July 8, 2025 • 32 mins
We share strategies for managing a busy clinical caseload when juggling multiple patients with different injuries, surgeries, and protocols across various settings.
• Organizing patient information systematically through spreadsheets listing surgical details, protocols, and progression points
• Creating tables to track swelling measurements, range of motion, and strength over time
• Establishing consistent assessment routines when patients arrive for appointments
• Using technology and automated calculators to track progress and compare to past measurements
• Translating complex clinical measurements into understandable metrics for patient education
• Leveraging colleagues' expertise when facing cases outside your comfort zone
• Dividing responsibilities between clinicians to optimize patient care
• Creating documentation systems that allow quick retrieval of important patient information
• Establishing data-driven rationales for return-to-sport decisions with athletes
• Setting realistic expectations about progress timeframes based on research
If you're feeling overwhelmed by your caseload or want to improve your organizational systems, reach out to us on Instagram or email with questions or suggestions for future episodes.
We appreciate you listening!
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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.
Okay, on the same line, I thinkthese three episodes naturally
go together because it's likedan, progression to acute care,
progression to managing abanana's caseload.
So, um, yeah, on the vein of uh, these podcasts come from a
combination of what people askus to help them with and then
(00:27):
also what uh is actively betweena lead and I's brain right now.
We usually chat about stuffback and forth and then I have
an idea.
I'm like sitting in the clinic,I'm like, oh, this would be a
good topic to kind of chat about, or something like that.
So this uh situation is in realtime.
The fact that champion ingeneral has never been busier in
our entire life.
So this time of the year injune where we kind of planned
this for um, all the collegekids are coming home from
(00:50):
schools or wherever and they'reworking out fitness, pt,
whatever, and then all the highschool kids are now out of
school and either finishingtheir seasons or are summer
training with us, and so thatleads to a large amount of
people who have surgeries at theend of season and they come
back and they rehab with us forthe first three months, or they
had an injury during the yearthat wasn't surgical but it was
annoying and they're trying torehab that.
Or people on the strength sidethat are like training with us
(01:12):
and are going back to school inSeptember or stuff, and so, um,
yeah, I don't know whether I'mjust busier than normal or what,
but I posted about this lastweek but I have like 45 people
actively on my caseload rightnow and 25 of them are gymnasts
from all walks of life, fromcompulsory to elite, with like
different schools.
So I have like seven to 10different colleges with seven
(01:34):
people who had surgery fromdifferent surgeons with
different protocols three of thesame surgery, three different
surgeons and protocols like twoUCLs, two ACLs.
It's like a lot to manage and Iavowed them all in two weeks
when they all came home becausethey just all wanted to get in.
So I had like a 30 hour workweek where I did like seven to
eight avows.
And then I remember being likethe next week I'm like well,
(01:54):
this is like a lot to likeprocess where everybody's up and
like what?
Like what do you need?
Like can you strength trainwith the coaches, and they're
kind of like joint programstogether to kind of keep them
going.
So on Sunday I had to spend twohours making a Google doc, which
I'll share, which isessentially like how to organize
my own brain around.
Like these are the patientsthat I have in this particular
(02:16):
gymnastics bucket here's theirsurgeon, here's their date of
surgery, here's their protocolprecautions.
Here's where they're at.
Some did rehab at school beforecoming home.
Here's their notes and whatthey've done with their trainer
or with a different PT.
And like this is what the bigrocks are that we're going to
kind of tackle, because you know, some people are doing great
but some people are still prettysore and pretty struggling and
(02:38):
you know we're trying to scratchour heads about it.
So that's where it comes from.
I don you said, you know, whenwe were setting up these
episodes, that you just got ahuge influx of post-ops and that
you have a lot on your mind.
You know.
Speaker 1 (02:47):
Yeah, I have so many patients right now.
We're so, so busy.
Speaker 2 (02:50):
It's a wicked smart.
Speaker 1 (02:52):
Picking up overtime because I can't, we can't fit
our post-ops in, like that'swhere we're at.
So I have lots of post-opsright now lots of other patients
, so we're I'm in the same boatas you.
Speaker 2 (03:01):
Yeah, yeah, and it's hard sometimes to you know.
You go through waves where somepeople are, you know you have a
chunk of your schedule which islike you did the eval.
You kind of know what's goingon and you have a plan for them
and it's just executing the planand doing it over.
You know two to four weeks andthey're just, I would say,
normal treats quote unquote.
Whereas when someone's surgical, you're adding a lot, you're
changing a lot, you're tweakinga lot, you're progressing people
(03:32):
a little bit, and if you get alittle mixed up, it's really
hard sometimes in a busy day toknow where someone's at, what
they're doing and what happenedlast week when they were sore.
So this system is what I havedone internally like for a long
time and I figured it might bejust useful to share it.
So this is how I organizethings and I maintain anonymity
to make sure I was HIPAAcompliant, um, but these are all
my current caseloads.
So um for gymnastics.
So I have no like handful ofpeople but essentially along the
(03:55):
left-hand side.
These are just like theirinitials.
It's their name when I'm not ona podcast, live with them, but
their uh initials, their name,what level they're working, what
college they're at or whateverthey're doing, whether they're
recruiting or whether they'rejunior or freshman.
And essentially, when I come upto this main thing, I have a
approach of now I can just likeclick people as they come in.
This is based on, like myMonday, tuesday, wednesday
(04:16):
schedule, so Monday throughFriday.
So like these I think like fourare Monday and then, like these
four maybe are Tuesday orwhatever.
But essentially, um, I try touh get the information from them
about, like at a glance, if Ijust look at this really quick,
I know exactly what needs tohappen with this person in the
next visit or where they camefrom in the last visit.
So this situation um, she had auh right ACL reconstruction, uh
(04:39):
, bone patellar, bone grafts, apatellar tendinograph.
She also had an LET on March21st with Dr Ramapa.
So I know that if I have aquestion I can just text Ramapa
real quick or like get an emailchain with somebody else.
Right, notes precautions At thetime when this was earlier, it
was like weight bearing,whatever as tolerated, because
she has meniscus repair orcrutches for four weeks.
(05:00):
Weight bearing is tolerated,brace comes off at six weeks.
She has a six weeks follow-up.
Whatever it is Stitches comeout two weeks, like all those
precautions and protocols andthe things I need to know are at
the top so I can quickly atglance realize what's going on.
And then for me, early post-ops.
But even as some of these caseswe'll talk about, even like not
post-ops that are just far out,that are six, eight months that
(05:20):
have generalized pain, a lot ofthe important stuff comes from
just basics, right Basicswelling, basic joint mobility,
basic symmetrical, pain-freerange of motion, basic pain-free
active range of motion and thenpain-free strength.
So in this girl's case, whenshe's three months post-op right
now, this is really all we'refocusing on right, she's really
just in the middle part of rehaband she just needs to get
(05:41):
strong.
In this particular case she wasthe one we talked about in the
last episode that did have somestruggle with extension.
So I'm like all right, I got tomeasure cold hyper extension
every time she comes in and Iwant to make sure that we get
her at least eight to prevent,like, any serious issues.
And she's strength trainingwith us.
So now it's about we know shehas to strength train hard three
times per week and I want tomake sure that what I'm doing in
my side of the rehab is themore I would say spicy stuff
(06:03):
that is more like dependent onmedical based limitations and
graph choice Right, and then dous, is free to do all the stuff
that I've done before in thefirst three months safely and
that all the extra things thatshe doesn't have on her own.
So BFR, stem, the kneeextension machine I want to make
sure that when she's in, everysingle time she has access to
all that kind of stuff, becausethat's how she's going to get
(06:23):
her quad strength up quite a bitand kind of combat this little
bit of AMI that she had.
So I kind of write out okaywell, I know she had some AMI,
so what are we going to do forthat?
That's a huge impairment.
Oh, sorry, the first part.
So swelling she has a mildamount of swelling still,
mobility restrictions, so selfmobs quite a bit.
She is close but doesn't havefull, pain-free passive range of
(06:49):
motion and a hyper extension.
She's close on flexion.
So it's about in her homeprogram on the day.
She's not a champion, it'sabout got to get that knee
propped up, got to hyper extend,it got to make sure it's all
set, blah, blah, blah and thenalso doing some like knee
bending on her own, some sometowel bending, some quad rocking
, just consistently throughoutthe day.
Thankfully she's not in schoolnow so she has like unlimited
hours where she can do it, butshe had surgery in the middle of
(07:10):
her spring semester for highschool so she was very busy with
other stuff.
So finding times to make surethat she's doing this is really
important, right, and then sothat's it pain-free, passive
range of motion.
She doesn't have full activerange of motion because her quad
is still weak.
So we have to make sure weprogram open chain type stuff to
get that full motion with aknee extension.
And then she clearly doesn'thave quad strength uh,
symmetrical side to side.
Not that I've strength testedit.
(07:30):
We'll strength test her in likeanother month, but she doesn't
have that yet.
So her whole program is basedaround okay, we have to get full
motion in full strength.
