July 1, 2025 • 33 mins
Every day we pay our dues by doing the harder thing when it's the right thing to do, especially when managing the complicated early weeks of post-operative rehabilitation.
• Understanding surgical procedures through observation, surgical textbooks, and building relationships with surgeons
• Establishing direct communication with surgeons to obtain critical information rather than navigating complex administrative channels
• Managing pain through appropriate medication, consistent icing, and education about maintaining comfort
• Controlling swelling with compression, elevation, and controlled movement to prevent quadriceps inhibition
• Prioritizing full hyperextension for knee surgeries to prevent complications like cyclops lesions
• Using "consistency over intensity" approach with gentle, frequent interventions rather than aggressive stretching
• Activating key muscles through neuromuscular electrical stimulation (NMES) in conjunction with volitional efforts
• Progressing from assistive devices based on functional criteria rather than arbitrary timeframes
• Applying similar systematic principles across different joints with appropriate modifications for specific procedures
• Focusing on early hip labral repair rehabilitation with controlled motion and gradual progression
We appreciate you listening!
To learn more about SHIFT, head here - https://shiftmovementscience.com/
To learn about SHIFT's courses, check our website here - https://courses.shiftmovementscience.com/
Also, please consider rating, reviewing, and sharing the podcast with your friends!
Thanks :)
Thanks for listening to The SHIFT Show! Check out SHIFT's most popular courses here!
https://courses.shiftmovementscience.com/
Want to join our online educational community of over 1000 gymnastics professionals and get 40+ hours of gymnastics lectures? Join The Hero Lab below!
https://shiftmovementscience.com/theherolab/
Check out all our past podcast episodes here!
https://shiftmovementscience.com/podcast/
Mark as Played
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.
Dan dan will always have like athousand tabs open on his
laptop.
That's like his go-to strategy,okay, yeah, speaking of dan, um
, this episode uh was going tokind of uh progress off of.
You know, if you can't tell, thetheme that I was I was thinking
through the last two weeks waslike I'm very busy in the clinic
(00:27):
.
Probably honestly the busiestthat champions ever been and
definitely the on the busiestthat I've ever been is like
trying to manage a lot of peopleand then trying to understand
how to help people who have avariety of different diagnoses,
and it's a lot to keep up with.
I mean, like, unless you'reworking on like a very specific
type of surgical floor or a veryspecific practice near you that
all they do is shoulders youknow, lenny and Mike, obviously
(00:49):
a lot of knees and elbows, butlike they still see a very wide
array of cases of things thatare going on.
So you kind of got to be nimbleon your feet about like what do
people need and where are theyat along the continuum of rehab,
and so, building off of thething that I think is the most
stressful for people is I wantto do an episode sharing kind of
the systems that I use toapproach very acute people
surgeries, very acute injuries,um, that have been cleared of
(01:10):
like serious pathology andgetting them through more or
less the first eight weeks,because that is extremely
intimidating when someone is ina ton of pain, um, and really
doesn't know the best way toapproach that.
So that's where my head was at.
Speaker 1 (01:33):
I'm not sure if you want to share an experience on.
You know your initial gettingyour feet under you with acute
care and how you developed moreconfidence and stuff like that
was just looking at swelling,looking at range of motion and
then looking at simple strengthmeasurements.
And then I did that like everysingle time that they came in to
see where they were progressingand see if we needed to change
up anything or just to make surethat they were making progress
(01:53):
each session.
Speaker 2 (01:54):
Yep, I agree, um, and I would add to that too.
I think that it doesn't reallymatter what diagnosis or what
surgery they're coming for, buteven if the person comes to you
for the post-op visit beforehand, you want to have a really good
working knowledge of thesurgeries you're seeing.
Generally and we kind of talkedabout this with Dan is that try
to put a third, maybe a half,of your content education into
(02:15):
like, okay, I see a lot of kneeACLs, I see a lot of
meniscectomies, I see a lot oftotal knee replacements, because
we have three knee docs thatare, like you know, in this
local practice.
So the more that you know theanatomy and the more that more
that you know the injuries, thepath, the mechanics.
Oftentimes you don't see thesepeople pre-op, before they come
to you, so you're kind ofgetting a first glance of you
know.
You got to get to know somebodyand make them trust you and
develop a rapport and haveempathy.
(02:36):
At the same time you have stuffto do in an hour or 45 minute
eval.
So try your best, as a precursor, to know what does each joint
kind of have for major surgeries.
That I'm probably going to seeand I think that helps you, as I
said in the last episode, helpsyou be a bit more nimble on
your feet in the clinic and kindof answer questions more
fluidly, versus like I don'tever treat ankles and now I have
an Achilles repair in front ofme.
That's, you know, four monthsor four weeks post-op or
(02:59):
something like that.
So do yourself a favor and tryto be a bit ahead of the curve.
Versus like you see all ACLsand you want to learn about
concussions, so all you'retalking about is concussions
Nothing wrong with that, but youhave to laser focus on what's
in front of you.
Speaker 1 (03:10):
You know what I mean Absolutely, and I think if
you're in a space where you cango watch a surgery, that's
probably one of the biggestthings that helps me with
answering questions aboutsurgery, Cause I've I've been
through it.
So when, especially with mypre-op kids who are, you know,
they haven't gone through thisprocess yet I can say I know
where they're going to go, Iknow what's going to happen when
they walk back in the room.
(03:30):
I know what's going to happenwhen they wake up, Like I know
what happened during theirsurgery, and it puts watching
videos or actually going towatch the surgery itself.
Just everything looks so muchdifferent than you might have
like thought in your head, Likeit.
Just I think it changes thegame a little bit when you can
actually see the surgery andlike see what they do and see
what happens, Cause I mean therewere definitely a couple of
(03:51):
surprises that I had like like,for example, like I went and
watched a TTO surgery.
I don't know if you've ever seenone of those, but it was like
gruesome.
I was like, oh my God.
I thought this was like alittle basic surgery where you
just like take the little pieceof bone and just move it over.
Oh no, hammering.
Oh yeah, the bone out.
Speaker 2 (04:08):
I was like whoa.
Yeah, I understand why they'rein so much pain now Like, yeah,
exactly I was trying to uh showmy, my uh bookcase but my
headphones were connected but Ican maybe turn my computer.
But like I just have like a, a,a bookcase of like different
books that I really enjoy, likethat I've read all the time but
I was able to invest via likeshift and company work.
But like your clinic shouldhave a surgical hip book.
(04:29):
You know what I mean.
There's like surgical textbooksfor the hip, uh, athlete,
shoulder with with Mike andLenny, so like if you can't
afford them yourselves, but likeknee disorders by noise that's
like a 2000 page textbook.
And if you have those in theclinic, you know, the night
before or the morning of or evenin the moment, if something
comes on you're not familiarwith, you can kind of scoot to
the back real quick and be like,oh, let me just look this up
real fast and see what thatsurgery was and like what's
(04:50):
going on.
Bob, obviously the protocol willbe different from a doctor that
you see, but you know thosesurgical textbooks and the
combination of ones, like Mikedid with everybody, were super
helpful.
But the hip one is from theguys at HSS.
I want to say what's his name,I forget, I can't think of my
head, but he essentially editedthe entire hip repair, surgical
repair book.
It's two volumes, there's ashoulder one, there's an ankle
one.
(05:11):
So reading those chapters ofwhat you commonly see are really
helpful.
But then also having those inthe clinic to kind of refer to
and understand like, oh yeah, itmakes sense why this person's
really having a tough time withclot activation because they had
this huge LAT and they had thishuge meniscus repair or like
whatever it is.
So, um, yeah.
So on the second piece of thatI would say is you made a really
good point, which is thatunderstanding the surgery or
(05:34):
visiting surgeries is good foryou, but establishing
relationships with doctors andbeing a face and seeing them
right, I think the best thingyou can do is be a bit nimble
and understand the surgery soyou can ask good questions.
