now
they're in a cash based practicewhere that person's coming to
them first instead of a doctor.
But we see a lot of people whoare literally like the next day
after an ankle sprain day topost op ACL, you know, very

(06:00):
acute stuff.
And I think for us maybebecause we just have more time
in the trenches it's not asintimidating.
But I do remember being a newgrad and like a post-op shoulder
repair like was one of theworst things to see on my
schedule.
I had like anxiety attacks.
I was like man, there's so muchI could possibly screw up and I
don't know what to do and Idon't want to hurt this person.

(06:22):
They're in so much pain.
Is it overwhelming for you knowthe pain part of it.
Is there a lot to know Like?
What is your thoughts from justyour experience?

Speaker 2 (06:29):
Yeah, I think there's a bunch of those.
I think, as a new grad, one ofthe things at least was floating
around in my head is thatbasically, this person's coming
in, they've got a serious injuryand obviously it's the PTs or
the clinician's responsibilityto do a good job, or next
several weeks to months, rightand the clinician doesn't feel
like they have all the skillsthey need to do a great job and

(06:50):
because of that there's a ton ofanxiety, fear, right.
You don't know if this is goingto be a good experience, bad
experience?
Is this person going to seethrough my lack of knowledge and
see that I'm green, see that Idon't really know what I'm
talking about?
That type of deal.
And I think two things.
It's not just a lack ofknowledge, it's lack of

(07:11):
experience, and I see this allthe time with the students that
we work with at Champion.
So, essentially, someone comesin and they've got, let's say,
knee pain, and I'm working withthe student, we're doing the
evaluation, and they go throughthe entire evaluation and I'm
like, dang, you know she's doinga great job.
This student is actually likeknocking out of the park.
And then we get to the portionwhere we're going over the
diagnosis, I'm like, oh, what doyou think is going on?
And the you know the student islike I think it's a meniscus

(07:33):
injury.
I'm like, yeah, it definitelyis like you did a good job,
right?
So people just don't have theexperience and the reps to to
know that what their skills areactually accurate, right, and
every and every once in a whilepeople go down the wrong pathway
, for sure, but I think it's um,not having the knowledge is
part of it, for sure, but thesecond part is just not having
experience and the confidencebecause they haven't had those
reps over the course of time.

Speaker 1 (07:52):
So yeah, I totally agree, and I think you know,
kind of thinking back to maybethings I was worried about or
things that I also see instudents too, as well, as I
think when you're in the frontpart of your career, you don't
know what normal is from thatexperience, right.
So like I don't know, I mean, Ithink, probably back pain I've
treated a thousand people forback pain.
When somebody comes to me withlike ripping, acute sciatica,
I'm like I don't want to say I'mnot alarmed, but like I'm like

(08:13):
I know what normal is.
You know I'm like, oh yeah,thanks man.
Like you know positions andfeelings and whatever.
So for me, now that I seesomebody comes in, I feel pretty
comfortable telling that personabout, like here's the expected

(08:34):
timeline, like this is actually, excuse me, very normal.
Like it's it's part of theprocess.
Like I know it's not great.
But I think when I was a newgrad because I didn't have that
frame of reference around howlong it takes, what to expect,
what's normal versus what's notwhen somebody came in with acute
back pain, acute shoulder painor like possibly, you know, an
ACL injury, I kind of freakedout internally because I was
like, oh my God, I don't reallyknow, like, what to do to help

(08:57):
this person.
And dovetailing off of that, Ithink I was doing too much when
I was in the acute care.
If I'm being honest, you know,I think I was trying to fix
everybody with these magicpotions of exercises or whatever
, when in reality, you knowsomebody who is in that really
acute phase it's just going totake time and like yes, there's
things you can do to help thatperson, but there's no magic
bullet for making someone's painjust dramatically go away or

(09:17):
completely away after a biginjury.
So, yeah, I think maybe just mypiece of advice is like don't
be afraid to just be okay withthe uncertainty of not knowing
how long this is going to be.
And also just like you don'thave to do everything on day one
or day two or day three, right?
Like sometimes you make thatperson worse by doing too much.

Speaker 2 (09:34):
Yeah, I agree with you.
You know you gotta, you know,rely on your skills and be
confident and learn more overthe course of time and you'll
get there.

Speaker 1 (09:43):
The uh.
The other piece of it that Ithink we should probably touch
on and I can do real quick, islike there's there's phases of
rehab that I think are reallyimportant, that people don't
realize you have to go through.
So this acute phase, thesubacute phase, maybe together,
like six weeks, like I said,more or less with injury, but
like essentially you have to gothrough that like initial
healing and we maybe four weeksif it's less of an injury, but

(10:04):
the intermediate phase, you know, getting back to just normal
human life.
Can you walk, can you drive,can you, can you do all things.
Then generally be athleticagain, you know, and then
generally go back to your sportagain.
And I think when you tellpeople in the very beginning
that that road is in front ofthem, they don't get as worried
when they're not weeks in anormal healthy person, and then

(10:25):
maybe I'll get back to all thefun things that I want to do.
When you're in that verybeginning phase are there
educational things?
You're telling athletes, you'retelling parents of people to
help them, kind of like backaway from the ledge and not have
that spiral you mentioned.

Speaker 2 (10:36):
Yeah for sure, and even take a step further back.
I think that you know,determining what the next steps
are is going to rely heavily onyour clinical examination, right
, and then the knowledge youhave.
And I think it's not just aclinical examination but it's
also that plan of care.
I've been finding myself usingthe word plan of care a lot more
, a little longer, a littlelater into my career as I
educate more and more students,just because A we need to get a

(10:57):
good diagnosis and then we needto know what the next steps are,
right, and that's reallyimportant.
Good example and you justmentioned this is I had an
athlete that's coming in and Iwas treating for a low back pain
15 year old, the cross playerand showed up, uh, I would say
about 10 or 15 minutes late tohis appointment and he had
crutches.
I'm like what the heck is goingon, right, but he just like

(11:18):
sprained his ankle really badly,uh, like you said, and he came
in.
He's kind of hopping around.
He has this like big tournamentcoming up in like 10 days,
right, and I've got 15 minutesto try to like figure everything
out and then like set them on aplan, right, and a couple of
things in my head.
It's like, okay, if you rolledyour ankle, there's a few big
players in my mind.
Um, if it's a lateral anklesprain, this can be very