And I did a lit review with someof the other guys earlier, but
I just remember looking back onthe research like what is the
best research supported ways tocombat AMI, right?
So ice pre-training is reallygood for 20 minutes, so we were
(07:51):
doing that for a long time, butthe priority is a, not a cyclops
lesion, and not gettinghyperextension loss.
So although she does have AMI,the more important A1 is not
losing hyperextension and thequad will come.
There's many other ways to getthe quad going.
There's not many other ways toget a cyclop to go away besides
another surgery which we don'twant.
So she was doing ice for a longtime until we realized that the
(08:11):
AMI was probably at bay andthat the hyper extension was
kind of slipping.
So we switch her to.
She comes in before her PTtraining session 15 minutes, 30
minutes early, or her strengthsession and does propped
extension for 15 minutes.
Um, and then she comes to mefor PT or goes to do ash and
then after she doesn't like 15minutes at the end too as well,
and then she has another one ather house at home.
So because her quad is weak shecan't actively get her heel to
(08:34):
full hyper extension.
So it's a bit of an uphillbattle to maintain that before
the quad comes back.
So we're trying to combat theAMI with that.
Maybe it would be ice insomebody else's situation.
I have a few other patients whoare not as behind, a little bit
with the quad strength becausetheir surgery was just an ACL,
not an LAT.
So maybe they're doing icebefore.
I have one girl who's like sixor seven months out.
She does ice before just to gether quad really turned on
(08:55):
before she does some advancedstrengthening.
But then also the propextension helps and then
vibration is helpful for AMI too.
So while she's heating um, Itake it off and then I work on
her patellar mobility and shedoes AMI vibration to her quad
to try to activate some of theneural stuff as well.
And then before she shranktrains she has quite a bit of um
foam rolling on a vibrationmachine or something like that.
So that's the most important,like basic steps for her.
(09:17):
And then between me and Duesh Iknow we want to get a full
spread three days of all thedifferent movements she needs.
So I've done step up, kneeextension, split squats and NMS.
Burnout would be a far before.
So Duesch takes all that in hisprogram and, make sure, a whole
body program.
I take on the new stuff whichis a step down, some TKE stuff,
some some spicier, you know,lateral work which is maybe more
on the LAT, and I take that.
(09:39):
And then her home program isjust all the stuff that we
talked about.
So I had to sit down for like 10minutes and work through her
case mentally about like, doesshe have this?
No, what do we do for that?
Does she have this?
No, what does the research sayfor this?
Does she have this?
Yes, okay, ignore that or nevermove on from that.
But that's kind of how Iapproach it is.
I sit down with each case andtry to think about the things
(10:01):
yep, cool.
And then the other thing that Ithink comes along with this is
you get a.
Very quickly you realize thatyour caseload is shotgun across
a whole bunch of differentproblems.
So, um, I don't know how manyof these this was an old one
that I've updated since then butmaybe there's like six or seven
that are at the top here.
So first one, let's see.
So we have an acl bone tenantbone.
She's probably at 10 o'clock,11 o have a uh gymnast who's a
(10:25):
junior in college.
She had an Achilles 10 X andshe has a protocol that did not
come with her the doctor.
Her gymnastics doctor is nother team doctor.
So her other doctor did her 10X, but her team doctor is
different.
So she had a 10 X procedurewith a different person that's
friends with this surgeon to dothe actual 10 X procedure, um,
but neither of them really sentthe formal protocol.
(10:46):
She kind of had a range ofexercises to do and she's going
back to school.
So they were like, yeah, justlike you know, do this kind of
ish for a couple of weeks andcome back and we'll see you.
So I had to talk to a differentdoctor who does 10Xs just to
make sure that we gave her aprogression.
It was like stretch your calfand then do bump things down and
start with, like you know,plantar flexion with a band and
then seated calf raises andwhatever.
(11:06):
So so, yeah, so that was at 10o'clock.
Is this girl with a knee?
11 o'clock?
Is this girl with Achilles?
10 X?
Completely different surgery,different school, different
surgeon.
Same kind of thing.
Do you have swelling?
Do you have your joint mobility?
Do you have your passive range,your active range of strength,
right?
All kind of no.
So different types of uhprogressions for that, things
that I can do with her and thenthings that she's doing on her
(11:27):
own as well in a home program.
And then this girl navicularfracture.
She had a debridement sixmonths ago.
She's going to be a freshman atschool.
Um, she has a handful of thingsthat are really, really good.
But all her pain and her issuescome up when she vaults.
So she uh has going.
She's in her return to sportprogram, she's back to full
gymnastics.
But if she does too many uh,one and a half on vault she
starts to get some soreness ather foot.
(11:48):
So completely different end ofthe spectrum versus the person
who's missing the extensionpost-op week two right.
So for her all these things arefine.
Passive range is good, activerange is good, maybe a little
calf strength deficit, but it'snegligible.
But all her issues come up withsingle leg uh, so single leg ply
work or very high impact, um,two legged power work off a
springboard.
That's where she gets symptoms.
So all her stuff.
(12:08):
One of the strength coaches,mike, does her programming twice
a week.
Um, we have to split all herstuff between the two of us and
also make sure that she'sgetting the right dosage of
workload right.
So she needs to vault twice aweek and not have symptoms the
next day for us to go to threetimes a week.
And also, she has to tolerateall her single leg jumping, all
her eccentric work, all herheavy, heavy stuff and not have
(12:32):
a flare up of symptoms, which iswhere she's at now.
She kind of had a flare up amonth ago, backed off for a week
and like all right, two times aweek.
She was also just doing way toomuch.
She was doing beam and vaultand floor the same day.
She was excited Soers and thenfive vaults and then five layout
step outs and then on that dayyou can't do floor on a hard
surface, nor can you do beam.
So she's at 12.
And then we have a girl who is aslap repair.
(12:52):
She's 12 weeks out of a slaprepair I'm sorry, 12 months out
of a slap repair and she's endstage.
She's fine, free of herconditions, but she has cuff
tendonitis.
She's a long standing cufftendonitis, cuffed in the night.
So she needs, you know,shoulder strength stuff.
I gotta take her numbers again.
I have to do thoracic mobilitywith her.
I have to do injection stuffmid-season.
If it's not going to work out,I have to do some dry needling
right, her home program isdifferent.
And then this girl is sixmonths out of a ucl.
(13:14):
This is the kid who I said uhfell and didn't know his
protocol.
I love him to death.
He's a good kid but he's farout of a triceps repair.
And and then this person's acuff 10.
I mean so like the schedule isall over the place capsular
shift and if I don't put thisstuff out in front of me and
outline this thing, this guy hasa C7 disc bulge, like so
different than the other stuff Iget so overwhelmed and I feel I
(13:37):
feel like I'm doing a bad job.
I think is the only way to doit if I overwhelm myself so much
that I can't remember thenuances of their surgery.
But old me would just be likeremember it all and like work
harder.
Right, but how the hell am Igonna remember?
Is 20 people on this list?
How am I gonna remember 20people with 13 different joints
and 13 different schools and 13different surgeries and surgeons
?
Right, like it's impossible.
So I really support peopletrying to spend, unfortunately,
(14:00):
extra time to map this all out,because every night when I see
them on the schedule, I gothrough and I think about are we
better or worse the same?
Are we moving in the rightdirection?
Did I miss something?
Do I have to read some research?
Like, where do I have to gethelp from?
Do I got to call a doc, likeall that kind of stuff is what I
think about the morning ofbefore I go in.
Do you have any thoughts?
Speaker 1 (14:17):
on that.
Um, I mean I pretty much do thesame things, like generally.
I mean our documentation systemis through Epic, so it's much
more wordy, I guess is the wordfor it, but pretty much the same
thing is.
Like I'm with my post-ops inparticular I'm.
I have so many of them rightnow that is really hard to keep
everything straight, likeremembering, like what their
motion should be.
So I think, doing yourself afavor at the eval and making
(14:40):
sure that you're getting theother side measurements so that
know your comparisons for eachside, especially for motion, and
then also making sure that,like sport wise, for gymnasts
and for other sports, you'rejust writing down everything
that their goals are to get backto.
Like for a gymnast, I'll sitthere and I'll write down all of
their events and like all theskills that they're trying to
get back to and then, like forother sports too, like what
(15:01):
events they do within that sportor nuances that I remember with
the goals that we're trying toget back to eventually.
Um, but then, just like I, Ithink I create like a good habit
with all the post-ops that comein.
Like every time they come in,they warm up, we take all of
their measurements and then weget started.
So it's like a habit of likeevery time we're going to check
and see where we're at, and Ithink it's helpful for you as a
(15:22):
clinician to kind of like getyourself familiar with the
things that we need to beworking on, like, okay, maybe
they weren't missing fivedegrees of extension last time,
but today they are.
So we need to work on extensiontoday, like that kind of thing.
And then also just from aneducation piece for the patient
as well, because they're alsoinvested in their numbers.