So you know, don't pestersurgeons because they're so busy
and they have a lot going on.
But once in a while, you know,if I have clarification that I
need, I can call a PA or someonethat I'm very friendly with and
say, hey, like what do you?
I don't have any post-op stuff.
(05:55):
They didn't come in anythinglike what do you want to do with
the brace?
How long for the brace?
How long are they weightbearing?
Do they kind of meniscus repair?
How many anchors like you canask those very quickly in a
three minute phone conversationand I forget when I posted it,
but I've gotten to the pointwith a lot of surgeons in Boston
that I work with that likethey're very, very friendly and
very nice If you deliver veryquick, need to know information
and you ask, need to knowquestions.
(06:16):
We have like cell phones of alot of the team docs that are in
Boston and you know this doctor, dr Ramappa, who's amazing.
He does a lot of the labor,repairs the surgeries on
shoulders and stuff or ACLs thatwe see with like a lot of the
high level gymnasts, and sohe'll scrub out and call me and
leave a 13 second voicemail onwhat he did and that helps me
exponentially more than tryingto call his front desk who leads
(06:38):
me to the PA, who looks up thenotes for the doctor, who sends
them back to the PA, who sendsthem back to the.
You know it's all like thisroad of nightmares.
So if you can get enoughexposure with people and refer
back and forth, they start tosend you people and they're very
friendly with you and helpingyou.
So that's the best thing I'veever done, because I can
literally call docs from BostonChildren's like, hey, I'm with
this person right now.
Um, what do you think about this?
(06:58):
This and this?
It's a 17 second phoneconversation and then we move on
with life and it's great, youknow.
But I've been to ramapa'soffice.
I mean, my mom had surgery withhim and I've sat with him and
I've talked with him and heknows mike and lenny really well
.
But whatever the doctors inyour area are, try your best to
be on board with them.
You know what I mean?
Is choa directly in a hospital,right?
Speaker 1 (07:16):
yeah, so you guys have a benefit of that, you know
yeah, we're not like in thehospital but we have, like my
clinic, for example, has likethe ortho side right across the
hallway, so like if I have anyquestions I usually just as long
as they're over there I'll justgo question them about whatever
I need.
But we also have the luxury ofhaving Epic and so I already see
like all of those no, it's likethey're just like in there, so
it's easier than trying to likemake sure the patient brings it
(07:37):
or like trying to look it up oryou know, trying to get a
patient to bring all their stuffand obviously their mom can
help but like they are often ina lot of pain and very high and
very stressed out about theirsituation.
Speaker 2 (07:48):
So I was actually going to share the outlines that
we make so that we can gothrough this together.
Let me make sure I have theright tab open.
Yeah, so I just had twoexamples here of things like if
I see somebody post-op for anACL, for example, or just a knee
surgery in general, meniscusTTO has a little bit of
obviously different but likeMPFL reconstruction, there's
probably going to be a handfulof things that you want to know
from the beginning.
So before you do all this, youwant to try to get an operative
(08:10):
note, you want to try to get adiagnosis or some sort of PT
eval, you want to try to get aprotocol or precautions right.
So you need to know thosethings ahead of time.
What are limited you can't doand I'll.
There's an example I have rightnow is literally a kid who's
five days post-op um ACL, bonetendon graft, lat and a meniscus
repair.
So medium meniscus repair.
So he's non-weight bearing forsix weeks because their meniscus
(08:31):
repair is pretty hefty.
He is not allowed to bend past90 degrees for six weeks because
the meniscus repair is prettyinvolved.
And then, um, they have him ina brace for six weeks crutches,
I want to say, for I don't evenknow how long.
It depends on his weightbearing progression.
But that's like baseline rightand so like you have to know
those things going into it.
We'll talk about the hip oneseparately.
But there are differentprotocols and different
restrictions on purpose forcertain tissues because you
(08:53):
don't want to compromise thetissue.
So a rotator cuff repair, abiceps repair, a hip labor
repair, an Achilles tendon thing, there are very set
research-based guidelines thesurgeons use to have
progressions for these peopleand the exercise selection
oftentimes, if they do a greatprotocol, is based on that stuff
too as well.
So you want to have that inyour background of kind of do
your homework to know what thesurgery is and what the protocol
is.
And if they come to you andthey don't know what surgery
(09:15):
they had I've literally had thisbefore what surgery to have?
I think about a kid.
He's a level 10 gymnast.
He tore his ucl and had atricep repair.
He's doing a ginger, justliterally dislocated his elbow
and blew his arm up.
He came six week post-op and Iwas like, yeah, man, like what'd
you have done?
He's like I don't really know.
They like cut the inside andlike the back's repaired.
I was like that's a big scar.
I'm like, did you have atriceps repair?
He's like, yeah, maybe.
I was like what, bro?
I was like you're killing meright now and his mom was there,
(09:35):
but his mom had left to go, youknow, do something else with
his other uh brother.
So and I'm like, did he have aUCL repair?
Did he have an augmentation?
Did he have a TJ three?
I have no idea.
So we did the basics of whatevery elbow needs and didn't go
outside what I know the limitswere.
And then, as I got moreinformation, we kind of
progressed things for it.
So on a knee situation, right,the big rocks that you're trying
to get through just throughthis list is like pain, right,
(09:58):
pain management, pain affectseverything If it quad inhibition
comes with that.
So there's meds for a reason,right, like dosage of a high,
higher grade dosage.
Drugs are there for a reason,in the first few weeks to sleep
or kind of get through PT, tomove um.
Tons of ice right, especiallyat night before they go to bed,
because it's super painful.
They're oftentimes on like aCPM combined with some degree of
an ice machine to as wellrotating, and that doesn't help
(10:19):
with swelling, right, but thatdoes help with pain management
and if you don't have as muchpain you can move more often and
tolerate more exercise.
So don't poopoo ice.
I know a lot of people who arelike don't use ice ever because
it's going to delay healing.
But like I'm telling you, ifyou have a massive rotator cuff
repair and you don't want totake a lot of drugs, ice is your
(10:40):
best friend to get through thatfirst couple of weeks.
And they have a TED stockingsometimes.
And then after a couple of weekswhen the stitches come out, you
can wear like a knee sleeve ordo an ACE wrap or something like
that and then just regularmotion, right, like I'd rather
somebody do 10 to 20 repetitionsof hyperextension, inflection
every hour for the entire daythan one epic stretching session
where they push their knee toomuch and it gets too cranky.
(11:01):
Then they're flared up and theyreally can't tolerate anymore.
So pain's massive.
Educating a patient on theirprecautions, what they can do,
what they can't do, you know youcan't weight bear, you can't
bend your knee when it's on theground, you can unlock your
brace and sit if you cancomfortably get past your limit,
but not past 90 because there'sa meniscus thing.
So you need to be very clearand tell them about what they
can and can't do and oftentimeseducate their parents or
(11:23):
whoever's like their caregiverthat's with them, because the
person again is probably oncloud four, you know, with an
oxycontin pumping through theirsystem.
They're not really with youright now.
So trying to uh kind of getthrough all that.
And then you think about whatare the most immediate emergent
things that have to happen tonot have an issue come up.
And the biggest thing for aknee is full hyperextension to
prevent a cyclops lesion, right,so you have to get someone's
full knee hyperextension towithin a couple of degrees of
(11:46):
the other side, because, um, ifthey get scar tissue in the, in
the neural gutter of their ACL,they can't ever get full
hyperextension back.
And then you're really in a ina tough situation.
And we've done you know somethings on the Mike Ronald show
about how to do that and longload stretching and stuff like
that, but, um, that's likepriority.
Number one is like protect thegraph, get the swelling down,
get the pain down, um, helpsomebody understand their
(12:06):
precautions and gethyperextension back.
It's like the immediate firstsession.
If you didn't know theirsurgery, you didn't know what's
going on.