(11:38):
different than if he has afracture, even if he has a high
ankle sprain, right.
So like it's kind of funny tome because if you have a lateral
ankle sprain, the averagereturn to sport time is like 1.5
days, like most people justlike limp it off and keep
playing.
But if it's a high ankle sprain, that might be, I don't know,
10 weeks or more.
Yeah, there's actually a prettyhigh prevalence of folks to get
fractures in their ankles afterthey have a fall or they twist

(12:01):
their ankle.
So you got to do a really goodjob with examination and I think
that is going to help with yourpatient education.
So we did a auto ankle rulestest that was negative, very
sensitive tasks, so pretty surehe doesn't have a fracture.
And then we did a whole bunchof tests differentiate between a
lateral ankle sprain as well asa high ankle sprain, just
because what's going to happenover those next like 10 ish days

(12:22):
is totally dictated by what wefigure out from the examination.
Fortunately it was a lateralankle sprain.
And what's really cool aboutthose lateral ankle sprains is
like, hey, look, you don't havesomething more serious going on.
We know this is something thatgets better relatively quickly.
We talk a little about thosereturn to sport times.
We talk about how movement isreally important because this
guy just stopped putting anyweight on it and was using
crutches.
We know that's wrong, yeah,right.

(12:43):
So that sets their mind at ease.
We let them know there's like areally fast period of time
where folks get better, um, butyou know there's a very high
recurrence rate that comes alongwith that.
So I think there's a ton ofeducation about what's going on.
Um, I think that the patient'smom was a little bit more
concerned than the patient likethis.
You know, patient's ankle wassuper swollen, right, it was a

(13:03):
pretty good ankle sprain, but atleast in his mind he wasn't too
freaked out.
The mom was a little bit morefreaked out.
But the other part I think istricky for clinicians is that
you have to figure out the typeof patient they're dealing with
within like the first 10 minutesof meeting with them.
This guy was ready to go backand play, had a nop in for his
dad who told him to go oncrutches right, and we probably
need a little bit more of abalanced thought process there.

(13:25):
It's like, okay, this is aninjury, we have to respect it,
we don't have to be fearful ofit right, we know what it is.
But we have to be smart, likehe wants to go out and just play
, you know, later that afternoonand you get some folks that
they'll have, let's say, a basicinjury that they shouldn't be
that fearful of, like a lot ofankle sprain.
They won't wait, bearwhatsoever and they're super
scared despite what you tellthem.
So I think a lot of that istrying to figure out the type of

(13:47):
person and person and thencommunicate very clearly the
type of injury and then settingup some of those expectations
and giving them a really goodplan of care, good exercises,
expectations, so they feel likethey're now in control of the
situation.
I think that's kind of step onein terms of um, you know the Q
care rehab, which is theeducation, and really good
clinical examination plan ofcare.

Speaker 1 (14:09):
So yeah, and kind of like I think you you mentioned a
really important point is likea lot of these people who are
coming to us are active, theyhave things they're doing, they
want to train, they want to play, and I find that another thing
new grads struggle, whether evenlike the athletes themselves
and parents you said, is notreally understanding or knowing
when is it okay to maybe likepush that aggressively and try
to play in this game or play inthis tournament or you know when
you kind of got to be the badcop and tell somebody that you

(14:30):
know maybe this is not a greatidea to to push back so hard and
to your point.
A lot of it will depend on, youknow, a good clinical exam,
because an ankle sprain versus,you know, a high ankle sprain or
lateral ankle sprain, becauseobviously those are going to
have very different long-termimpacts in that person's season
and career.
Um, but in that beginning, likehow are you determining whether
somebody is like you know, has?
You know this will be a twoweek thing and we don't have to

(14:51):
cancel that tournament in Jerseythat you know your college uh,
people are looking at you for orthis is actually something more
serious and maybe we shouldkind of pull out of that
tournament and wait until, youknow, a month or two months from
now, because that's going to bewhen you're in better fight
shape.

Speaker 2 (15:03):
Yeah.
So this happens a lot withinseason athletes and I think the
common injuries that we see issomething like ankle sprains,
like I just said, but you seethis a lot with like a hamstring
strain injury, a lot of likefield sports out there
hamstrings one of the mostcommon ones, and oftentimes I
tell patients in the first fewdays after this injury that
doesn't give us greatinformation, because most of
these folks feel terrible.
They have a hard time walking,they can't do a lot of their

(15:24):
activities right, and then theirpain usually rapidly gets
better.
So if I have someone who justhad like an ACL tear, complete
tear, I mean obviously that'sgoing to be very different.
Like send you back to thedoctor Like this is something
that we probably are not goingto play through.
There's a good chance you'regoing to need surgery with this.
We need to dial back yourexpectations totally.
But if it's something that Ithink that there is an

(15:44):
opportunity for folks to getback, usually I recommend a
couple physical therapy visitsup front, kind of quickly.
So if I have a patient thatcomes in on a monday or tuesday,
I basically give them a coupleexercises, let's say, for that
lateral ankle sprain, somebalance, some range of motion,
some ankle circles, basicwalking stuff, and then I say,
hey, come back in in two days,because what I gave you today is

(16:05):
going to be very different thanwhat you need in two to three
days usually.
And then usually in that firstweek or so you have a good idea
of how fast this is progressingright, and one of the things
that I do with my ankle sprains,my hamstring strains, is that
we try to push them as fast asthe injury allows us, I think at
least the hamstring.
We have some good research byjack hickey that kind of shows
that we can push these as fastas tolerated.

(16:27):
It doesn't increase theirre-injury risk, right, which is
phenomenal.
Because if I have an athlete,let's say they just strain their
injury or strain theirhamstring, they come in to see
me two, three days after they'veinjured themselves or having a
hard time walking.
I'm not going to sprint withthem, but the next time they
come in I'm going to try to run.
I'm gonna see how that goes.
That goes well, I'm gonna try alittle sprinting.
That goes well, I'm gonna go alittle faster.

(16:48):
Yeah, and essentially we getgood feedback about how they're
progressing um over the courseof time and we try to have a
couple visits leading up to thatbig competition.
Like you said, there's thateducational process of like, hey
, you know there's a risk inthis.
We know that for hamstringstrain injuries same thing with
lateral ankle injuries we isthat the faster we get back, the
higher the likelihood that thisrecurs.