At that point too, they're likeyou know, they're tracking
(15:42):
themselves too.
They're like oh, last time Iwas at 98, today I'm at 103 and
they're like get really investedand it's kind of fun.
Yeah, yeah, doing yourself afavor of like keeping good
documentation session to session, so you can really track their
progress, because you might likemiss somebody in the weeds.
If you're not doing that likeyou might you know four weeks
later you're like, oh crap,you're like 12 weeks out and we
(16:02):
don't have this, like why don'twe have this?
Because we, we haven'tmeasuring it or, you know, you
just missed it somewhere alongthe way.
So, just creating the habit oftaking those measurements and
setting yourself up for successand having their protocols like
ready wherever they are, likewherever you're going to plan,
to keep them just like have themhandy so that you know your
dates, like at the eval.
I'll set up like a we I'll setup like a.
We have a little like calendarthing that we have in Excel
(16:25):
where you can like put the dateof surgery in and it calculates
out like two weeks, six weeks,eight weeks, and then like
literally on that eval, if theyhave restrictions, I'll just
write in there.
It'll be like the date andit'll say when they can do this
and the date when they do that.
So it's like really easy for mewhen I opened the computer, I'm
like, okay, we're like threedays away from this or two weeks
away from being able to unlockour brace or weight bearing or
(16:45):
whatever it is.
So it just makes it like easy,accessible.
You don't have to remember allthe things about each person.
Speaker 2 (16:51):
Super helpful.
Yeah, and I think to your pointof measuring things
systematically each time.
Like you know, I didn't mentionit last episode, but like knee
swelling measurements, like fivebelow joint line, five above 10
, 20, like every day you seethem.
For the first three weeksprobably, you're measuring those
middle joint line type ones andyou want to make sure
centimeters are going down andquads hopefully going up.
But like you have to have, Ijust use tables.
I don't know if, like softwareis allow you to do that, but
(17:12):
like I find that if I have liketwo or three tables from the
very beginning, about like thisis a swelling table, this is an
active range of motion or apassive range of motion table
and a strength range of motionor a strength table.
The strength table might notediting because it's not clear.
You can't, uh, strength testsomebody or dynamometry test
someone early out of surgery.
But I keep them in there sothat down the road I can
reference these things.
As you save a note and a new onecomes up, I can see that over
(17:35):
the course of four to six weeksthe swelling has gone down, the
motion has changed and how muchthey have, and then eventually
when you get into, like thethree to four month mark for a
lot of people.
Or if you have someone who'snot post-op and they're just
coming in for a shoulder painand you took their strength
numbers, dynamometry wise, oryou tested their quad and their
hamstring LSI, torque numbers ona dynamometer.
You want to track those monthto month and keep referring back
(17:56):
to those because it showsprogress, it has buy-in to your
point exactly and it's reallyimportant to track those things.
If that's the main KPI or likekey performance indicator is
strength, quad strength, aclwise while you're saying to
someone who's six months out hey, I know you got cleared to run
and clear to do sports, but youhave an 80%.
You know strength differentialside to side.
Um, it's probably not the bestif we start you on cutting
pivoting until we get this LSInumber up, you can kind of
(18:19):
explain with hard numbers whileyou're making that choice, not
like well, I just don't thinkyou should run right now.
Right, you want to have a veryfirm.
You know this is the researchshows us that we want to have a
good 90 plus 95 LSI before weget somebody on very aggressive
cutting.
So let's make a plan in place,let's measure this and then in a
month from now, you know youhave to have a lot of data
behind the decisions that youmake when you're working
particularly with with athletes,and with high-level athletes
(18:41):
because they think you're smart,that's great.
But if you tell them they'renot gonna be able to train or do
a meet or compete or somethinglike that, you better have some
pretty good rationale for whyyou know, and data helps a ton.
Speaker 1 (18:50):
Absolutely.
Yeah, I like I like doing tests.
Tests are great.
It gives me more information.
It gives them more information.
It helps with them buying intothe process of like, okay, I got
to work harder here, or I gotto do more here, or I got to do
more here, or I got to do lessthere.
Like it helps, like trackingwise, just making sure they're
on track and, I think, settingyourself up at the beginning
with the eval, kind of like whatI was talking about, and then,
(19:12):
like when you get to the pointwhere strength testing like I'll
look out like okay, on my table12 months, okay, we're strength
testing here.
And then, based on how they did,I'm like, okay, we're really
behind.
Or, like you know, it's 50%.
Like, okay, we're not going tomake significant gains, but I
still want to test it in likethree to four weeks just to make
sure that we're improving.
And then, like I pick a date.
(19:33):
Each time I'm like, okay, whenare you here?
That's close enough to three orfour weeks from now.
I pick that date.
I tell them, I say, on this daywe're retesting your strength.
So they know, we know if Iforget, they remind me.
Speaker 2 (19:41):
Yeah, yeah, right, exactly, and to that point is
like it's, you know I can'tshare because it's it's like
HIPAA data with champion.
But, um, the best thing you cando is, if you know there's like
certain metrics or things thatyou're going to test for like
knee ACL or for like shoulderstrength dynamometry or for
whatever you want to havespreadsheets and tables that can
help auto punch that, autocalculate that to make sure that
(20:02):
when you put in new data itcompares it to the old data.
They see like, oh, this was mynumber before, here's my number
now.
And one of our students in anin-service where he did it for
ACLs and for like LSI and likequad testing, then somebody else
has done it.
I think Anthony did it for likeshoulder strength measurements,
right.
So we know that, like we wantthe ER, you know, to be at least
66% as strong as the IR, wewant the you know the ER on each
(20:24):
side to be symmetrical.
So if we put those numbers inin a table that's blank, when I
fill in those numbers it autopopulates this is the percentage
of body weight, this is the ERratio, and now they've done it
with the quad stuff too as well.
So we have like an Excel sheetwe make in our Google drive.
It's like all right, this isthis girl's three month post-op
number.
This was how much she weighed,this was how long her shin was,
and then this is our LSI forquad, lsi for hamstring.
(20:47):
Here's our torque angle and wehave all that data in one column
.
And then in another month whenshe tests again, we just fill in
a new data and we can see oh,she went from 71 to 74% LSI.
That's not a huge jump, but sheactually jumped 80 newtons in
quad strength.
So that's a good thing, rightHelps you make sense of a lot of
data and it's very hard tosometimes figure out what is
worth measuring.
But you can be overwhelmed withhow much you have to measure.
(21:09):
But if you find a couple ofreally important things on the
strength side, they do like CMJ10 hop.
You know things like depth dropstuff with with loading from
valve um vault.
But if you have those things inline and you just sit down and
make a table that is repeatable,use over and over and over a
spreadsheet Like you, save hoursof your life in the clinic over
time.
And then quickly, as soon asyou punch the numbers.
You can turn the computeraround Like all right, here's
(21:30):
our numbers are at.
You know we're doing good here,we have some progress here and
like it's it's one of the bestbuying things I've ever done is
giving like involvement in, likethis is what these numbers mean
.
This is why it're good to dothese things, but I'm not
letting you do these things yet.
You know it's like your goalsare this.
I'm trying to help you getthere as fast you can, but
safely yeah, there's a reallycool acl calculator.
Speaker 1 (21:50):
I'll have to find it.
I can't remember the name of itright now, but you can just
like input the numbers.
It's really cool.
Actually.
That's it's one of the newprojects that a couple of
different like pediatrichospitals have been working on
that gives like normative valuesfor kids based on their body
weight, which is cool.
I'll have to find the thing soyou can like link it in the show
notes or something it also haslike fun diagrams.
(22:10):
So I don't really use it thatmuch, because we already have
like our flow sheets for ourdocumentation and like comes out
, pops out into a table, um.
But this one has cool likediagrams of.
It will like show you in a piechart, like okay, you're here
and you need to be here.
Everyone else is here andyou're like you got here.
So it's like kind of fun forlike an educational piece from
like for the kid or the patientand the family so you can kind
(22:31):
of see like okay, this is whereyou are, this is where you need
to be, you know, like helps them.
Yeah, you know where they are inspace.
Speaker 2 (22:37):
But yeah, and the end advice I always give people is
like I think we talked about itwith dan maybe is like people
they're, they want to know thatyou know a lot but they don't
really care about the veryin-depth, nerdy LSIs with torque
ratios and stuff.
They really don't care at all.
Like they.
Some people are really hardcoreand they want that, but most
people just want to know am Imaking progress or not in the
(22:57):
things that matter?
And what do I need to do?
Or like what's the plan Right?
So the analogy I always give topeople is making a psi change
at the level of the belt whichcauses hydraulic.
I'm like dude, I have no ideawhat you're saying.
That's what's happening whenyou explain to somebody this
in-depth lsi with torque ratiosand the patellar tendon graph,
(23:20):
like I'm looking at this guy.
I'm like okay, can you, can wefix it?
Like I just don't want to dieon the highway.
Like how much, how, how long doI need to leave my car here?
What do I have to do?
And like and then he'll tell melike all right, leave your car
overnight.