Most of those things are okay,depending.
Maybe if they have like ananterior meniscus repair, you
wouldn't push hyperextension.
That's a nuanced thing, butmost people that's pretty good,
along with making sure theincisions are clean, covered,
stuff like that.
So I'll probably go like fiveat a time and then we'll stop
and chat in case you have anyquestions.
But does that make sense?
(12:27):
Is there anything in there thatI think you know I went over
too quickly or it doesn't makesense?
Speaker 1 (12:30):
No, I pretty much follow all those same rules too.
I think hyperextension is oneof the biggest ones.
I feel like we miss asclinicians making sure that
you're actually measuring, evenif it's five degrees
hyperextension.
but also it is hard to get likea quad set or do a straight leg
raise without your extension,Like if you cannot extend your
(13:00):
knee all the way it is reallyhard to like fully contract your
quad If you've sat around andtried just like with your knee
not all the way straight to tryand contract your quad.
It's so hard.
So I think missing extension isone of the biggest things that
I think people are missing outon early on in the rehab process
for post-ops.
Speaker 2 (13:18):
Exactly too, and I know the other side of the
pendulum is surgeons get nervousabout stretching the graft out.
But we're not talking aboutlike end range 10, 15, 20
degrees.
This is going from negativefive to plus five when somebody
has 10 on the other side right,we're just trying to get them
enough.
There's a lot of long-term,like a moon group outcome
studies that show that peoplewith hyperextension within a
couple of degrees of the otherside overall have better
outcomes long-term Right.
And there's a whole notherrabbit hole about why, like you
(13:38):
know, having not hyperextensionleads to like some quad
activation and some some uhscarring, but also just problems
when they try to go to strengthtraining or run or jump.
So the hyperextension is veryhelpful and on top of that, you
know six and five are flippedhere.
But patellar mobility is superimportant early on because
regaining your full kneehyperextension requires superior
patellar mobility and tiltingside to side.
So oftentimes they have, youknow, a scar above or below if
(14:00):
they have a BTB um patellartendon or a quad tendon graph.
So you just work around thatyou know it's not the most
comfortable thing in the world,but you put gloves on and you
teach somebody how to go up anddown and teach them on their own
, because if they can get morepatellar motion they're going to
get to end range hyperextensionand if they get more inferior
gliding over time as the scarshere, they're going to get more
comfortable flexion right.
So, um, back to your pointabout um quad strength and
(14:23):
getting that back very early on.
The hardest thing to do is geta quad to turn back on.
Between you know the nerveblock and some of the issues
like that.
But even trace amounts ofswelling 40 CCs of swelling, 40
cc's of swelling in the kneeinhibits the quad quite a bit as
a protection mechanism.
So if you have somebody who hasthis big ballooned knee, it's
very hard to get them to get aquad set and then a leg raise
which eventually helps them walk.
So the best tool we have forthis is like NMES, like a
(14:45):
trigger-based NMES, where youput two pads on their quad and
they volitionally try to controla quad set as much as possible,
but they turn the stem up sothat they can do it on their own
.
Some units are like time-based,like five on, 10 off or
whatever.
But the first day post-opsomebody comes to us, we have
the quad, you know, uh, themachine on and they're doing
their own tolerance and stuff.
And I'm doing assisted quadsets, assisted leg raises,
(15:07):
passive hyperextension with atowel or a belt.
Um, they're just reppingthrough those because, you know,
the faster you can get somebodyto turn the quad back on, it's
a, it's a positive flywheel,right, if your your knee is less
swollen and your quad works abit better, you can maintain
hyperextension a bit easier,which means that eventually,
when you start to get off yourcrutches and brace, you're going
to walk smoothly.
So we want to facilitate, youknow, swelling and kind of
motion because it helps kind ofget the fluid out and helps the
pain reduce when someone's notafraid of their knee.
(15:36):
But, um, pretty big surgery forher ACL and she was just very
hypersensitive.
You know she had like some verylike couldn't touch her scar,
she was very nervous, she wassqueamish, it was like hard.
She just had like a very mildCRP yes, I think, starting, and
we just had to more or less saylike every 30 minutes, you know,
move your kneecap up and down,get your knees straight, try to
flex your quad as hard as youcan.
And she's three months now andwe're going to have an uphill
battle with getting her quadstrength back but she gets the
plus eight hyperextension.
(15:57):
She's out of the woods but shegoes from two to eight within
one session.
She's at two when she comes inbecause of her quad is not fully
strong and fully active.
It's not activelyhyperextending her when she does
exercises.
So he in soft own two moretimes that day and then just
hammer her quads over and overthree times a week.
So it's hard.
(16:22):
But quad soft tissue orhamstring soft tissue to help
somebody regain hyperextensionis very important.
So yeah, swelling patellarmobility, quad activation with
NMES, regular exercise whenthey're ready for the bike.
Maybe not a revolution of thebike, but you can get somebody
kind of like halfway on eachside to get them to like 90
degrees.
Um, yeah, I think those areprobably the next ones.
Speaker 1 (16:37):
You have any extra ones to add there before?
Yeah, the only thing I wantedto say, with like hyperextension
, I had two things.
One, when we're trying to gethyperextension, obviously we're
not like pushing it down reallyhard.
In hyperextension it's more oflike I'll, you know, put an
ankle weight over there and justsit there for like five minutes
, you know, and just like let itkind of droop down with a heel
prop.
And I think one of the biggestlike pieces of education that
you can give to like the familyand the patient is to make sure
(17:00):
that you're not putting anythingunder the knee.
Speaker 2 (17:02):
Right, I feel like.
Speaker 1 (17:03):
I get that all the time where they're like sleeping
at night for like eight hoursand they've got a pillow under
the knee Cause that's like themost comfortable place to be
Right.
If you're like in that littlebaby bend, you got a little blow
under there and it's socomfortable and like do not do
it, cause you're just going toend up stuck missing that.
You know like five to 10degrees of knee extension and
that's going to put you in areally bad place.
And I always tell them I'm likeif we start to miss extension,
(17:23):
it's going to push our timelineback.
So like exactly hammer homeextension, cause it's going to
push your timeline back morethan you think with your
strength and motion for sure.
Speaker 2 (17:31):
Yeah, and I agree, yeah, go ahead.
Oh yeah, and swelling too aswell, right?
Um, I think that it's better tojust take the entire mindset
with post-ops especially kneesof like consistency over
intensity.
I'd rather do stuff multipletimes per day.
Prop your heel up with a heatpack and a lightweight and just
scroll through tiktok, watch anetflix show while it just kind
of sits there passively for 10minutes, right, versus this big
epic stretching session whereyou make the knee a little angry
(17:53):
and and hyperextension issometimes a bit more passive and
easy.
But same thing with flexion orsorry for hyperextension.
I know like prone hangs arevery popular in many circles,
but like that oftentimes willcause a hamstring contraction
which makes it like you'refighting uphill both ways.
Gravity's pulling down, ithurts their hamstrings, firing
back and forth.
So we personally don't usethose and Lenny has some really
great videos on the metrics ofthat.
(18:14):
But prop hyperextension with aknee and a heat is probably our
go-to way.
Speaker 1 (18:18):
I just had a conversation with my coworkers
about that Cause.
I was like I feel likeinitially, when I was starting,
I like I feel like a lot ofpeople did that and I was I
started doing that and then atsome point in time I don't even
know when I just kind ofchampion.
No, it was after.
It was like when I started likemy job, yeah, like when I
started residency here, and thenat some point I just kind of
like stopped doing it and one ofmy other co-workers like
(18:40):
started doing prong hangs and Iwas like why did you start doing
?
that or like what was yourreasoning?
Because I guess I was trying to, I don't know.
There's one kid that we wereworking really hard on her
emotion, that we're tryingeverything that we possibly
could.
But I agree with you.