(17:09):
Based on what you're showing mein the clinic, it looks like
you can run, jump, cut, changedirection to everything fairly
well, but there's still thatrisk.
Yeah, and it comes down to thediscussion with the athlete like
how important is thiscompetition?
Yeah, I mean to your, you knowmy, your earlier point and for
my patient, who's 15, that hethinks his competition is like
the most important thing in hislife right now, but long,

(17:29):
long-term it's.
It's really not that big in thebig picture and you don't want
these injuries to end upbecoming a long-term issue,
which we know they can.
So you may want to tell themthat, hey, maybe it is a good
idea to kind of back off, but atthe end of the day it's just I
think it's the patient'sdecision and they can make
whatever decision they want, aslong as they're well educated
about it.

Speaker 1 (17:47):
Yeah, those are really good points and I agree,
I think one of the best thingsabout champion, that I really
enjoy the process is that I feellike we are much more like
consultants or where people whoare like on their team, so to
speak, then, you know, maybe ina, in a in a cash base, non-cash
base setting, where you're kindof just like they come in, they
get rehab, they go home andthey work with athletes year

(18:08):
round.
And we have clients I've hadfor five, six, seven years.
They value our opinion a lotand I think sometimes we're able
to help I don't know what theright word is but just help sway
them or help them see a biggerpicture around their long term
career.
Because you know, you and I andMike have seen people across
literally from middle school tograduating On a scholarship, and
I think it's important in thesesituations is to to, if you're

(18:30):
new to this person is reallygetting an understanding of like
, what are your like short,medium and long-term goals?
Right, like, short-term, I wantyou to play right now, of
course you do too as well.
Right, like, we all want thatfor you.
But medium term is like, howbig and important is this season
If you're a 15 years old, as afreshman, you know that's not
nearly as important.
Your year um championshipseason, when all eyes are on you
for showcases and stuff likethat and then that's not as

(18:51):
important.
As you know, what you tell meis your biggest goal is college.
You know you want to play incollege, you want to have that
experience and especially thegymnastics side.
Uh, I think a lot of the kidscoming in with acute injuries
are panicking because they needto get on the college track or
the radar, whatever, and theythink that they have to compete
in everything all the time.
But having being friends with alot of college coaches who are
recruiting these kids, theydon't want these athletes to

(19:12):
hurt themselves and have thesechronic snowballing injuries
that they drag with them intocollege, right?
So, like, a lot of theseinjuries happen and if you don't
let them heal properly, if youdon't, you know, actually
address a full six monthsurgical repair, you always have
nagging something.
And then now you're a freshmanand you're popping, you know,
ibuprofen every practice to tryto get through.
So it's it's just interestingto me to see someone across two

(19:32):
years or three years you canhave a big step back, like
listen, like this randomlacrosse tournament that you
want to play in because yourankle is is kind of bummed, it's
not really that important ifyou want to play in this huge
tournament later in the year,and I find myself having more of
those conversations than like.
Here are the five bestexercises for your ankle.
I'm not sure if you're in thesame boat or not.

Speaker 2 (19:48):
Yeah, for sure, and I think a lot of this.
I think like Mike Mike Reinaldis a master with this and it's
one of the things I didn't thinkabout too much when I was a
newer grad PT.
Essentially, if someone came in, I was my goal is like let's
get him back as fast as possible, and it still kind of is.
But now I just, you know,listening to Mike and you know
when that comes in, that'spotentially higher caliber,
going to college, maybe pro work, a lot of pro baseball players.

(20:10):
There's a lot of planning.
Yeah, that goes into thedecision making process, right.
Especially if you've gotsomething that looks like you
might need a tommy john surgeryor something has like a year of
recovery.
It's like, all right, let's getthis done now, as opposed to
like being a little bit moreconservative, um, based on the
patient's goals.
So a lot of what you do is verymuch dictated by this long-term
planning process, which, when Iheard Mike talk about this, I

(20:33):
was like, wow, that's absolutelya no-brainer.
I can't believe that I didn'tthink about this more.
So I just find myselfcommunicating a lot more, you
know, with the athlete abouttheir goals and trying to have a
long-term plan that's best forthem, right?
And I think the other one isthat you know, know, obviously
we talk a lot about sports, butI think the other one is very
important is long-term health.
Yeah, so what is the bestchoice for your long-term health

(20:54):
, right?
Kind of, keep on going back inand playing through this.
You know, low back pain,whatever it is.
Maybe you can get through it,you know, be sore, but I think
that probably increases thelikelihood this becomes a little
bit more chronic andsomething's tougher to deal with
.
You want to keep on pushingthrough this pain over and over
again, um, so that you can, youknow, have success in the sport,
whatever it is.
And sometimes the answer is,yes, right, sometimes that

(21:14):
really is the right answer.
But, um, you also might behaving some problems longer term
because of your decision makingthere.

Speaker 1 (21:20):
So yeah, no, I agree, and I think maybe the other
side of this coin to touch onbefore we I want to offer some
like very specific advice oncertain joints that are
intimidating is, you know, thereare definitely times that I
have athletes when they actuallyare in that junior year.
It's, you know, regional levelor national level, championship,
and not fully, but a lot oftheir uh ability to stay on
someone's radar for a collegerecruiting depends on how they

(21:40):
do at these big competitions.
And so, again, I've been on theother side of the coaching side
.
I see how they organize theirrecruiting sheets.
They go to this large nationalmeet.
They're watching 200 kids andyou know more.
More importantly to to to speakon is like they want to see you
compete and do well because youknow if they're going to give
you a four-year scholarship,they want to make sure you're a
good fit for the team.
You can hit under pressure.
So there are times when youhave to throttle through

(22:01):
something that's maybe not themost comfortable, and we've
tried to clear our best of like.
We understand that we're not ata hundred percent, you know.
Maybe we're 80%.
So even last year I had twoathletes that were at nationals
more managing, like rotator cufftendinopathy, one with managing
low back pain.
And you know, we just openlysaid four weeks before, like,
listen, these are the optionsyou can have.
You can do nothing.