And then when you drive on theroad, you know, do this and this
and tell me if it clicks, I'mlike sounds good, I'll see you
in a week.
You know that's all they need're talking about.
(23:49):
This is research-based.
There's data behind it.
But like what's my plan and howdo I know if I'm following the
plan, yes or no?
What things should I avoid?
That's about it.
That's what most people want todo.
You know, and then peoplefollow the rules.
Speaker 1 (23:58):
Yeah, I feel like establishing those tables and
stuff to make it easier foryourself will just make it
easier for you to stay organizedtoo, and you have a lot of
other things going on, like whenyou have lots of different
people.
I mean, in general you're doinglike the same kinds of things,
it's just a different jointright, like you're still making
a four inch motion, having fullstrength you pick some
functional tests that you wantthem to pass before you return
them to running, jumping sportsstuff.
(24:18):
And you just like those things,create your tables and then like
if it's an ankle, you're doingthat, there's shoulder, you're
doing that.
So I feel like setting yourselfup organizationally, especially
if you're like newer.
That way you can kind of likeorganize your brain better yes I
think.
I mean I work in a clinic that Ithink has I have a pretty high
like volume of patients, likeI'm seeing like 14 plus patients
(24:40):
a day, so I'm overlapped withlots of different diagnoses.
Post-ops, non-post-ops have,like you know, a seven-year-old
with ankle pain that doesn'twant to walk because it hurts,
and then I'll have, like youknow, a six-month-out post-op
that we're working on startingto like run and jump again, you
know.
Speaker 2 (24:57):
Yep, and to that point too, of like having tables
organized and like dividing andconquering is like, remember
that we know normal versus notnormal ranges for a lot of
things, right Shoulder range,most of the best.
Like they don't know that 45versus 90 is bad versus good.
So like simple math of like one60 divided by one, 70 is what
(25:18):
percentage compared to the otherside, of how much shoulder
flexion I'm missing, or whateverelse it is.
So sometimes not only is itlike useful for you to organize
yourself, but then if you can dojust basic out of a hundreds or
side to side comparisons oflike percentage of side to side,
they see like oh, I'm 81% asstrong as my left side.
That's it, that's all I careabout.
They don't need to know that Ineed 105 degrees of shoulder ER
(25:38):
at 90 degrees, but 105 degreesat 45 is not going to happen.
Like they don't understand thatat all.
So for your own educationalsimplicity, try to sometimes
normalize things and things theyunderstand.
You know, green is good, yellowis not good, red is oh, that's
okay, you're 70%.
Speaker 1 (25:53):
You need to get to 80 before we run.
Speaker 2 (25:56):
Yeah and set realistic goals right, like
jumping 10% LSI is not going tohappen in six weeks.
You say, like the researchshows that you know a three to
4% jump is pretty good, or athree to four you know LSI jump
is pretty good, so don't behorribly disappointed when 74 is
what we got for 71.
That's actually a really goodjump, you know.
It means that you're doingreally well and it just takes
time.
Speaker 1 (26:14):
Cool yeah.
Do you have any advice for likenew word grads, for instance,
or, I guess, anyone who has likea very different caseload Like
I think it like for mepersonally, I feel like I've
gotten a lot better with it justby getting reps in, like I.
I have now like okay, you havethis diagnosis, I like know what
I want to do with you, but Ifeel like that just comes with
time.
(26:35):
I don't feel like all asidefrom like organization and like
getting your reps in adviceabout like different patients
and caseloads.
Speaker 2 (26:43):
Sure Now.
Now it's obviously a bit moremanageable because I have a lot
of experience in many differentjoints.
The problem and the blessingand the curse of gymnastics is
that everything is hurt.
So I had to learn each jointand understand the surgeries
around there, versus like onlybeing an ankle guy or only being
a back guy, right.
So now I can do it, but earlyon I would say that I was
definitely a couple of jointswere a little more intimidating
to me and I was not afraid toask coworkers for help if they
(27:06):
have experience.
Like I think at my first job Iworked with a person who was
like a pretty good running PTand at that time I really did
not understand foot and anglethat well at all.
So I would either lean on themabout like, hey, what do you
think about?
Like this Achilles tendinopathy?
I don't treat a lot of these,you know, is this is my plan
normal, is it not?
Or just like you're probably inbetter hands with somebody else
(27:26):
because they really know highdistance running, and that
happens now all the time.
I mean I treated a girl, um thehusband.
The husband I treated he was apower lifter, but the wife was a
long distance runner and shewanted to come see me because
she just knew me from his caseand like, wanted to work with me
, which was cool.
Um and like, all right, I canhelp you get back to like the
average stuff and I can get youout of pain acutely.
(27:48):
But like after two or threevisits, probably better if you,
if you see Kevin and just kindof give him your whole situation
because you're better inKevin's hand, who literally runs
competitive marathons the sameway you do, to understand tempo
and pacing and running and allthat kind of stuff.
And even so, when I made herfirst program, I just asked Kev
I was like hey, like what wouldyou do for return to running
program for a first person whohas the eventual goal of a
(28:08):
competitive marathon?
He's like, oh yeah, no problem,I got like this program and
I've made this protocol, I madea return to running program and
so that's the strength of havinga coworker staff with a diverse
set of, you know, people islike Lisa treats a about this
girl who had a pretty stiff kneeevery day.
(28:29):
I was like Lenny, like what doyou think?
Feel this real quick for me?
Is this like normal?
Would you say yeah, and he waslike, you know, it's a little
bit let's, it's really hammeredpretty home.
And last week he checked andwas like, yeah, it's pretty good
, other people, you know, givepeople to other people and
people send people to me.
Anthony yesterday in the clinicwas like, hey, this kid's got a
(28:50):
spondy stress reaction, um,flared up a throwing.
Can you just chat with themreal quick and let us know
whether you think we should goto the doctor?
It's like, yeah, I figured athousand spondys I probably have
a better pattern recognitionthan see as many as me, you know
.
But things that I no problem,but if Anthony hears them, maybe
it's not the same register,same way with Mike and elbows
and stuff.
So that would be it.
Lean on other people.
Delegate your case one or twohere there to other people and
(29:13):
then learn from their case howthey treat them.
If you don't have access tothat, research books as much as
you can to try to learn, oronline mentorships are great.
Online forums, chat with people.
You know there's a lot of greatthings online that you can
follow with people.
Speaker 1 (29:25):
Yeah, I agree completely.
I just have that like a reallysimilar tough knee case and I
reached out to probably eightpeople and was like how do I
know that this is wrong and likeif it's wrong, what do I do,
like send help.
Speaker 2 (29:38):
And the imparting thought on this is that as you
get better as a clinician youtend to see harder cases, right,
because people value yourexpertise and people value your
input and value your expertiseand people value your input and
so you know early on you mightjust see the textbook kind of
back pain with like a stressreaction.
But like I've seen some casesthat come from two or three
other people who, like you know,I'm super grateful they fly in
for a one time console and it'slike a very complex case or an
(29:59):
elite who has an old spondy andthey have nerve issues and
they're trying to make a teamand like it's not easy.
So with those higher complexitycases there's nothing wrong
with asking around and gettingopinions from different people.
I referred someone to Ellen, uh, who was a complex spine case
that had some like possible bonedensity issues and she got told
by a surgeon like yeah, neverdo gymnastics, ever again.
(30:19):
And I was like I don't think Iagree with that, but I'm not a
surgeon, how can I say not to dothat?
And so Ellen was able to kindof have a level head around that
being a doctor andunderstanding that case and
she's doing great now but likeit took Ellen and her opinion.
Then there's another.
There's like a PA, anotherdoctor locally, ellen and me all
kind of like what do you guysthink you know, and that's a
regular level nine case.
It wasn't something crazy, sothere's nothing wrong with.
(30:41):
I need help.
I don't know.
Hey, what do you think aboutthis?
And just talking over cases forsure, yeah, it can only make
you better.
Totally yeah.
Speaker 1 (30:49):
They will learn more.
The patient will get better.
Speaker 2 (30:51):
Yeah, exactly, and Mike and Lenny will tell you
that they've picked up a lotfrom me and Dan about hips and
backs, because they treated armsand legs for 20 years, you know
, and now that the last 10 yearswe've all been together, they
treat a lot more.
But you know, lenny and Mikeare mentors of mine and I
(31:12):
considered idols when I was ingrad school and you know them
asking for me advice is like youknow, that's cool to see that
they're still humble and theywant to just help the patient.
They care more about that thanyou know, mike, knowing this or
that Cool beans, cool beans.
All right, hope that washelpful.
We'll get these three out andthen I don't know when we'll
film the next ones down the road, but if people have questions
about these episodes, instagramfor us or email is fine, and if
(31:34):
you want an episode covered likea certain topic, you want more
on email, instagram too, as well.
I think we're pretty open tochat about whatever.
So we're doing good.
I think this is our 12, six,nine, it's like up to 10 or 12
that we've done, so I thinkwe're cooking.