I feel like, no matter theweight, like it's really hard
for them to relax in thatposition if they're tight or if
it's painful or uncomfortable,especially if it's uncomfortable
over the front of their kneeand any of their knees on the
(19:02):
table and they take that quad weget mostly quad graft so like
they take that piece of quad outright above the patella which
is going to be right wherethey're going to put their.
Like that pressure is going tobe pushing on the table right
over that piece.
It just gets irritated andangry and it doesn't.
Speaker 2 (19:17):
Yeah, and you can sometimes do like you know.
We have like the ice bags thatare saran wraps that you open up
to put over the incisions.
You can put like the ice bagover there and then another
layer of like a towel orsomething that's going to be not
as direct contact of the heatpack on top of their need.
That might sometimes help, likethe sensitivity of the skin a
little bit more.
Um, but yeah, I think trying todo regular hamstring type stuff
or stretching lightly and thenget the hyperextension that way,
(19:38):
and then you know, with seated,with flexion too as well, I
mean, gravity is your bestfriend when you're sitting over
the edge.
I used to supine people andjust crank on them, cause I
thought that's what you diduntil I met Lenny and thought
about, if you know, shoot theshit and be casual.
And you know another ACL that Ihad.
Um, he had surgery last Thursdayand I saw him Monday, so five
(19:59):
days post-op.
There was a delay in the CPMgetting there.
The person didn't know how toset it up with instructions, so
I was the first person whowanted to wrap his leg and bend
his knee in five days.
He was just straight the wholetime.
Homeboy was not happy.
He's a good kid, really nicekid, but we barely got him to 35
(20:20):
degrees right.
It took three bouts to pass arange of motion to barely get
him to 90.
He's the one with the LAT andthe meniscus repair.
So obviously more surgery, moreswelling, but we had to.
You know, just talk aboutNetflix and talk about the Red
Sox game and I'm just trying toignore it and like just really
relax and sneak a bit here andhe jumps off the table and then
Ooh, it's all good, and then wego do exercise, then we come
back and do another bout ofmotion in the hour, then we do
another set of this, then wecome back and do another bout of
motion in the hour.
So try your best to know thatit's going to be uncomfortable
(20:41):
but like, make light of thesituation, sit people on the
edge.
You don't just sit there andhammer on their knee bent,
because it's very hard to relaxwhen someone's towering over you
, yanking on your knee andflexing.
Speaker 1 (20:55):
So yeah, yeah, yeah, hyper extension and C deflection
.
Speaker 2 (20:56):
Are you getting CPMs?
For most of your?
Yeah, yeah, most of them um,most doctors want them in the
CPM like eight hours per daybecause of, um, the concerns for
stiffness.
You know, a lot of these peopleare big surgeries, like an LAT,
acl, meniscus, and so they'reworried about motion stiffness,
but they're also worried thatperson's going to push past
maybe a protocol limit so we canset an MPFL reconstruction to
30, right, and not go past that,versus someone who's going to
(21:16):
go to 90 or 60.
So, yeah, most of them aregetting CPMs, yep.
Speaker 1 (21:20):
We don't really get that here.
We get CPMs for, like any ofour OCDs and our knees, but,
like, hardly ever do we get thepatients get CPMs for yeah,
there've been a couple ofpatients where I'm like I would
love to have a CPM.
Speaker 2 (21:34):
Oh yeah, for sure.
Speaker 1 (21:35):
Get them to emotion and I feel like it improves
compliance so much because it'sso easy you just stick your knee
in it and you just go.
Speaker 2 (21:44):
It's like, yeah, this kid that I was talking about.
On Monday he came to PT and Ithink he could feel the aura
that I was like brother, we gotto get on this thing.
You know what I mean, but hewent home and he put himself on
the CPM and set it up and hefell asleep.
He fell asleep for two hours,yeah, so he was just like
chilling out.
I mean, probably there wereoxys involved, obviously, but he
was just chilling there and hegot.
When he came back on Thursday,three days later, he was at
(22:04):
sleep 65, right.
So he doubled his motion byjust daily CPM, consistently
nice and easy, wasn't crankinghis leg, you know.
So he alternated betweenhyperextension, quad sets, basic
CPM, just really really easyopen chain stuff, and he was
much less painful as hisyesterday and um, much more
comfortable with all of PT.
You know, leg raises the nextthing we'll tackle, but um, yeah
, so, um, basic consistentadvice is probably good for that
(22:27):
.
And the last thing that alwayscomes down to is like gate.
You know you want to normalizesomeone's gate as fast as
possible.
So I will say it's a bit murkywhen the surgeons aren't really
like clear about when you canunlock a brace.
In this case, one of the kids,six weeks non-weight bearing,
you know, locked in extensionbecause the meniscus repair.
But the other person, um, whohad the LAT as well, um, you
know the, the surgeons see themone week post-op and six weeks
(22:47):
post-op one week for the surgery, stitches, and then, you know,
another six weeks later for justto check up generally.
So in that time though, they'regenerally want to get off a
brace and get off crutches right, they say crutches two to four
weeks weight bearing istolerated for most ACLs and then
unlock the brace when you quote, have quad control, like
involitional quad control.
So I think that the best way tothink about it is, when you're
(23:08):
locked in the brace you want togo from two crutches to one
crutch, you know, in two hourspurts.
So when you first wake up inthe morning, get the knee heated
, get it kind of ready, do someexercise, and then do two hours
on two crutches or on one crutch, and then go to two crutches
for the rest of the day.
The next day add maybe one ortwo more hours, and then
throughout the course of theweek, on Sunday to Sunday, you
go from two hours on one crutchto eventually getting up like
(23:30):
the full day on one crutch andjust being around your house,
maybe at the end of the day ifit's a bit sore, and then you do
the exact same thing with onecrutch, is that when you're at
home.
Try to spend two hours whereyou're doing no crutches but you
have your tabletops around youand your couches, in case you
want to, kind of the day with nocrutches versus you had like
two hours on one crutch or sorry, two hours on no crutches, you
(23:51):
added one crutch at school orsomething like that.
So I find that with like comingout of boots or coming off
crutches, it's better to do twohour stepwise progression to not
make someone's knee prettyangry.
And then in PT you obviouslywant to be the first person who
tests an unlocked situation andwith most ACLs that are weight
bearing, you know you're doingmini squats, you're doing weight
shifts, you're doing open 9050s, you're doing closed chain.
(24:11):
You know stuff a little bit.
So I have three right now thenon weight bearing meniscus.
One is obviously locked, butthere's another one that's two
weeks post op was an ACLmeniscus and he's weight bearing
is tolerated.
They want him to get off hiscrutches in two or four weeks.
So he's doing mini squats andweight shifts and he's pretty
good with hands on the table sothat in a week or two when his
quad is quote, unquote back andfor me that means like you're
(24:31):
doing leg raises in eachdirection.
You have a pretty solid 90 50contraction.
You can do a mini squat prettywell.
Um, you're doing weight shifts,maybe some mini step ups like
that's showing me that you havebasic volitional quad control.
We would unlock the brace maybeto 45, which is what you need
for functional ambulation.
So zero or hyper extension to45 so that when walks he has
like a little bit of a swingwith him.
But you know, god forbid,something happens where he slips
(24:52):
or something happens, his kneesnot going to bend fully to 90.
So that's kind of, you know,probably going to happen for him
at four weeks.
I think the other girl I want tosay it happened at six weeks
because she had a pretty, like Isaid, ami case of mild
sensitivity.
So she was off her brace around, I want to say six weeks.
After four to six weeks we keptthe brace but unlocked it and
she slowly weaned off thecrutches.
(25:12):
So at four weeks she was offcrutches.
But that progression from fourto six weeks it was like unlock
your brace for an hour, walkaround your house, go to the
bathroom, you know, do yournormal stuff, but then lock it
at school and make sure you'resafe when you're, when you're
getting walked by in classes andstuff.
So, yeah, that's the next bigthing and you know that whole.