(22:25):
You can not compete atnationals and hope that in the
summer are not quite there yet,or you can do all four events
and you can do a fullcompetition.
I'm here to help you make adecision on what you want to do
with your shoulder.
That's more or less where itput.
And we just lay out all thesethings in front of them and they
make their decision.

(22:46):
And this one girl was like no, Iwant to go, I want to push, if
it's.
You know, I would like to tryto do it and we did, you know.
So she got a course on shot,she went through and then she,
she got through.
She still manages things, butin that moment you know that was
a decision that she made and Iwas helping her with.
And I just think it's importantsometimes to remember that you
are a person who is helping thisperson get through their goals.
You are not telling them whatto do.

(23:06):
And sometimes I think in thisacute PT situation, we have a
lot of education and we have alot of like leverage in terms of
like influence on them, and Ithink it's important to remember
that you're serving theperson's long-term goals, but
they ultimately are making thedecision.
You know what I?

Speaker 2 (23:20):
mean, yeah, that really should be it.
You know, sometimes you'refrustrated with the patient's
decision-making, but at the endof the day, it's their life,
it's their body.
They can do what they want andthat's fine.
We're just there to help them.

Speaker 1 (23:32):
Yeah, and I think again, I think we covered a lot
of big-picture rock things here,but I'd like to definitely
spend a couple minutes onprobably the two, maybe for me,
the most intimidating thingsthat I dealt with when I was a
new grad.
So one was being like a post-opshoulder and I think it's a
good way to kind of proxy notonly practical advice on what to
do but maybe more or lesstaking a systematic approach to

(23:53):
joints, right, I think that'ssomething that a lot of people
just don't really do well, meincluding.
That's why I met Mike and Lennyand got more.
But, um, I also don't thinkeveryone's going to have surgery
and need a post op.
But that's definitely the mostintimidating because you know,
if you can do well with thesetwo situations, you can probably
do well with, like the crankycuff that just comes into you.
You know that's like a flare up.
So let's talk maybe about likea slap repair.
So someone you know has abiceps, not a t-dendesis, but

(24:16):
like a slap repair, a labelrepair, and they come to you
three days post-op.
You know, in this giant slingthey're not a happy camper.
They're arguably maybe veryhigh on drugs.
What are you doing in thatfirst appointment to try to help
this person, you know, throughthis very cranky time.

Speaker 2 (24:30):
Yeah, for sure.
Um, I think there's a lot ofthings.
You can focus on one we alreadykind of talked about this, but
talk a little about education.
Um, reiterate if they weren'tgoing over already with the
things that the patient's notsupposed to do.
Right, and I think forsomething like a slap repair,
you have to think about theanatomy.
So, taking even a step back,probably want to make sure you
have a post-op report and seewhat's actually going on within

(24:51):
the shoulder.
If we know it certainly is aslap repair and there was
nothing else that occurred, um,then yeah, we have to make sure
we protect that surgical siteand I think, early on and to be
honest, this is with everysingle injury, I'm always
thinking about this Um, we haveto protect the injury and we
have to try to progress as fastas we can, um, without
aggravating that area right,injuring that area further.

(25:12):
And then we're also trying tomaintain sport quality as much
as we can.
This is tough, right, after youhave a slap repair, it's not
like you do a ton, um, uh, asopposed to, let's say, a rotator
cuff, where we have to be verycareful about activating muscles
around the shoulder, we don'thave that problem as much with
the slap repair, but we do needto protect the biceps, right?
So think about the anatomicalum considerations.

(25:35):
I guess I'll say after a slaprepair.
So the biceps along the bicepsattaches directly into the
labrum there.
That's where the surgery was.
So we have to be careful withrange of motion.
It is going to strain that, sothat's at the bicep.
So if I go into shoulderextension and I also go into
elbow extension, that's going tostretch the bicep probably not
phenomenal.
Don't want to go into a ton ofextension right after this
injury.
And the other one is going tobe any sort of layback, yeah,

(25:57):
overhead activities.
Uh, hopefully you have a goodprotocol to guide you.
If not, I just highly recommendstarting to find some good
protocols and using them andpotentially tweaking them a
little bit, based on thesurgeons that you're dealing
with, and educating the patienton those contraindications.
I think the other piece you'retrying to do is make them feel a
little bit better and improvethat range of motion without

(26:19):
aggravating or injuring the area.
So we do a lot of soft tissueinterventions, which patients
usually tend to like quite a bit.
Makes them feel a bit better,move their arm around, maybe
some very light, some very light, easy joint mobs, that type of
thing, depending on the type ofpost-surgical injury that you're
dealing with.
Um, yeah, that's probably mystart, right?

Speaker 1 (26:37):
yeah, it's, it's boring, yeah yeah, and it's kind
of intentionally why I want tostart with slap, because you
know a good first session isn'triveting, you know what I mean.
Like I think the first post-opof a shoulder or a knee is a lot
of times education, talking,clearing all that stuff.
You just said like how'd youfeel after surgery?
Do you have an operative report?
You know what exactly did youdo?
And I think there's two thingsthat working with Mike and Lenny

(26:58):
really opened my eyes and oneis how insanely good you have to
be with the underlying anatomyto understand these surgeries
right.
So like I really did not have agood in-depth mastery of the
shoulder or the hip anatomybefore I started seeing post-op,
so I was more or less justgoing on what the protocol said.
But there's so many variationsof like how many anchors where
the slap is, do they have abiceps, tenodesis along with
that, and I think it's obviouslyreally good to know that

(27:21):
information to have bettertalking with surgeons, but also
like it just gives you a lotmore confidence inside the
clinic to talk to them aboutwhat's going on.
I think that builds a lot ofrapport.
So, understanding the anatomyand doing that work to really
get in the weeds and readsurgical textbooks and see what
they're looking at and whatthey're working on is good.
The other piece is that youknow you and I both kind of were
starting our career in the verymuch like zoomed out functional

(27:41):
movement, not as joint specificapproach and something like a
surgery really made me go theother way, which is like really
knowing how to just master ajoint, because pretty much
everything from a functionalmovement assessment is off the
table in that.
First you know, you know,couple days like sure could you
do some T spine work.
Of course could you somescapular work.
Of course Could you work onsome hip stuff.
Of course, but there are somany other things that are more