Speaker 1 (31:46):
We're doing good.
Speaker 2 (31:47):
Got this format down.
I like this 30, 40 minute, youknow, debrief.
We'll definitely get Lenny onhere for quad and my situation
and stuff like that, but he'sbusy, unfortunately when we film
.
He's taking his daughter togymnastics.
So we'll get him on here though.
Alrighty, have a good weekend,everybody, take care.
Speaker 1 (32:02):
Bye.
every day.
You essentially pay your duesby doing the harder thing when
it's the right thing to do.
Okay, on the same line, I thinkthese three episodes naturally
go together because it's likedan, progression to acute care,
progression to managing abanana's caseload.
So, um, yeah, on the vein of uh, these podcasts come from a
combination of what people askus to help them with and then
(00:27):
also what uh is actively betweena lead and I's brain right now.
We usually chat about stuffback and forth and then I have
an idea.
I'm like sitting in the clinic,I'm like, oh, this would be a
good topic to kind of chat about, or something like that.
So this uh situation is in realtime.
The fact that champion ingeneral has never been busier in
our entire life.
So this time of the year injune where we kind of planned
this for um, all the collegekids are coming home from
(00:50):
schools or wherever and they'reworking out fitness, pt,
whatever, and then all the highschool kids are now out of
school and either finishingtheir seasons or are summer
training with us, and so thatleads to a large amount of
people who have surgeries at theend of season and they come
back and they rehab with us forthe first three months, or they
had an injury during the yearthat wasn't surgical but it was
annoying and they're trying torehab that.
Or people on the strength sidethat are like training with us
(01:12):
and are going back to school inSeptember or stuff, and so, um,
yeah, I don't know whether I'mjust busier than normal or what,
but I posted about this lastweek but I have like 45 people
actively on my caseload rightnow and 25 of them are gymnasts
from all walks of life, fromcompulsory to elite, with like
different schools.
So I have like seven to 10different colleges with seven
(01:34):
people who had surgery fromdifferent surgeons with
different protocols three of thesame surgery, three different
surgeons and protocols like twoUCLs, two ACLs.
It's like a lot to manage and Iavowed them all in two weeks
when they all came home becausethey just all wanted to get in.
So I had like a 30 hour workweek where I did like seven to
eight avows.
And then I remember being likethe next week I'm like well,
(01:54):
this is like a lot to likeprocess where everybody's up and
like what?
Like what do you need?
Like can you strength trainwith the coaches, and they're
kind of like joint programstogether to kind of keep them
going.
So on Sunday I had to spend twohours making a Google doc, which
I'll share, which isessentially like how to organize
my own brain around.
Like these are the patientsthat I have in this particular
(02:16):
gymnastics bucket here's theirsurgeon, here's their date of
surgery, here's their protocolprecautions.
Here's where they're at.
Some did rehab at school beforecoming home.
Here's their notes and whatthey've done with their trainer
or with a different PT.
And like this is what the bigrocks are that we're going to
kind of tackle, because you know, some people are doing great
but some people are still prettysore and pretty struggling and
(02:38):
you know we're trying to scratchour heads about it.
So that's where it comes from.
I don you said, you know, whenwe were setting up these
episodes, that you just got ahuge influx of post-ops and that
you have a lot on your mind.
You know.
Speaker 1 (02:47):
Yeah, I have so many patients right now.
We're so, so busy.
Speaker 2 (02:50):
It's a wicked smart.
Speaker 1 (02:52):
Picking up overtime because I can't, we can't fit
our post-ops in, like that'swhere we're at.
So I have lots of post-opsright now lots of other patients
, so we're I'm in the same boatas you.
Speaker 2 (03:01):
Yeah, yeah, and it's hard sometimes to you know.
You go through waves where somepeople are, you know you have a
chunk of your schedule which islike you did the eval.
You kind of know what's goingon and you have a plan for them
and it's just executing the planand doing it over.
You know two to four weeks andthey're just, I would say,
normal treats quote unquote.
Whereas when someone's surgical, you're adding a lot, you're
changing a lot, you're tweakinga lot, you're progressing people
(03:32):
a little bit, and if you get alittle mixed up, it's really
hard sometimes in a busy day toknow where someone's at, what
they're doing and what happenedlast week when they were sore.
So this system is what I havedone internally like for a long
time and I figured it might bejust useful to share it.
So this is how I organizethings and I maintain anonymity
to make sure I was HIPAAcompliant, um, but these are all
my current caseloads.
So um for gymnastics.
So I have no like handful ofpeople but essentially along the
(03:55):
left-hand side.
These are just like theirinitials.
It's their name when I'm not ona podcast, live with them, but
their uh initials, their name,what level they're working, what
college they're at or whateverthey're doing, whether they're
recruiting or whether they'rejunior or freshman.
And essentially, when I come upto this main thing, I have a
approach of now I can just likeclick people as they come in.
This is based on, like myMonday, tuesday, wednesday
(04:16):
schedule, so Monday throughFriday.
So like these I think like fourare Monday and then, like these
four maybe are Tuesday orwhatever.
But essentially, um, I try touh get the information from them
about, like at a glance, if Ijust look at this really quick,
I know exactly what needs tohappen with this person in the
next visit or where they camefrom in the last visit.
So this situation um, she had auh right ACL reconstruction, uh
(04:39):
, bone patellar, bone grafts, apatellar tendinograph.
She also had an LET on March21st with Dr Ramapa.
So I know that if I have aquestion I can just text Ramapa
real quick or like get an emailchain with somebody else.
Right, notes precautions At thetime when this was earlier, it
was like weight bearing,whatever as tolerated, because
she has meniscus repair orcrutches for four weeks.
(05:00):
Weight bearing is tolerated,brace comes off at six weeks.
She has a six weeks follow-up.
Whatever it is Stitches comeout two weeks, like all those
precautions and protocols andthe things I need to know are at
the top so I can quickly atglance realize what's going on.
And then for me, early post-ops.
But even as some of these caseswe'll talk about, even like not
post-ops that are just far out,that are six, eight months that
(05:20):
have generalized pain, a lot ofthe important stuff comes from
just basics, right Basicswelling, basic joint mobility,
basic symmetrical, pain-freerange of motion, basic pain-free
active range of motion and thenpain-free strength.
So in this girl's case, whenshe's three months post-op right
now, this is really all we'refocusing on right, she's really
just in the middle part of rehaband she just needs to get
(05:41):
strong.
In this particular case she wasthe one we talked about in the
last episode that did have somestruggle with extension.
So I'm like all right, I got tomeasure cold hyper extension
every time she comes in and Iwant to make sure that we get
her at least eight to prevent,like, any serious issues.
And she's strength trainingwith us.
So now it's about we know shehas to strength train hard three
times per week and I want tomake sure that what I'm doing in
my side of the rehab is themore I would say spicy stuff
(06:03):
that is more like dependent onmedical based limitations and
graph choice Right, and then dous, is free to do all the stuff
that I've done before in thefirst three months safely and
that all the extra things thatshe doesn't have on her own.
So BFR, stem, the kneeextension machine I want to make
sure that when she's in, everysingle time she has access to
all that kind of stuff, becausethat's how she's going to get
(06:23):
her quad strength up quite a bitand kind of combat this little
bit of AMI that she had.
So I kind of write out okaywell, I know she had some AMI,
so what are we going to do forthat?
That's a huge impairment.
Oh, sorry, the first part.
So swelling she has a mildamount of swelling still,
mobility restrictions, so selfmobs quite a bit.
She is close but doesn't havefull, pain-free passive range of
(06:49):
motion and a hyper extension.
She's close on flexion.
So it's about in her homeprogram on the day.
She's not a champion, it'sabout got to get that knee
propped up, got to hyper extend,it got to make sure it's all
set, blah, blah, blah and thenalso doing some like knee
bending on her own, some sometowel bending, some quad rocking
, just consistently throughoutthe day.
Thankfully she's not in schoolnow so she has like unlimited
hours where she can do it, butshe had surgery in the middle of
(07:10):
her spring semester for highschool so she was very busy with
other stuff.
So finding times to make surethat she's doing this is really
important, right, and then sothat's it pain-free, passive
range of motion.
She doesn't have full activerange of motion because her quad
is still weak.
So we have to make sure weprogram open chain type stuff to
get that full motion with aknee extension.
And then she clearly doesn'thave quad strength uh,
symmetrical side to side.
Not that I've strength testedit.
(07:30):
We'll strength test her in likeanother month, but she doesn't
have that yet.
So her whole program is basedaround okay, we have to get full
motion in full strength.
And I did a lit review with someof the other guys earlier, but
I just remember looking back onthe research like what is the
best research supported ways tocombat AMI, right?
So ice pre-training is reallygood for 20 minutes, so we were
(07:51):
doing that for a long time, butthe priority is a, not a cyclops
lesion, and not gettinghyperextension loss.
So although she does have AMI,the more important A1 is not
losing hyperextension and thequad will come.
There's many other ways to getthe quad going.