You know 12 things, right?
There is more or less the firstsix weeks of acute ACL or knee
repair, right?
(25:33):
Um, yeah, any additions on thatCause?
The labor one is the same thing, but just in a different
context.
Speaker 1 (25:38):
Yeah, not really.
I feel like unlocking the bracefor me if they can, kind of
similar ideas.
But as long as they can standon one leg pretty solidly for 30
seconds and they can do adecent step up, Like I like to
see that they can do a step up,just in case like again, like
just being able to, like, almostlike, catch themselves that
they were to step wrong, orsomething.
Being able to do that, I think,is important?
Speaker 2 (25:58):
Yep, for sure, um.
And so here on the uh, I'llslide down to the next one.
Um.
So for hip labrum, I took theexact same kind of uh thoughts I
would say like of thecategories and I tried to, you
know, apply them to what itwould be maybe in a in a labor
repair.
So we won't go into it deep now.
But labor repairs are very, umare variable based on how many
sutures are put in.
(26:18):
Do they have any boneinvolvement?
So did they have like a pincherlesion debrided or a cam lesion
debrided, which would be anosteoplasty.
So acetabular osteoplasties withcapsular closures are treated a
bit more like a cartilagesurgery than a labor repair
surgery, because you have topull down and delaminate some of
the cartilage to repair it.
So they're a lot more cautiouswith weight bearing versus
somebody who just had a laborrepair with no osteotomies at
(26:40):
all.
They're going to be probablyweight bearing is tolerated, but
they probably will have a brace.
So pain is the exact same thing, right?
Meds, ice, reduce your swellingaround the hip.
There's you can't see it asmuch in the hip versus a knee,
but there's obviously a lot ofswelling going on.
So look at the incisions.
They usually have three portalholes to make sure they're clean
, they're not rubbing on theirskin or their underwear or
something like that if they'rewearing running shorts.
And then regular motion too aswell.
(27:01):
Is that you know the the kneeprecaution situation is that if
you have a meniscus repair orsomething, you don't go past 90
with flexion but you can havefull hyper extension with a hip
label repair.
You oftentimes are limited to90 degrees of passive motion.
Obviously don't cross your legs.
So no ir past a certain 10degrees but then no er for 40
degrees because you don't wantsomebody to have, you know, too
much stress on the labral tissue.
(27:21):
So passively when you're doingmotion you want to do to those
tolerances and you want to kindof work in the mildly abducted
yard plane, because that's howthe scap or the acetabular plane
kind of lines up, normally thesame way that like a scaption
plane in the shoulder we don'treally range in close flexion
because of the impingementpossibly in a rotator cuff.
So we put them slight abductedjust to kind of clear more space
.
So I do all my passive range ofmotion there.
(27:44):
And then also the version ofhyperextension, propped and knee
flexion is circumduction andlog rolling for somebody who's
labor-opera, becausecircumduction and log rolling
aren't closing the femoral neckon the tissue that was repaired,
but it's moving the hip jointin circles or moving the
synovial fluid around quite abit right.
So you want to have regularmotion.
They can't circumductthemselves.
But in PT a lot of your work iscircumduction, log rolling,
(28:05):
basic tolerance to flexion, irlightly on their back, log
rolling, basic tolerance,deflection, er, ir lightly on
their back and then within theirprotocol they'll probably have
those restrictions of how long.
It's typically four to sixweeks, based on kind of how
involved the surgery was.
But it's the exact same thingas like a knee has like patellar
mobility and this and that youknow a quad head or a hip has
some quad and adductor softtissue.
That's probably pretty helpful.
It has circumduction, it haslog rolling and stuff.
(28:27):
And then after a couple ofweeks you know they're on there.
Um, they have a hip brace that'skind of locked in to prevent
them from abducting or abductinginside neutral, but that kind
of lasts for you know, up tofour weeks and the exact same
progression will happen.
If they're just a labor repair,they're going to be, weight
bearing is tolerated and it'sthe exact same crush progression
.
You know two hours and then gofrom two to one.
Make sure you're not limping.
Uh, you don't want to hyperextend your hip too far, um,
(28:50):
because it passes zero becauseof that.
So you have to take very shortsteps.
You can't, like, take a longstride with your leg behind you,
because that will pull on someof the anterior tissue.
Um, they oftentimes have noactive hip flexion as well, um,
but the the version of, uh, youknow, propped hyper extension
for the knee is prone lying inthe hip.
So a lot of surgeons want thesepeople on their stomach for
five to 10 minutes throughoutthe day multiple times, just to
(29:11):
prevent the risk of any scarringin the anterior tissue where
they put the portals through andstuff like that.
So lying on your stomach is thesame as prop hyperextension to
get that motion back.
And then they generally usequad rocking as the main way to
get patient controlled flexionback, in the same way that if
you're sitting on the table athome you would put your own
other good knee behind your badknee and use that to kind of
bend your knee or a CPM.
(29:32):
So the analogous CPM is is quadrocking make sure your knees
are apart and make sure yourhips are slightly turned out.
So we're clearing that space.
Um, but literally all the exactsame things.
Is a checklist for the knee?
It's the exact same approach toa hip, it's just about what
surgery, what's the jointdiffering?
You know, shoulder has its ownset, elbow has its own set,
ankle has its own set, wrist hasits own set.
You know it'd be a two and ahalf hour episode to go through
(29:54):
them all, but the principles arethe same that if you do the
work we said about reading andunderstanding, talking to
surgeons, taking courses, you'llget to a point where, between a
protocol and your own knowledge, you feel pretty confident with
you know, the first, definitelythe first couple of weeks that
are terrifying for new grads orpeople who have not seen a lot
of post-ops, but up to the pointwhere when you're off crutches,
then it becomes more about like, okay, how do we start a
(30:18):
strength program?
You know, how do we startprogressing?
Speaker 1 (30:20):
Make sense Yep.
Any questions?
No, we pretty much do all thesame things.
I think crutch training is moreimportant with the hips than it
is.
Speaker 2 (30:26):
Totally, but more sensitive than yep because it's
hard to do stairs without usingyour hip a little bit yeah for
sure.
Speaker 1 (30:34):
Yeah, so I just like to prevent any sort of like
inflammation or irritation atthe like interior hip with like
your hip flexors, because theycan like just they get
overworked, especially if I havea lot of kids that are like
going to school and they'redoing their schools are just so
spread out and they're doingwalking and I'm like I don't
want you in a wheelchair, butlike yeah too, and um on the.
Speaker 2 (30:55):
The same kind of point of the quad turning back
on in the knee is that theglutes and the glute med are of
the hip so, like lots of glutesets, lots of lateral abduction
raises, if they can't toleratethat, just line your back and,
do you know, pass, or supineslides on a towel in and out.
There's lots of modificationsand when you do start somebody
back with active hip flexion,that's probably best done in
side lying or in somethingthat's a little bit less intense
(31:17):
than anti-gravity.
So, yeah, I have a patient.
I have two labral repairs rightnow and one of them is like
literally on it.
She's cleared to do a hipflexion fully, but she can't do
a full anti-gravity to 90 hipflex because it's just like
hasn't done it.
She had a huge repair so theydidn't let her for six weeks.
If you didn't use your arm forsix weeks it'd be hard to do a
bicep curl.
So just lie on sideline and, doyou know, she's perfectly fine
to do it in sideline.
(31:37):
There's gravity taken away.
Speaker 1 (31:39):
Yeah definitely I do a lot of isos yeah, oh yeah,
tons of isos, for sure, I haveaddiction and then with hip
flexion I just try to minimize.
I honestly don't do a lot ofhip flexion and initially if
they're weight bearing, becauseI know that they're doing a lot
of like stress with walking andwalking in normal stairs when
you get off your crutches is hipflexion.
Speaker 2 (31:57):
You know it's like you have to use hip flexion,
which is why the the crutchprogression of like six weeks is
often lines up with the activehip flexion of six weeks as well
.