(28:01):
important and in an hour longsession and a post-op slap then
you know a hip hinge and somethoracic spine work.
So it's just important toremember that you do want to be
really good at treatingindividual joints, because
people have surgery, people haveinjuries that are not going to
fit that kind of functionalmovement bill.
But yeah, I think the thingsyou said, like education,
understanding the surgery rightand making sure they have a
protocol protecting them fromthemselves, because they don't

(28:24):
really understand how maybereaching in the backseat is not
great for their shoulder whenthey are in a sling Right, but
the other thing it.
Maybe reaching in the backseatis not great for their shoulder
when they are in a sling right,but the other thing it's like.
You know, people poo-poosometimes like manual therapy
and heat, but like, of course,exercise is what we want people
to get to.
If manual therapy and heathelps that person exercise more
comfortably, along with, maybe,pharmaceuticals, if those three
things can dramatically reduceyour pain so you can exercise
more comfortably, well of courseI would like to use that, you

(28:46):
know.
And ice too as well.
Ice post-op sometimes is like avery helpful pain management
tool.
And, uh, I think you don't wantto, you know, throw the baby
out with the bath water.
As I say that just because acouple of studies showed that
manual therapy or icing is notgood, we're never going to use
those things ever.

(29:06):
And now you have this person infront of you who's in a ton of
pain't sleep, you know, yeah forsure.

Speaker 2 (29:12):
Um, and to your point about the functional movement
thing, I think, um, and we wesaw this a lot in our last uh
cohort for the, the mentoringprogram but essentially early on
I you know you as a physicaltherapist.
I think especially for physicaltherapists like we are, where
we want to do a great job, we'retrying to do as much as we
possibly can to help that person.
Yeah, I think that's tough inthe early stages of rehab

(29:32):
because you can't do a whole lotand you're more lines of just
kind of trying to protect thisjoint, improve range of motion,
sometimes visit one.
You have contraindications forrange of motion and essentially
they get to those super easy.
You're like I don't even knowwhy I'm doing range of motion
anymore.
You're like I'm at the limit ofeverything you can do.
Um, and that feels bad becauseit feels like you have to do
more.
And what I kind of did early onand what it sounds like a lot

(29:55):
of other folks are doing,they're probably advancing
people too fast or doing alittle bit too much early on,
right, especially aftersomething like a rotator cuff
repair where we we really dohave to protect that thing a
little bit more.
So early on and I learned thisfrom from Mike.
Mike again, he's like if yourrehab is boring, that's, that's
a good thing.
Yeah right, you don't want tohave these ups and downs all the
time like, oh my shoulder'ssore, oh, it feels better, oh,
my shoulder's sore.

(30:15):
You kind of want to be veryslow, progressive, and if you're
not doing a whole heck of a lot, that's okay.
Yeah right, I do think theproblem is like sometimes
physical therapists get a littlebit, you know, too complacent
and maybe not doing enough.
But for a lot of students thatwant to learn more, I think the
folks we tend to work withsometimes end up overdoing it
because they want to just jam asmuch as possible in there.
It's like whoa, pump the brakes.

(30:36):
This might be a little bit toomuch there yeah.

Speaker 1 (30:37):
So, yeah, very good points.
And another thing I'm just liketrying to think of things I've
learned from mike and lenny.
Pretty much, um, the, I think alot of times what you watch
mike and I do really well isobviously they have so much
experience, they're very wellread the literature, they can
answer questions just on thetalking part alone.
They're relaxing someone,they're letting them kind of
chill out.
This person's extremely anxious.
When they come in they're verypost-op, they're very sore.
So just being in front ofsomeone who like knows what

(30:58):
they're talking about and hasseen this before, it's good.
They're already pretty chill.
But the first thing that mikealways does when he starts with
someone on of motion and likeworks on like the bicep and like
gets them to relax a bit, andthen he like sneaks in some soft
tissue, some range of motion,sneaks in like one measurement.
Then he comes back down, hechills out, he works on the
wrist, and so I think likethere's a maybe more of like the

(31:19):
art side of it, which is likeyou don't have to just lay.
I think it's important for themto realize that like there's a
lot of other things that can begoing on besides just the three
to five pieces of objectiveinformation that you'd like to
get.
Um, and I would just advisepeople to kind of have maybe
five, five or so things in theirmind of like what could I do to

(31:41):
help this person, you know,feel better.
And then also during those fivethings like can I sneak in you
know my range of motionmeasurements?
Can I sneak in some of theother stuff that I need?
Versus just kind of like yeah,I think the knee is probably
more example.
If you just lay someone down,just crank someone in the
flexion, and it's not a reallygood way to start the eval.

Speaker 2 (31:57):
No for sure.
I think the other thing thathelps out and I tried to do this
a lot early in my career and Igot pretty frustrated just
because I didn't get a lot ofanswers, um is if you're ever
having any questions aboutwhat's okay with given patients,
you can always reach out to thedoctor, right?
Um, I think what's veryfrustrating I hear this over and
over again is that a lot of Idon't know.
I don't want to throwphysicians under the bus,
because a lot of them areawesome, right, and you just

(32:19):
have to find them, but, um, somephysicians aren't responsive at
all and if you do hear backfrom anyone, it might be like an
ma and ma's are not bad but ifyou ask for like a protocol or
whether I can do X, y and Z,oftentimes we'll send back the
first protocol that pops up onGoogle that we've all seen
before on, like you know, biceps, tenodesis or something along
those lines.
But make good relationships withthe doctors as best you can,

(32:40):
and then you can bouncequestions off of these folks if
you ever have issues, and aftera while I think that just puts
your mind at ease.
So if you're working with agiven patient, there's a lot of
slap repairs and you see their,their, their post-op slaps a lot
.
You can basically say like, oh,this doc typically wants to
swing the sling for this amountof weeks.
This is the reason why, right,we're going to go through with
this the way it usually goes.

(33:00):
But if you have questions,reach out to the doc.
But yeah, you get an idea ofwhat docs want, and I think that
that allows you to sound alittle smarter to your patient,
which again puts their mind atease.
It also makes you feel morecomfortable too, because when
the patient's asking thesequestions, you have the answers
and you have an idea of why.
Right, and all that stuff justmakes your life and the
patient's life a little bitbetter, I think early on.