There's not many other ways toget a cyclop to go away besides
another surgery which we don'twant.
So she was doing ice for a longtime until we realized that the
(08:11):
AMI was probably at bay andthat the hyper extension was
kind of slipping.
So we switch her to.
She comes in before her PTtraining session 15 minutes, 30
minutes early, or her strengthsession and does propped
extension for 15 minutes.
Um, and then she comes to mefor PT or goes to do ash and
then after she doesn't like 15minutes at the end too as well,
and then she has another one ather house at home.
So because her quad is weak shecan't actively get her heel to
(08:34):
full hyper extension.
So it's a bit of an uphillbattle to maintain that before
the quad comes back.
So we're trying to combat theAMI with that.
Maybe it would be ice insomebody else's situation.
I have a few other patients whoare not as behind, a little bit
with the quad strength becausetheir surgery was just an ACL,
not an LAT.
So maybe they're doing icebefore.
I have one girl who's like sixor seven months out.
She does ice before just to gether quad really turned on
(08:55):
before she does some advancedstrengthening.
But then also the propextension helps and then
vibration is helpful for AMI too.
So while she's heating um, Itake it off and then I work on
her patellar mobility and shedoes AMI vibration to her quad
to try to activate some of theneural stuff as well.
And then before she shranktrains she has quite a bit of um
foam rolling on a vibrationmachine or something like that.
So that's the most important,like basic steps for her.
(09:17):
And then between me and Duesh Iknow we want to get a full
spread three days of all thedifferent movements she needs.
So I've done step up, kneeextension, split squats and NMS.
Burnout would be a far before.
So Duesch takes all that in hisprogram and, make sure, a whole
body program.
I take on the new stuff whichis a step down, some TKE stuff,
some some spicier, you know,lateral work which is maybe more
on the LAT, and I take that.
(09:39):
And then her home program isjust all the stuff that we
talked about.
So I had to sit down for like 10minutes and work through her
case mentally about like, doesshe have this?
No, what do we do for that?
Does she have this?
No, what does the research sayfor this?
Does she have this?
Yes, okay, ignore that or nevermove on from that.
But that's kind of how Iapproach it is.
I sit down with each case andtry to think about the things
(10:01):
yep, cool.
And then the other thing that Ithink comes along with this is
you get a.
Very quickly you realize thatyour caseload is shotgun across
a whole bunch of differentproblems.
So, um, I don't know how manyof these this was an old one
that I've updated since then butmaybe there's like six or seven
that are at the top here.
So first one, let's see.
So we have an acl bone tenantbone.
She's probably at 10 o'clock,11 o have a uh gymnast who's a
(10:25):
junior in college.
She had an Achilles 10 X andshe has a protocol that did not
come with her the doctor.
Her gymnastics doctor is nother team doctor.
So her other doctor did her 10X, but her team doctor is
different.
So she had a 10 X procedurewith a different person that's
friends with this surgeon to dothe actual 10 X procedure, um,
but neither of them really sentthe formal protocol.
(10:46):
She kind of had a range ofexercises to do and she's going
back to school.
So they were like, yeah, justlike you know, do this kind of
ish for a couple of weeks andcome back and we'll see you.
So I had to talk to a differentdoctor who does 10Xs just to
make sure that we gave her aprogression.
It was like stretch your calfand then do bump things down and
start with, like you know,plantar flexion with a band and
then seated calf raises andwhatever.
(11:06):
So so, yeah, so that was at 10o'clock.
Is this girl with a knee?
11 o'clock?
Is this girl with Achilles?
10 X?
Completely different surgery,different school, different
surgeon.
Same kind of thing.
Do you have swelling?
Do you have your joint mobility?
Do you have your passive range,your active range of strength,
right?
All kind of no.
So different types of uhprogressions for that, things
that I can do with her and thenthings that she's doing on her
(11:27):
own as well in a home program.
And then this girl navicularfracture.
She had a debridement sixmonths ago.
She's going to be a freshman atschool.
Um, she has a handful of thingsthat are really, really good.
But all her pain and her issuescome up when she vaults.
So she uh has going.
She's in her return to sportprogram, she's back to full
gymnastics.
But if she does too many uh,one and a half on vault she
starts to get some soreness ather foot.
(11:48):
So completely different end ofthe spectrum versus the person
who's missing the extensionpost-op week two right.
So for her all these things arefine.
Passive range is good, activerange is good, maybe a little
calf strength deficit, but it'snegligible.
But all her issues come up withsingle leg uh, so single leg ply
work or very high impact, um,two legged power work off a
springboard.
That's where she gets symptoms.
So all her stuff.
(12:08):
One of the strength coaches,mike, does her programming twice
a week.
Um, we have to split all herstuff between the two of us and
also make sure that she'sgetting the right dosage of
workload right.
So she needs to vault twice aweek and not have symptoms the
next day for us to go to threetimes a week.
And also, she has to tolerateall her single leg jumping, all
her eccentric work, all herheavy, heavy stuff and not have
(12:32):
a flare up of symptoms, which iswhere she's at now.
She kind of had a flare up amonth ago, backed off for a week
and like all right, two times aweek.
She was also just doing way toomuch.
She was doing beam and vaultand floor the same day.
She was excited Soers and thenfive vaults and then five layout
step outs and then on that dayyou can't do floor on a hard
surface, nor can you do beam.
So she's at 12.
And then we have a girl who is aslap repair.
(12:52):
She's 12 weeks out of a slaprepair I'm sorry, 12 months out
of a slap repair and she's endstage.
She's fine, free of herconditions, but she has cuff
tendonitis.
She's a long standing cufftendonitis, cuffed in the night.
So she needs, you know,shoulder strength stuff.
I gotta take her numbers again.
I have to do thoracic mobilitywith her.
I have to do injection stuffmid-season.
If it's not going to work out,I have to do some dry needling
right, her home program isdifferent.
And then this girl is sixmonths out of a ucl.
(13:14):
This is the kid who I said uhfell and didn't know his
protocol.
I love him to death.
He's a good kid but he's farout of a triceps repair.
And and then this person's acuff 10.
I mean so like the schedule isall over the place capsular
shift and if I don't put thisstuff out in front of me and
outline this thing, this guy hasa C7 disc bulge, like so
different than the other stuff Iget so overwhelmed and I feel I
(13:37):
feel like I'm doing a bad job.
I think is the only way to doit if I overwhelm myself so much
that I can't remember thenuances of their surgery.
But old me would just be likeremember it all and like work
harder.
Right, but how the hell am Igonna remember?
Is 20 people on this list?
How am I gonna remember 20people with 13 different joints
and 13 different schools and 13different surgeries and surgeons
?
Right, like it's impossible.
So I really support peopletrying to spend, unfortunately,
(14:00):
extra time to map this all out,because every night when I see
them on the schedule, I gothrough and I think about are we
better or worse the same?
Are we moving in the rightdirection?
Did I miss something?
Do I have to read some research?
Like, where do I have to gethelp from?
Do I got to call a doc, likeall that kind of stuff is what I
think about the morning ofbefore I go in.
Do you have any thoughts?
Speaker 1 (14:17):
on that.
Um, I mean I pretty much do thesame things, like generally.
I mean our documentation systemis through Epic, so it's much
more wordy, I guess is the wordfor it, but pretty much the same
thing is.
Like I'm with my post-ops inparticular I'm.
I have so many of them rightnow that is really hard to keep
everything straight, likeremembering, like what their
motion should be.
So I think, doing yourself afavor at the eval and making
(14:40):
sure that you're getting theother side measurements so that
know your comparisons for eachside, especially for motion, and
then also making sure that,like sport wise, for gymnasts
and for other sports, you'rejust writing down everything
that their goals are to get backto.
Like for a gymnast, I'll sitthere and I'll write down all of
their events and like all theskills that they're trying to
get back to and then, like forother sports too, like what
(15:01):
events they do within that sportor nuances that I remember with
the goals that we're trying toget back to eventually.
Um, but then, just like I, Ithink I create like a good habit
with all the post-ops that comein.
Like every time they come in,they warm up, we take all of
their measurements and then weget started.
So it's like a habit of likeevery time we're going to check
and see where we're at, and Ithink it's helpful for you as a
(15:22):
clinician to kind of like getyourself familiar with the
things that we need to beworking on, like, okay, maybe
they weren't missing fivedegrees of extension last time,
but today they are.
So we need to work on extensiontoday, like that kind of thing.
And then also just from aneducation piece for the patient
as well, because they're alsoinvested in their numbers.
At that point too, they're likeyou know, they're tracking
(15:42):
themselves too.
They're like oh, last time Iwas at 98, today I'm at 103 and
they're like get really investedand it's kind of fun.
Yeah, yeah, doing yourself afavor of like keeping good
documentation session to session, so you can really track their
progress, because you might likemiss somebody in the weeds.
If you're not doing that likeyou might you know four weeks
later you're like, oh crap,you're like 12 weeks out and we
(16:02):
don't have this, like why don'twe have this?