We can't climb a stair without,you know, somewhat involving
your hip flexor.
I think it's more along thelines of like loaded hip flexion
they're worried about.
Sure, yeah, um, cool, so we'llkeep this one to 30 minutes and
uh, yeah, hopefully that washelpful.
Um, I think I, I knew, I knowthat I wish I had something
(32:19):
along the lines of like a basicsystematic approach and, like I
said, if you just tackle maybeone month on each joint, you and
your homies at the clinic, andkind of get yourself together on
a good like, okay, here's theimmediate must do things, and
then here's the next yellow flagthings.
Then here's the next end of thestage goal by six weeks or
something like that.
But, yeah, hopefully that washelpful.
Yeah, all right, we'll see youguys in the next one.
Bye, bye.
every day.
You essentially pay your duesby doing the harder thing when
it's the right thing to do.
Dan dan will always have like athousand tabs open on his
laptop.
That's like his go-to strategy,okay, yeah, speaking of dan, um
, this episode uh was going tokind of uh progress off of.
You know, if you can't tell, thetheme that I was I was thinking
through the last two weeks waslike I'm very busy in the clinic
(00:27):
.
Probably honestly the busiestthat champions ever been and
definitely the on the busiestthat I've ever been is like
trying to manage a lot of peopleand then trying to understand
how to help people who have avariety of different diagnoses,
and it's a lot to keep up with.
I mean, like, unless you'reworking on like a very specific
type of surgical floor or a veryspecific practice near you that
all they do is shoulders youknow, lenny and Mike, obviously
(00:49):
a lot of knees and elbows, butlike they still see a very wide
array of cases of things thatare going on.
So you kind of got to be nimbleon your feet about like what do
people need and where are theyat along the continuum of rehab,
and so, building off of thething that I think is the most
stressful for people is I wantto do an episode sharing kind of
the systems that I use toapproach very acute people
surgeries, very acute injuries,um, that have been cleared of
(01:10):
like serious pathology andgetting them through more or
less the first eight weeks,because that is extremely
intimidating when someone is ina ton of pain, um, and really
doesn't know the best way toapproach that.
So that's where my head was at.
Speaker 1 (01:33):
I'm not sure if you want to share an experience on.
You know your initial gettingyour feet under you with acute
care and how you developed moreconfidence and stuff like that
was just looking at swelling,looking at range of motion and
then looking at simple strengthmeasurements.
And then I did that like everysingle time that they came in to
see where they were progressingand see if we needed to change
up anything or just to make surethat they were making progress
(01:53):
each session.
Speaker 2 (01:54):
Yep, I agree, um, and I would add to that too.
I think that it doesn't reallymatter what diagnosis or what
surgery they're coming for, buteven if the person comes to you
for the post-op visit beforehand, you want to have a really good
working knowledge of thesurgeries you're seeing.
Generally and we kind of talkedabout this with Dan is that try
to put a third, maybe a half,of your content education into
(02:15):
like, okay, I see a lot of kneeACLs, I see a lot of
meniscectomies, I see a lot oftotal knee replacements, because
we have three knee docs thatare, like you know, in this
local practice.
So the more that you know theanatomy and the more that more
that you know the injuries, thepath, the mechanics.
Oftentimes you don't see thesepeople pre-op, before they come
to you, so you're kind ofgetting a first glance of you
know.
You got to get to know somebodyand make them trust you and
develop a rapport and haveempathy.
(02:36):
At the same time you have stuffto do in an hour or 45 minute
eval.
So try your best, as a precursor, to know what does each joint
kind of have for major surgeries.
That I'm probably going to seeand I think that helps you, as I
said in the last episode, helpsyou be a bit more nimble on
your feet in the clinic and kindof answer questions more
fluidly, versus like I don'tever treat ankles and now I have
an Achilles repair in front ofme.
That's, you know, four monthsor four weeks post-op or
(02:59):
something like that.
So do yourself a favor and tryto be a bit ahead of the curve.
Versus like you see all ACLsand you want to learn about
concussions, so all you'retalking about is concussions
Nothing wrong with that, but youhave to laser focus on what's
in front of you.
Speaker 1 (03:10):
You know what I mean Absolutely, and I think if
you're in a space where you cango watch a surgery, that's
probably one of the biggestthings that helps me with
answering questions aboutsurgery, Cause I've I've been
through it.
So when, especially with mypre-op kids who are, you know,
they haven't gone through thisprocess yet I can say I know
where they're going to go, Iknow what's going to happen when
they walk back in the room.
(03:30):
I know what's going to happenwhen they wake up, Like I know
what happened during theirsurgery, and it puts watching
videos or actually going towatch the surgery itself.
Just everything looks so muchdifferent than you might have
like thought in your head, Likeit.
Just I think it changes thegame a little bit when you can
actually see the surgery andlike see what they do and see
what happens, Cause I mean therewere definitely a couple of
(03:51):
surprises that I had like like,for example, like I went and
watched a TTO surgery.
I don't know if you've ever seenone of those, but it was like
gruesome.
I was like, oh my God.
I thought this was like alittle basic surgery where you
just like take the little pieceof bone and just move it over.
Oh no, hammering.
Oh yeah, the bone out.
Speaker 2 (04:08):
I was like whoa.
Yeah, I understand why they'rein so much pain now Like, yeah,
exactly I was trying to uh showmy, my uh bookcase but my
headphones were connected but Ican maybe turn my computer.
But like I just have like a, a,a bookcase of like different
books that I really enjoy, likethat I've read all the time but
I was able to invest via likeshift and company work.
But like your clinic shouldhave a surgical hip book.
(04:29):
You know what I mean.
There's like surgical textbooksfor the hip, uh, athlete,
shoulder with with Mike andLenny, so like if you can't
afford them yourselves, but likeknee disorders by noise that's
like a 2000 page textbook.
And if you have those in theclinic, you know, the night
before or the morning of or evenin the moment, if something
comes on you're not familiarwith, you can kind of scoot to
the back real quick and be like,oh, let me just look this up
real fast and see what thatsurgery was and like what's
(04:50):
going on.
Bob, obviously the protocol willbe different from a doctor that
you see, but you know thosesurgical textbooks and the
combination of ones, like Mikedid with everybody, were super
helpful.
But the hip one is from theguys at HSS.
I want to say what's his name,I forget, I can't think of my
head, but he essentially editedthe entire hip repair, surgical
repair book.
It's two volumes, there's ashoulder one, there's an ankle
one.
(05:11):
So reading those chapters ofwhat you commonly see are really
helpful.
But then also having those inthe clinic to kind of refer to
and understand like, oh yeah, itmakes sense why this person's
really having a tough time withclot activation because they had
this huge LAT and they had thishuge meniscus repair or like
whatever it is.
So, um, yeah.
So on the second piece of thatI would say is you made a really
good point, which is thatunderstanding the surgery or
(05:34):
visiting surgeries is good foryou, but establishing
relationships with doctors andbeing a face and seeing them
right, I think the best thingyou can do is be a bit nimble
and understand the surgery soyou can ask good questions.
So you know, don't pestersurgeons because they're so busy
and they have a lot going on.
But once in a while, you know,if I have clarification that I
need, I can call a PA or someonethat I'm very friendly with and
say, hey, like what do you?
I don't have any post-op stuff.
(05:55):
They didn't come in anythinglike what do you want to do with
the brace?
How long for the brace?
How long are they weightbearing?
Do they kind of meniscus repair?
How many anchors like you canask those very quickly in a
three minute phone conversationand I forget when I posted it,
but I've gotten to the pointwith a lot of surgeons in Boston
that I work with that likethey're very, very friendly and
very nice If you deliver veryquick, need to know information
and you ask, need to knowquestions.
(06:16):
We have like cell phones of alot of the team docs that are in
Boston and you know this doctor, dr Ramappa, who's amazing.