Speaker 1 (33:22):
Yeah no, I totally agree.
Um, the other thing I thinkmaybe just to wrap up the
shoulder is there's also thisweird in-between period of like,
okay, they're past theprecautions, or past the like,
the basic range of motion,passively, but like strength in
um, strength and full range ofmotion is very intimidating to
get back, cause it hurts, youknow, or it's like sometimes
it's not the most comfortablestuff.
Um, and I think there's beensome tricks that I've learned
from Mike and Lenny around, likeprogressing people, the

(33:53):
no-transcript motion back,because I feel like for me that
marks the end of the acute phasewhen someone's or subacute,
when someone is more or lessactive range of motion is along
the way and their strengtheningprogram has started.
I feel like, okay, we'regetting somewhere right now.

Speaker 2 (34:07):
So are yeah, for sure .
I think we've talked about thisa lot on different podcasts,
but where I think we're big fansof frequency over intensity,
right.
So early on, like you know, weuse the word strengthening.
But is it really strengthening?
Are we approaching failure?

(34:28):
Are we doing enough to actuallylike make a true change in
strength compared to likesomeone who's actually healthy?
I would argue probably not.
Yeah, we're probably doing isput a little input into the
shoulder, trying to put a littlebit of stress through the
surgical area, maybe to help itheal a little bit.
Uh, we're also trying to getthe muscles back on board,
getting the fire a little bitbetter, restoring a motor
control, right.
So it's it's not purelystrength, I'd say.

(34:50):
Uh, from a strength perspective, we often like to start with
isometrics, very easy isometrics, and we're probably helping to
reduce pain by doing that,getting the muscle used to
firing.
I usually tell my patients tryto do these frequently
throughout the course of the day.
So I you know I understandpeople are busy.
If they do it once, perfect,that's awesome.
But I'd rather see them do it acouple times a day.
If you do this like three timesa day, that'd be amazing.

(35:11):
I tell folks to try to do somein the morning, then at lunch,
then again in the evening, ifyou're able to.
A lot of these folks are athome.
They're not doing a whole heckof a lot in the very early
stages, so they're able to dothat as they progress along, get
back to work and more training,so on and so forth.
It usually gets a little bitharder After we've gone through
isometrics for a little bit.
We start doing some isotonics,but essentially without any load

(35:33):
, things like sideline externalrotation, no load, you don't
have to add weights to these.
We do things like scaption, um,usually in front of a mirror.
Before we actually start someof the isotonics we're often
doing active assist range ofmotion.
So think about using, let's say, a pbc to do your scaption
early on and eventually justgoing with your body weight.
A lot of this is dictated bythe type of surgery that you

(35:54):
have.
So for a slap maybe you'restarting somewhere around four
to six weeks with some of theactive assist range of motion,
progressing to active range ofmotion for another week or two
and then eventually putting aweight in their hands and then
doing more resisted range ofmotion.
And I tend to think about allthe basic motions of the
shoulder.
So basically you have flexion,extension kind of rotation, so
some sort of extension-basedexercise, some sort of

(36:16):
flexion-based exercises,internal-external rotation.
And then we start getting morefancy with, let's say, scapular
exercises, a's, t's, y's,starting with easier partial
range of motions and progressingto larger range of motions over
the course of time, neverreally going heavy or pushing
through pain, just listening tothe body.
And if you're not feeling asthough you're progressing as

(36:38):
fast as you should, again justreach out to the docs they have.
I'm not really happy withthings, how things are
progressing.
And they may say this happensso often that you're a little
concerned or at least it doesfor me with the patient's range
of motion and you say, hey,let's, let's have you call the
doc and just see what's going on.
And doc's like you're fine,just keep going.
You know what I mean and that'sfine.
But sometimes it's not.

(36:58):
So if you are concerned, thensend to the doc and they'll let
you know if they are actuallyconcerned.

Speaker 1 (37:03):
Yeah, no, that's great and I think I think that
highlights very well how youknow it's.
It's a lot of things it soundslike, but it's more or less very
straightforward, right, likethe session of, uh, touching
base with people, hands-on work,you know, heat, soft tissue,
passive range of motion on theirown, and then a handful of new
exercises that are very basiceither modifying, so gravity is
not fully involved Like asideline flexion, I think is a
great example progressing to ano weighted flexion and

(37:25):
progressing to a, you know, uh,or a dollar assisted to no
assisted.
Um, you know that progressioncould take two weeks on its own
because, again, we're not tryingto jump these hurdles day by
day.
Right, these are like twice aweek, three times a week.
Maybe we bump things up, butthese people are trying to just
do this multiple times a day andI think that the strengthening
progression looks very not sexy,you know, as the old way to put

(37:47):
it.
You know, of course we want toget in the gym and do dumbbell
snatches, but like the first 10weeks I would say of like a slap
repair or like that is veryuneventful and it should be
boring, right, like to yourpoint with Mike, it's like if
you're doing it well, there'snot these big flares, he's not
these big setbacks.
It's because you're just slowly, just snail crawling along,
hitting all these milestones andthere's no, like giant, you
know, the heavens open up andall of a sudden your shoulder

(38:08):
works great.
And I think taking thatapproach is the opposite of what
I Can.
We bump the weight up now, likeno, just slowly, boringly, do
three sets of 10 of theseexercises and you'll wake up.
You know, two weeks later myshoulder feels pretty solid.
You know what I mean.
And I think that the same istrue for motion, as you said,
which is like I'd rather seesomebody do, you know, three

(38:31):
bouts of 10 to 20 reps of theirrange of motion throughout the
day to tolerance than you know,just crush themselves once or
every other day and it kind oftransitions well to the other
joint.
I think people have a lot ofintimidation with which is the
knee and like if we take like anACL, uh, uh, reconstruction,
for example, um, that's a veryintimidating thing, cause
somebody you know we would seepeople day one post-op, like

(38:52):
literally like the next morningafter they have surgery.
It's like swollen and crankyand angry.
You're unwrapping the gauze forthe first time.
So I think it might be good forus to kind of go through a
little bit of an approach to theACL, to kind of like wrap
things up here no pun intendedand kind of offer people some
solutions for like a checklistbased approach that might be
different than the shoulder,which is, you know, I think
there's a lot more things toconsider in the knee than the

(39:12):
shoulder for what you can dopost-op.
Um.
So yeah, what are your thoughtsthere?
What are your thoughts on thefirst maybe one to seven days of
an ACL or a knee injury?