Because we, we haven'tmeasuring it or, you know, you
just missed it somewhere alongthe way.
So, just creating the habit oftaking those measurements and
setting yourself up for successand having their protocols like
ready wherever they are, likewherever you're going to plan,
to keep them just like have themhandy so that you know your
dates, like at the eval.
I'll set up like a we I'll setup like a.
We have a little like calendarthing that we have in Excel
(16:25):
where you can like put the dateof surgery in and it calculates
out like two weeks, six weeks,eight weeks, and then like
literally on that eval, if theyhave restrictions, I'll just
write in there.
It'll be like the date andit'll say when they can do this
and the date when they do that.
So it's like really easy for mewhen I opened the computer, I'm
like, okay, we're like threedays away from this or two weeks
away from being able to unlockour brace or weight bearing or
(16:45):
whatever it is.
So it just makes it like easy,accessible.
You don't have to remember allthe things about each person.
Speaker 2 (16:51):
Super helpful.
Yeah, and I think to your pointof measuring things
systematically each time.
Like you know, I didn't mentionit last episode, but like knee
swelling measurements, like fivebelow joint line, five above 10
, 20, like every day you seethem.
For the first three weeksprobably, you're measuring those
middle joint line type ones andyou want to make sure
centimeters are going down andquads hopefully going up.
But like you have to have, Ijust use tables.
I don't know if, like softwareis allow you to do that, but
(17:12):
like I find that if I have liketwo or three tables from the
very beginning, about like thisis a swelling table, this is an
active range of motion or apassive range of motion table
and a strength range of motionor a strength table.
The strength table might notediting because it's not clear.
You can't, uh, strength testsomebody or dynamometry test
someone early out of surgery.
But I keep them in there sothat down the road I can
reference these things.
As you save a note and a new onecomes up, I can see that over
(17:35):
the course of four to six weeksthe swelling has gone down, the
motion has changed and how muchthey have, and then eventually
when you get into, like thethree to four month mark for a
lot of people.
Or if you have someone who'snot post-op and they're just
coming in for a shoulder painand you took their strength
numbers, dynamometry wise, oryou tested their quad and their
hamstring LSI, torque numbers ona dynamometer.
You want to track those monthto month and keep referring back
(17:56):
to those because it showsprogress, it has buy-in to your
point exactly and it's reallyimportant to track those things.
If that's the main KPI or likekey performance indicator is
strength, quad strength, aclwise while you're saying to
someone who's six months out hey, I know you got cleared to run
and clear to do sports, but youhave an 80%.
You know strength differentialside to side.
Um, it's probably not the bestif we start you on cutting
pivoting until we get this LSInumber up, you can kind of
(18:19):
explain with hard numbers whileyou're making that choice, not
like well, I just don't thinkyou should run right now.
Right, you want to have a veryfirm.
You know this is the researchshows us that we want to have a
good 90 plus 95 LSI before weget somebody on very aggressive
cutting.
So let's make a plan in place,let's measure this and then in a
month from now, you know youhave to have a lot of data
behind the decisions that youmake when you're working
particularly with with athletes,and with high-level athletes
(18:41):
because they think you're smart,that's great.
But if you tell them they'renot gonna be able to train or do
a meet or compete or somethinglike that, you better have some
pretty good rationale for whyyou know, and data helps a ton.
Speaker 1 (18:50):
Absolutely.
Yeah, I like I like doing tests.
Tests are great.
It gives me more information.
It gives them more information.
It helps with them buying intothe process of like, okay, I got
to work harder here, or I gotto do more here, or I got to do
more here, or I got to do lessthere.
Like it helps, like trackingwise, just making sure they're
on track and, I think, settingyourself up at the beginning
with the eval, kind of like whatI was talking about, and then,
(19:12):
like when you get to the pointwhere strength testing like I'll
look out like okay, on my table12 months, okay, we're strength
testing here.
And then, based on how they did,I'm like, okay, we're really
behind.
Or, like you know, it's 50%.
Like, okay, we're not going tomake significant gains, but I
still want to test it in likethree to four weeks just to make
sure that we're improving.
And then, like I pick a date.
(19:33):
Each time I'm like, okay, whenare you here?
That's close enough to three orfour weeks from now.
I pick that date.
I tell them, I say, on this daywe're retesting your strength.
So they know, we know if Iforget, they remind me.
Speaker 2 (19:41):
Yeah, yeah, right, exactly, and to that point is
like it's, you know I can'tshare because it's it's like
HIPAA data with champion.
But, um, the best thing you cando is, if you know there's like
certain metrics or things thatyou're going to test for like
knee ACL or for like shoulderstrength dynamometry or for
whatever you want to havespreadsheets and tables that can
help auto punch that, autocalculate that to make sure that
(20:02):
when you put in new data itcompares it to the old data.
They see like, oh, this was mynumber before, here's my number
now.
And one of our students in anin-service where he did it for
ACLs and for like LSI and likequad testing, then somebody else
has done it.
I think Anthony did it for likeshoulder strength measurements,
right.
So we know that, like we wantthe ER, you know, to be at least
66% as strong as the IR, wewant the you know the ER on each
(20:24):
side to be symmetrical.
So if we put those numbers inin a table that's blank, when I
fill in those numbers it autopopulates this is the percentage
of body weight, this is the ERratio, and now they've done it
with the quad stuff too as well.
So we have like an Excel sheetwe make in our Google drive.
It's like all right, this isthis girl's three month post-op
number.
This was how much she weighed,this was how long her shin was,
and then this is our LSI forquad, lsi for hamstring.
(20:47):
Here's our torque angle and wehave all that data in one column
.
And then in another month whenshe tests again, we just fill in
a new data and we can see oh,she went from 71 to 74% LSI.
That's not a huge jump, but sheactually jumped 80 newtons in
quad strength.
So that's a good thing, rightHelps you make sense of a lot of
data and it's very hard tosometimes figure out what is
worth measuring.
But you can be overwhelmed withhow much you have to measure.
(21:09):
But if you find a couple ofreally important things on the
strength side, they do like CMJ10 hop.
You know things like depth dropstuff with with loading from
valve um vault.
But if you have those things inline and you just sit down and
make a table that is repeatable,use over and over and over a
spreadsheet Like you, save hoursof your life in the clinic over
time.
And then quickly, as soon asyou punch the numbers.
You can turn the computeraround Like all right, here's
(21:30):
our numbers are at.
You know we're doing good here,we have some progress here and
like it's it's one of the bestbuying things I've ever done is
giving like involvement in, likethis is what these numbers mean
.
This is why it're good to dothese things, but I'm not
letting you do these things yet.
You know it's like your goalsare this.
I'm trying to help you getthere as fast you can, but
safely yeah, there's a reallycool acl calculator.
Speaker 1 (21:50):
I'll have to find it.
I can't remember the name of itright now, but you can just
like input the numbers.
It's really cool.
Actually.
That's it's one of the newprojects that a couple of
different like pediatrichospitals have been working on
that gives like normative valuesfor kids based on their body
weight, which is cool.
I'll have to find the thing soyou can like link it in the show
notes or something it also haslike fun diagrams.
(22:10):
So I don't really use it thatmuch, because we already have
like our flow sheets for ourdocumentation and like comes out
, pops out into a table, um.
But this one has cool likediagrams of.
It will like show you in a piechart, like okay, you're here
and you need to be here.
Everyone else is here andyou're like you got here.
So it's like kind of fun forlike an educational piece from
like for the kid or the patientand the family so you can kind
(22:31):
of see like okay, this is whereyou are, this is where you need
to be, you know, like helps them.
Yeah, you know where they are inspace.
Speaker 2 (22:37):
But yeah, and the end advice I always give people is
like I think we talked about itwith dan maybe is like people
they're, they want to know thatyou know a lot but they don't
really care about the veryin-depth, nerdy LSIs with torque
ratios and stuff.
They really don't care at all.
Like they.
Some people are really hardcoreand they want that, but most
people just want to know am Imaking progress or not in the
(22:57):
things that matter?
And what do I need to do?
Or like what's the plan Right?
So the analogy I always give topeople is making a psi change
at the level of the belt whichcauses hydraulic.
I'm like dude, I have no ideawhat you're saying.
That's what's happening whenyou explain to somebody this
in-depth lsi with torque ratiosand the patellar tendon graph,
(23:20):
like I'm looking at this guy.
I'm like okay, can you, can wefix it?
Like I just don't want to dieon the highway.
Like how much, how, how long doI need to leave my car here?
What do I have to do?
And like and then he'll tell melike all right, leave your car
overnight.
And then when you drive on theroad, you know, do this and this
and tell me if it clicks, I'mlike sounds good, I'll see you
in a week.
You know that's all they need're talking about.
(23:49):
This is research-based.
There's data behind it.
But like what's my plan and howdo I know if I'm following the
plan, yes or no?
What things should I avoid?
That's about it.
That's what most people want todo.
You know, and then peoplefollow the rules.