He does a lot of the labor,repairs the surgeries on
shoulders and stuff or ACLs thatwe see with like a lot of the
high level gymnasts, and sohe'll scrub out and call me and
leave a 13 second voicemail onwhat he did and that helps me
exponentially more than tryingto call his front desk who leads
(06:38):
me to the PA, who looks up thenotes for the doctor, who sends
them back to the PA, who sendsthem back to the.
You know it's all like thisroad of nightmares.
So if you can get enoughexposure with people and refer
back and forth, they start tosend you people and they're very
friendly with you and helpingyou.
So that's the best thing I'veever done, because I can
literally call docs from BostonChildren's like, hey, I'm with
this person right now.
Um, what do you think about this?
(06:58):
This and this?
It's a 17 second phoneconversation and then we move on
with life and it's great, youknow.
But I've been to ramapa'soffice.
I mean, my mom had surgery withhim and I've sat with him and
I've talked with him and heknows mike and lenny really well
.
But whatever the doctors inyour area are, try your best to
be on board with them.
You know what I mean?
Is choa directly in a hospital,right?
Speaker 1 (07:16):
yeah, so you guys have a benefit of that, you know
yeah, we're not like in thehospital but we have, like my
clinic, for example, has likethe ortho side right across the
hallway, so like if I have anyquestions I usually just as long
as they're over there I'll justgo question them about whatever
I need.
But we also have the luxury ofhaving Epic and so I already see
like all of those no, it's likethey're just like in there, so
it's easier than trying to likemake sure the patient brings it
(07:37):
or like trying to look it up oryou know, trying to get a
patient to bring all their stuffand obviously their mom can
help but like they are often ina lot of pain and very high and
very stressed out about theirsituation.
Speaker 2 (07:48):
So I was actually going to share the outlines that
we make so that we can gothrough this together.
Let me make sure I have theright tab open.
Yeah, so I just had twoexamples here of things like if
I see somebody post-op for anACL, for example, or just a knee
surgery in general, meniscusTTO has a little bit of
obviously different but likeMPFL reconstruction, there's
probably going to be a handfulof things that you want to know
from the beginning.
So before you do all this, youwant to try to get an operative
(08:10):
note, you want to try to get adiagnosis or some sort of PT
eval, you want to try to get aprotocol or precautions right.
So you need to know thosethings ahead of time.
What are limited you can't doand I'll.
There's an example I have rightnow is literally a kid who's
five days post-op um ACL, bonetendon graft, lat and a meniscus
repair.
So medium meniscus repair.
So he's non-weight bearing forsix weeks because their meniscus
(08:31):
repair is pretty hefty.
He is not allowed to bend past90 degrees for six weeks because
the meniscus repair is prettyinvolved.
And then, um, they have him ina brace for six weeks crutches,
I want to say, for I don't evenknow how long.
It depends on his weightbearing progression.
But that's like baseline rightand so like you have to know
those things going into it.
We'll talk about the hip oneseparately.
But there are differentprotocols and different
restrictions on purpose forcertain tissues because you
(08:53):
don't want to compromise thetissue.
So a rotator cuff repair, abiceps repair, a hip labor
repair, an Achilles tendon thing, there are very set
research-based guidelines thesurgeons use to have
progressions for these peopleand the exercise selection
oftentimes, if they do a greatprotocol, is based on that stuff
too as well.
So you want to have that inyour background of kind of do
your homework to know what thesurgery is and what the protocol
is.
And if they come to you andthey don't know what surgery
(09:15):
they had I've literally had thisbefore what surgery to have?
I think about a kid.
He's a level 10 gymnast.
He tore his ucl and had atricep repair.
He's doing a ginger, justliterally dislocated his elbow
and blew his arm up.
He came six week post-op and Iwas like, yeah, man, like what'd
you have done?
He's like I don't really know.
They like cut the inside andlike the back's repaired.
I was like that's a big scar.
I'm like, did you have atriceps repair?
He's like, yeah, maybe.
I was like what, bro?
I was like you're killing meright now and his mom was there,
(09:35):
but his mom had left to go, youknow, do something else with
his other uh brother.
So and I'm like, did he have aUCL repair?
Did he have an augmentation?
Did he have a TJ three?
I have no idea.
So we did the basics of whatevery elbow needs and didn't go
outside what I know the limitswere.
And then, as I got moreinformation, we kind of
progressed things for it.
So on a knee situation, right,the big rocks that you're trying
to get through just throughthis list is like pain, right,
(09:58):
pain management, pain affectseverything If it quad inhibition
comes with that.
So there's meds for a reason,right, like dosage of a high,
higher grade dosage.
Drugs are there for a reason,in the first few weeks to sleep
or kind of get through PT, tomove um.
Tons of ice right, especiallyat night before they go to bed,
because it's super painful.
They're oftentimes on like aCPM combined with some degree of
an ice machine to as wellrotating, and that doesn't help
(10:19):
with swelling, right, but thatdoes help with pain management
and if you don't have as muchpain you can move more often and
tolerate more exercise.
So don't poopoo ice.
I know a lot of people who arelike don't use ice ever because
it's going to delay healing.
But like I'm telling you, ifyou have a massive rotator cuff
repair and you don't want totake a lot of drugs, ice is your
(10:40):
best friend to get through thatfirst couple of weeks.
And they have a TED stockingsometimes.
And then after a couple of weekswhen the stitches come out, you
can wear like a knee sleeve ordo an ACE wrap or something like
that and then just regularmotion, right, like I'd rather
somebody do 10 to 20 repetitionsof hyperextension, inflection
every hour for the entire daythan one epic stretching session
where they push their knee toomuch and it gets too cranky.
(11:01):
Then they're flared up and theyreally can't tolerate anymore.
So pain's massive.
Educating a patient on theirprecautions, what they can do,
what they can't do, you know youcan't weight bear, you can't
bend your knee when it's on theground, you can unlock your
brace and sit if you cancomfortably get past your limit,
but not past 90 because there'sa meniscus thing.
So you need to be very clearand tell them about what they
can and can't do and oftentimeseducate their parents or
(11:23):
whoever's like their caregiverthat's with them, because the
person again is probably oncloud four, you know, with an
oxycontin pumping through theirsystem.
They're not really with youright now.
So trying to uh kind of getthrough all that.
And then you think about whatare the most immediate emergent
things that have to happen tonot have an issue come up.
And the biggest thing for aknee is full hyperextension to
prevent a cyclops lesion, right,so you have to get someone's
full knee hyperextension towithin a couple of degrees of
(11:46):
the other side, because, um, ifthey get scar tissue in the, in
the neural gutter of their ACL,they can't ever get full
hyperextension back.
And then you're really in a ina tough situation.
And we've done you know somethings on the Mike Ronald show
about how to do that and longload stretching and stuff like
that, but, um, that's likepriority.
Number one is like protect thegraph, get the swelling down,
get the pain down, um, helpsomebody understand their
(12:06):
precautions and gethyperextension back.
It's like the immediate firstsession.
If you didn't know theirsurgery, you didn't know what's
going on.
Most of those things are okay,depending.
Maybe if they have like ananterior meniscus repair, you
wouldn't push hyperextension.
That's a nuanced thing, butmost people that's pretty good,
along with making sure theincisions are clean, covered,
stuff like that.
So I'll probably go like fiveat a time and then we'll stop
and chat in case you have anyquestions.
But does that make sense?
(12:27):
Is there anything in there thatI think you know I went over
too quickly or it doesn't makesense?
Speaker 1 (12:30):
No, I pretty much follow all those same rules too.
I think hyperextension is oneof the biggest ones.
I feel like we miss asclinicians making sure that
you're actually measuring, evenif it's five degrees
hyperextension.
but also it is hard to get likea quad set or do a straight leg
raise without your extension,Like if you cannot extend your
(13:00):
knee all the way it is reallyhard to like fully contract your
quad If you've sat around andtried just like with your knee
not all the way straight to tryand contract your quad.