Speaker 2 (39:20):
Yeah, so I think it's pretty similar to the shoulder
in the sense you probably wantto post-op report and think
about the mechanisms of injuryfor, let's say, an ACL.
Sometimes you have meniscuspathology with it, sometimes you
have some MCL pathology alongwith it, right?
So I think a lot of it isreally going to depend on what
they're actually seeing and thenhopefully you do have a
protocol that comes along with asurgeon.
Be awesome if you had arelationship with that surgeon

(39:41):
as well.
Just have some expectations,right, because you see different
things.
Like we have um.
Dr ramappa locally hasdifferent protocols based on the
graph that he uses, right?
So he has people with, like nonweight bearing or partial
weight bearing, up to like fourweeks after a cadaver acl
reconstruction with the reasonbeing is that they just
basically take longer toligament, is it?

(40:03):
Ligament is eyesligamentization process takes a
bit longer.
I don't even know if I'm sayingthe word right.
I like that sounds good yeah, sohe will actually have
non-weight bearing longer forthose folks, despite them
feeling better.
So you want to try to have arelationship with a doctor if
you can make sure you have agood protocol.
And then I think the earlystages you're just trying to set
their mind at ease a little bit.
So with that patient education,talk about any sort of

(40:24):
contraindication they may haveif they have a meniscus repair.
There might be some weightbearing restrictions, so on, so
forth.
Right, and I think early stagewe're trying to work on a little
bit of range of motion.
We're trying to get that quadback on board.
Those are kind of the big onesin the first, like week or so.
So maybe we're thinking aboutthings like quad sets, maybe
we're using things like an MES.
We're doing a lot of ice icepotentially to get the swelling

(40:48):
down but also to reduce some ofthe arthrogenic muscle
inhibition.
Maybe using things like tens.
Tens has a good research toshow it helps with that as well.
Again, frequency over intensityeducating patients on the
importance of frequent range ofmotion throughout the course of
day a couple of times a day.
Quad sets, straight leg raisesa couple of times a day, every
single day, but not getting toofancy, you know, yeah, yeah
exactly.

Speaker 1 (41:08):
And I think a good, maybe reference point that I
help students with is ifsomebody is not surgical and
they're just coming to you forlike help on a general diagnosis
in your eval, you're trying tofigure out what are three
competitive diagnoses that Ihave and how can I maybe rule in
or rule out which one it is,whereas in this situation of a
post-op, I kind of I don't say Ithrow that out the window, but
like I know they have an aclreconstruction, I don't need to

(41:29):
figure that out.
I switch into like a checklistmode like what are the things
that I have to know or they haveto know to get this to go well?
So, like you know, measureswelling and then how do we help
with swelling?
You know a knee sleeveelevation.
You know range of motion Okay,uh, knee flexion and extension,
hyper extension props, maybepatellar mobility and then some
passive range over the edge andthen, to your point, strength

(41:51):
got to get the quad going again.
So what can we do for that?
We can do quad sets, we can dosome STEM right, and then maybe
some gait training and somebasic ADLs if they're not
comfortable in their crutches.
Like it's more or less like inchecklist of like all right
swelling, range of motion, painmanagement, strength and daily
life, like gait and or ADLs andlike, again, that alone.
If you just follow those thingsand progress people based on

(42:12):
the protocol and what theresearch has available, it's a
boring six weeks, you know,until you get to the point where
you're unlocking their braceand you're doing some more fun
stuff.
But, um, it's not glamorous.
You know, I have two ACLs rightnow.
They're literally I saw post-opday one and they're eight weeks
out.
They're very boring.
Visits they're fun, but they'rejust, they're not exciting.
Right, it's likeful.

Speaker 2 (42:28):
Yeah, it's funny when they come in like post-op day
one because then you see themfor like three weeks and you're
like oh man, it feels like we'reat three months, but it's not
Like you're still three weeks.

Speaker 1 (42:52):
Like you still need to go slow.
Yeah, yeah, exactly, cool, yeah.
So I think that the murkierpart of particularly like knee,
maybe hip, uh ankle, is likewhen you know doctors sometimes
are very loose with prescript,uh they're, they're uh weaning
off of crutches, weaning off ofboots, weaning off of braces, so
, like you know, no-transcriptshoe on and walk while limpy,

(43:27):
cause my foot's real stiff, likewhat do I do?
Um, what are yourrecommendations?
Cause to me that transitionedsomeone into like the
intermediate phase when they'reoff all of those things.

Speaker 2 (43:34):
For me, yeah, I think you know, I you know for the
meniscus and a little bit of ACL.
I've done some like literaturereviews and I think in terms of
like the braces and when you'reallowed to like weight bear
without it versus with it, andthen you know, limiting range of
motion, a lot of this stuff isa little bit more subjective.
Unfortunately, I don't think wehave great data to say like, at

(43:54):
this point you're allowed totake the brace off or go from,
you know 90 degrees full rangemotion, knee flexion.
So I I usually just throw itback at the surgeon, right, I do
think a big part of that isgoing to be dictated by the type
of injury that the patient had.
Let's say they have like aposterior medial meniscus repair
, bucket hangover, tear repair,then I'll probably be a little
bit more cautious with my rangeof motion and range flexion,

(44:15):
just because we know it putsmore strain on that area.
Um, but oftentimes I'm I'mallowing the surgeons to make
those decisions and if I'm everconcerned that I think the
surgeon is limiting thepatient's ability to progress
because the specific nature ofthe rehab, I'll just reach out
to the doctor and say, hey, isthere a reason why we have this
for so long and patientsexperiencing this and you know,
more often than not the doctorsas long be like, oh yeah, we can

(44:38):
definitely kind of progressforward.
That's a good point.
Like, yeah, let's, let's changethis.
But I'm usually throwing itback to the doctor.
But I will say that oftentimesphysicians will sometimes, I
think, give the patient badinformation, right, and I think
the thing to keep in mind isthat patients really look up to
surgeons, right, but physicaltherapists tend to spend a lot
more time with their patientsthan the surgeons.