Speaker 1 (23:58):
Yeah, I feel like establishing those tables and
stuff to make it easier foryourself will just make it
easier for you to stay organizedtoo, and you have a lot of
other things going on, like whenyou have lots of different
people.
I mean, in general you're doinglike the same kinds of things,
it's just a different jointright, like you're still making
a four inch motion, having fullstrength you pick some
functional tests that you wantthem to pass before you return
them to running, jumping sportsstuff.
(24:18):
And you just like those things,create your tables and then like
if it's an ankle, you're doingthat, there's shoulder, you're
doing that.
So I feel like setting yourselfup organizationally, especially
if you're like newer.
That way you can kind of likeorganize your brain better yes I
think.
I mean I work in a clinic that Ithink has I have a pretty high
like volume of patients, likeI'm seeing like 14 plus patients
(24:40):
a day, so I'm overlapped withlots of different diagnoses.
Post-ops, non-post-ops have,like you know, a seven-year-old
with ankle pain that doesn'twant to walk because it hurts,
and then I'll have, like youknow, a six-month-out post-op
that we're working on startingto like run and jump again, you
know.
Speaker 2 (24:57):
Yep, and to that point too, of like having tables
organized and like dividing andconquering is like, remember
that we know normal versus notnormal ranges for a lot of
things, right Shoulder range,most of the best.
Like they don't know that 45versus 90 is bad versus good.
So like simple math of like one60 divided by one, 70 is what
(25:18):
percentage compared to the otherside, of how much shoulder
flexion I'm missing, or whateverelse it is.
So sometimes not only is itlike useful for you to organize
yourself, but then if you can dojust basic out of a hundreds or
side to side comparisons oflike percentage of side to side,
they see like oh, I'm 81% asstrong as my left side.
That's it, that's all I careabout.
They don't need to know that Ineed 105 degrees of shoulder ER
(25:38):
at 90 degrees, but 105 degreesat 45 is not going to happen.
Like they don't understand thatat all.
So for your own educationalsimplicity, try to sometimes
normalize things and things theyunderstand.
You know, green is good, yellowis not good, red is oh, that's
okay, you're 70%.
Speaker 1 (25:53):
You need to get to 80 before we run.
Speaker 2 (25:56):
Yeah and set realistic goals right, like
jumping 10% LSI is not going tohappen in six weeks.
You say, like the researchshows that you know a three to
4% jump is pretty good, or athree to four you know LSI jump
is pretty good, so don't behorribly disappointed when 74 is
what we got for 71.
That's actually a really goodjump, you know.
It means that you're doingreally well and it just takes
time.
Speaker 1 (26:14):
Cool yeah.
Do you have any advice for likenew word grads, for instance,
or, I guess, anyone who has likea very different caseload Like
I think it like for mepersonally, I feel like I've
gotten a lot better with it justby getting reps in, like I.
I have now like okay, you havethis diagnosis, I like know what
I want to do with you, but Ifeel like that just comes with
time.
(26:35):
I don't feel like all asidefrom like organization and like
getting your reps in adviceabout like different patients
and caseloads.
Speaker 2 (26:43):
Sure Now.
Now it's obviously a bit moremanageable because I have a lot
of experience in many differentjoints.
The problem and the blessingand the curse of gymnastics is
that everything is hurt.
So I had to learn each jointand understand the surgeries
around there, versus like onlybeing an ankle guy or only being
a back guy, right.
So now I can do it, but earlyon I would say that I was
definitely a couple of jointswere a little more intimidating
to me and I was not afraid toask coworkers for help if they
(27:06):
have experience.
Like I think at my first job Iworked with a person who was
like a pretty good running PTand at that time I really did
not understand foot and anglethat well at all.
So I would either lean on themabout like, hey, what do you
think about?
Like this Achilles tendinopathy?
I don't treat a lot of these,you know, is this is my plan
normal, is it not?
Or just like you're probably inbetter hands with somebody else
(27:26):
because they really know highdistance running, and that
happens now all the time.
I mean I treated a girl, um thehusband.
The husband I treated he was apower lifter, but the wife was a
long distance runner and shewanted to come see me because
she just knew me from his caseand like, wanted to work with me
, which was cool.
Um and like, all right, I canhelp you get back to like the
average stuff and I can get youout of pain acutely.
(27:48):
But like after two or threevisits, probably better if you,
if you see Kevin and just kindof give him your whole situation
because you're better inKevin's hand, who literally runs
competitive marathons the sameway you do, to understand tempo
and pacing and running and allthat kind of stuff.
And even so, when I made herfirst program, I just asked Kev
I was like hey, like what wouldyou do for return to running
program for a first person whohas the eventual goal of a
(28:08):
competitive marathon?
He's like, oh yeah, no problem,I got like this program and
I've made this protocol, I madea return to running program and
so that's the strength of havinga coworker staff with a diverse
set of, you know, people islike Lisa treats a about this
girl who had a pretty stiff kneeevery day.
(28:29):
I was like Lenny, like what doyou think?
Feel this real quick for me?
Is this like normal?
Would you say yeah, and he waslike, you know, it's a little
bit let's, it's really hammeredpretty home.
And last week he checked andwas like, yeah, it's pretty good
, other people, you know, givepeople to other people and
people send people to me.
Anthony yesterday in the clinicwas like, hey, this kid's got a
(28:50):
spondy stress reaction, um,flared up a throwing.
Can you just chat with themreal quick and let us know
whether you think we should goto the doctor?
It's like, yeah, I figured athousand spondys I probably have
a better pattern recognitionthan see as many as me, you know
.
But things that I no problem,but if Anthony hears them, maybe
it's not the same register,same way with Mike and elbows
and stuff.
So that would be it.
Lean on other people.
Delegate your case one or twohere there to other people and
(29:13):
then learn from their case howthey treat them.
If you don't have access tothat, research books as much as
you can to try to learn, oronline mentorships are great.
Online forums, chat with people.
You know there's a lot of greatthings online that you can
follow with people.
Speaker 1 (29:25):
Yeah, I agree completely.
I just have that like a reallysimilar tough knee case and I
reached out to probably eightpeople and was like how do I
know that this is wrong and likeif it's wrong, what do I do,
like send help.
Speaker 2 (29:38):
And the imparting thought on this is that as you
get better as a clinician youtend to see harder cases, right,
because people value yourexpertise and people value your
input and value your expertiseand people value your input and
so you know early on you mightjust see the textbook kind of
back pain with like a stressreaction.
But like I've seen some casesthat come from two or three
other people who, like you know,I'm super grateful they fly in
for a one time console and it'slike a very complex case or an
(29:59):
elite who has an old spondy andthey have nerve issues and
they're trying to make a teamand like it's not easy.
So with those higher complexitycases there's nothing wrong
with asking around and gettingopinions from different people.
I referred someone to Ellen, uh, who was a complex spine case
that had some like possible bonedensity issues and she got told
by a surgeon like yeah, neverdo gymnastics, ever again.
(30:19):
And I was like I don't think Iagree with that, but I'm not a
surgeon, how can I say not to dothat?
And so Ellen was able to kindof have a level head around that
being a doctor andunderstanding that case and
she's doing great now but likeit took Ellen and her opinion.
Then there's another.
There's like a PA, anotherdoctor locally, ellen and me all
kind of like what do you guysthink you know, and that's a
regular level nine case.
It wasn't something crazy, sothere's nothing wrong with.
(30:41):
I need help.
I don't know.
Hey, what do you think aboutthis?
And just talking over cases forsure, yeah, it can only make
you better.
Totally yeah.
Speaker 1 (30:49):
They will learn more.
The patient will get better.
Speaker 2 (30:51):
Yeah, exactly, and Mike and Lenny will tell you
that they've picked up a lotfrom me and Dan about hips and
backs, because they treated armsand legs for 20 years, you know
, and now that the last 10 yearswe've all been together, they
treat a lot more.
But you know, lenny and Mikeare mentors of mine and I
(31:12):
considered idols when I was ingrad school and you know them
asking for me advice is like youknow, that's cool to see that
they're still humble and theywant to just help the patient.
They care more about that thanyou know, mike, knowing this or
that Cool beans, cool beans.
All right, hope that washelpful.
We'll get these three out andthen I don't know when we'll
film the next ones down the road, but if people have questions
about these episodes, instagramfor us or email is fine, and if
(31:34):
you want an episode covered likea certain topic, you want more
on email, instagram too, as well.
I think we're pretty open tochat about whatever.
So we're doing good.
I think this is our 12, six,nine, it's like up to 10 or 12
that we've done, so I thinkwe're cooking.
Speaker 1 (31:46):
We're doing good.
Speaker 2 (31:47):
Got this format down.
I like this 30, 40 minute, youknow, debrief.
We'll definitely get Lenny onhere for quad and my situation
and stuff like that, but he'sbusy, unfortunately when we film
.
He's taking his daughter togymnastics.
So we'll get him on here though.
Alrighty, have a good weekend,everybody, take care.
Speaker 1 (32:02):
Bye.
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I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com