(45:00):
I can't tell me how many timesyou've had a patient that was
like non-weight bearing, right,uh, because I had a fracture.
You get six weeks.
All right, take the boot off,you can just play your sport.
Now it's like whoa, this personhasn't put weight on this.
They're walking like sideways,like they look terrible, like
the patient has this expectation, like I can go play right away,
yeah.
So I think a lot of it reallydepends on, you know, the
specific injury and how theylook right afterwards and just

(45:21):
being more reasonable abouttheir progressions back to sport
, despite what maybe the doctorhas to say.

Speaker 1 (45:26):
You know, yeah, so your input as a physical
therapist is valuable, you know,to kind of trust your gut too
yeah, yeah, absolutely, and Ithink you know maybe my, my
parting advice on this is thisis why the the starting point of
like talking about those phaseprogressions and how you have
four phases and you know it is abit time-based with when you're
safe to load, but also it'svery much milestone based, like
we have to hit these milestonesin stride and smoothly in order

(45:47):
for us to move to the next one,and sometimes that takes one
week, sometimes it takes threeweeks, right.
So allowing someone to havethat upfront education.
But also on the more practicaladvice is, I think a lot of
times with braces and the bootand like crutches, is patients
and doctors again sometimes justare all or nothing.
And so almost every patient Ihave like, if they're cleared to
get off their crutches at fourweeks, like all right, we're

(46:08):
going to go at school.
I want you to bring two, youknow, and do two, and then at
lunchtime you can drop one inthe nurse's office and just go
with one the rest of the day orschool with two crutches.
And at home let's do one, right,just to make sure that if you
do hit a snag, you know, you canjust sit on your couch, you're
not in the middle of class,you're going to walk around, um,
and I think that helps peoplekind of wean off that kind of 50
, 50 day and then the same thingwith boot, like you know, like

(46:36):
at school, where, based on howyou feel in the moment, wait to
see how you feel the next day.
You know all these things arealmost always a hangover effect
where if you push it too muchyou wake up the next day and
you're really sore.
It doesn't come back down to abaseline level.
So having that maybe like 50,50 wean off progression, then
also having that day afterprogression helps people kind of
have a lot more guidelines tofollow versus just like, all
right, six weeks, I'm done withthis.

Speaker 2 (46:57):
Yeah, that's a really important point.
I know we talk a lot aboutprotocols being important.
I really think they are.
You have to make sure you havea good protocol, but the speed
at which you progress is alsobased on their symptoms, and I
think the symptoms look out for,like you already said, this was
basically pain, swelling andrange of motion.
If you have someone where youintroduce something new and
you're allowed to at this point,based on the protocol, the next
day they're more swollen andnow they're losing range of

(47:18):
motion.
That's something we probablyhave to be cautious with and
maybe pull back a little bit thenext visit so you can use that
as a bit of a guideline.
Uh, along your, along with yourprotocol, together to make good
decisions and your patientsyeah, no, it's great.

Speaker 1 (47:30):
I think it's a great point to uh wrap up and maybe
not just like keep throwing morepeople.
But, um, yeah, I think the timethis podcast is coming out, we
we are very close to startingour second cohort, which is
pretty insane because the firstone I did not think was going to
have a lot of people and we hada ton of people and I'm happy
to hear that people enjoyed it.
But I also think that werevamped a lot of stuff in this
one that's probably going tomake it more effective.
So, on the acute care and thereturn to sport stuff, it's like

(47:53):
what two of six or eightmodules that we have on this
stuff.
So, um, yeah, what are yourthoughts on?
Maybe the, the progression tocohort two and things you're
excited for?

Speaker 2 (48:01):
I'm pumped, like you said, we just kind of like threw
this out the first time becausewe wanted to see how it went,
but also we wanted to get goodfeedback and I think we've taken
a lot of that feedback andwe're trying to update this and,
excuse me, make it make it muchbetter, so that the course of
time.

Speaker 1 (48:17):
Yeah, exactly so.
If you want to join a lot ofother people who are signing up,
with Dan and I and Mike, it'sessentially a six week
mentorship.
Where we're going to give youis if you're sitting in the
clinic watching us treat and tryto offer you the best advice
that you know 30 years of adviceor 40 years of advice that we
have.
But I also like this becauseit's a great place for Q&A.
We have weekly comments andquestions.
There's like I just rememberbeing desperately wanting help

(48:38):
on a tough case that I couldn'tlike figure out and I wish I
could just have someone likelisten, like this person's not
doing well, what would you do inthis situation?
And then, you know, have Mikecome back and like I would do
this exercise and try to helpwith this.
Let's see how it goes, becausenot only do you get help for
that person in the moment, butalso that's like you're banking
a lot of future.
What do I do, you know?
And kind of like experiencethat you couldn't get, maybe in
the clinic.
If you're just the one personin your clinic who's grinding,

(49:00):
try to learn more.
So I love the part of ourdiscussion board and the part of
our like help me with thisright now.
And you know, you and I andMike can just jump in real quick
and like, yeah, this is what Iwould do.

Speaker 2 (49:08):
Yeah, for sure, it really is a sports physical
therapy clinic.
And you know, even if you do,because for me, I had a
background in sports, I had abig background in fitness, but I

(49:29):
didn't necessarily know how todo good kind of rehab for those
folks, right, I still needed tolearn how to figure out how to
do strength conditioningprinciples for my rehab patients
, right, like, how do I applyall these things I know about
strength conditioning to aninjured individual, acl
reconstruction, whatever it is,and, uh, I think that champion
has really helped me with thatbecause, you know, guys like
Mike and Lenny have been doingit their entire career and, um,

(49:49):
you know, that was that wassuper helpful for me, so we're
just trying to share the samething for others, yep.

Speaker 1 (49:53):
Yep, Absolutely so.
Yeah, if you want to jump inthe cohort, it starts January
6th.
There's a link down in the shownotes below and you'll see me
and Dan and Mike and we'll bethere with everybody but Dan, my
man.
Thank you for the wonderfulpodcast.
I think that's a lot of helpfulinformation for people to kind
of take with them.

Speaker 2 (50:06):
Thank you, man.
Thanks for having me on board.
I always love it.
We should do this more.

Speaker 1 (50:09):
Yeah, absolutely.
I'll see you on Monday at work.
Yeah, thank you.