It's so hard.
So I think missing extension isone of the biggest things that
I think people are missing outon early on in the rehab process
for post-ops.
Speaker 2 (13:18):
Exactly too, and I know the other side of the
pendulum is surgeons get nervousabout stretching the graft out.
But we're not talking aboutlike end range 10, 15, 20
degrees.
This is going from negativefive to plus five when somebody
has 10 on the other side right,we're just trying to get them
enough.
There's a lot of long-term,like a moon group outcome
studies that show that peoplewith hyperextension within a
couple of degrees of the otherside overall have better
outcomes long-term Right.
And there's a whole notherrabbit hole about why, like you
(13:38):
know, having not hyperextensionleads to like some quad
activation and some some uhscarring, but also just problems
when they try to go to strengthtraining or run or jump.
So the hyperextension is veryhelpful and on top of that, you
know six and five are flippedhere.
But patellar mobility is superimportant early on because
regaining your full kneehyperextension requires superior
patellar mobility and tiltingside to side.
So oftentimes they have, youknow, a scar above or below if
(14:00):
they have a BTB um patellartendon or a quad tendon graph.
So you just work around thatyou know it's not the most
comfortable thing in the world,but you put gloves on and you
teach somebody how to go up anddown and teach them on their own
, because if they can get morepatellar motion they're going to
get to end range hyperextensionand if they get more inferior
gliding over time as the scarshere, they're going to get more
comfortable flexion right.
So, um, back to your pointabout um quad strength and
(14:23):
getting that back very early on.
The hardest thing to do is geta quad to turn back on.
Between you know the nerveblock and some of the issues
like that.
But even trace amounts ofswelling 40 CCs of swelling, 40
cc's of swelling in the kneeinhibits the quad quite a bit as
a protection mechanism.
So if you have somebody who hasthis big ballooned knee, it's
very hard to get them to get aquad set and then a leg raise
which eventually helps them walk.
So the best tool we have forthis is like NMES, like a
(14:45):
trigger-based NMES, where youput two pads on their quad and
they volitionally try to controla quad set as much as possible,
but they turn the stem up sothat they can do it on their own
.
Some units are like time-based,like five on, 10 off or
whatever.
But the first day post-opsomebody comes to us, we have
the quad, you know, uh, themachine on and they're doing
their own tolerance and stuff.
And I'm doing assisted quadsets, assisted leg raises,
(15:07):
passive hyperextension with atowel or a belt.
Um, they're just reppingthrough those because, you know,
the faster you can get somebodyto turn the quad back on, it's
a, it's a positive flywheel,right, if your your knee is less
swollen and your quad works abit better, you can maintain
hyperextension a bit easier,which means that eventually,
when you start to get off yourcrutches and brace, you're going
to walk smoothly.
So we want to facilitate, youknow, swelling and kind of
motion because it helps kind ofget the fluid out and helps the
pain reduce when someone's notafraid of their knee.
(15:36):
But, um, pretty big surgery forher ACL and she was just very
hypersensitive.
You know she had like some verylike couldn't touch her scar,
she was very nervous, she wassqueamish, it was like hard.
She just had like a very mildCRP yes, I think, starting, and
we just had to more or less saylike every 30 minutes, you know,
move your kneecap up and down,get your knees straight, try to
flex your quad as hard as youcan.
And she's three months now andwe're going to have an uphill
battle with getting her quadstrength back but she gets the
plus eight hyperextension.
(15:57):
She's out of the woods but shegoes from two to eight within
one session.
She's at two when she comes inbecause of her quad is not fully
strong and fully active.
It's not activelyhyperextending her when she does
exercises.
So he in soft own two moretimes that day and then just
hammer her quads over and overthree times a week.
So it's hard.
(16:22):
But quad soft tissue orhamstring soft tissue to help
somebody regain hyperextensionis very important.
So yeah, swelling patellarmobility, quad activation with
NMES, regular exercise whenthey're ready for the bike.
Maybe not a revolution of thebike, but you can get somebody
kind of like halfway on eachside to get them to like 90
degrees.
Um, yeah, I think those areprobably the next ones.
Speaker 1 (16:37):
You have any extra ones to add there before?
Yeah, the only thing I wantedto say, with like hyperextension
, I had two things.
One, when we're trying to gethyperextension, obviously we're
not like pushing it down reallyhard.
In hyperextension it's more oflike I'll, you know, put an
ankle weight over there and justsit there for like five minutes
, you know, and just like let itkind of droop down with a heel
prop.
And I think one of the biggestlike pieces of education that
you can give to like the familyand the patient is to make sure
(17:00):
that you're not putting anythingunder the knee.
Speaker 2 (17:02):
Right, I feel like.
Speaker 1 (17:03):
I get that all the time where they're like sleeping
at night for like eight hoursand they've got a pillow under
the knee Cause that's like themost comfortable place to be
Right.
If you're like in that littlebaby bend, you got a little blow
under there and it's socomfortable and like do not do
it, cause you're just going toend up stuck missing that.
You know like five to 10degrees of knee extension and
that's going to put you in areally bad place.
And I always tell them I'm likeif we start to miss extension,
(17:23):
it's going to push our timelineback.
So like exactly hammer homeextension, cause it's going to
push your timeline back morethan you think with your
strength and motion for sure.
Speaker 2 (17:31):
Yeah, and I agree, yeah, go ahead.
Oh yeah, and swelling too aswell, right?
Um, I think that it's better tojust take the entire mindset
with post-ops especially kneesof like consistency over
intensity.
I'd rather do stuff multipletimes per day.
Prop your heel up with a heatpack and a lightweight and just
scroll through tiktok, watch anetflix show while it just kind
of sits there passively for 10minutes, right, versus this big
epic stretching session whereyou make the knee a little angry
(17:53):
and and hyperextension issometimes a bit more passive and
easy.
But same thing with flexion orsorry for hyperextension.
I know like prone hangs arevery popular in many circles,
but like that oftentimes willcause a hamstring contraction
which makes it like you'refighting uphill both ways.
Gravity's pulling down, ithurts their hamstrings, firing
back and forth.
So we personally don't usethose and Lenny has some really
great videos on the metrics ofthat.
(18:14):
But prop hyperextension with aknee and a heat is probably our
go-to way.
Speaker 1 (18:18):
I just had a conversation with my coworkers
about that Cause.
I was like I feel likeinitially, when I was starting,
I like I feel like a lot ofpeople did that and I was I
started doing that and then atsome point in time I don't even
know when I just kind ofchampion.
No, it was after.
It was like when I started likemy job, yeah, like when I
started residency here, and thenat some point I just kind of
like stopped doing it and one ofmy other co-workers like
(18:40):
started doing prong hangs and Iwas like why did you start doing
?
that or like what was yourreasoning?
Because I guess I was trying to, I don't know.
There's one kid that we wereworking really hard on her
emotion, that we're tryingeverything that we possibly
could.
But I agree with you.
I feel like, no matter theweight, like it's really hard
for them to relax in thatposition if they're tight or if
it's painful or uncomfortable,especially if it's uncomfortable
over the front of their kneeand any of their knees on the
(19:02):
table and they take that quad weget mostly quad graft so like
they take that piece of quad outright above the patella which
is going to be right wherethey're going to put their.
Like that pressure is going tobe pushing on the table right
over that piece.
It just gets irritated andangry and it doesn't.
Speaker 2 (19:17):
Yeah, and you can sometimes do like you know.
We have like the ice bags thatare saran wraps that you open up
to put over the incisions.
You can put like the ice bagover there and then another
layer of like a towel orsomething that's going to be not
as direct contact of the heatpack on top of their need.
That might sometimes help, likethe sensitivity of the skin a
little bit more.
Um, but yeah, I think trying todo regular hamstring type stuff
or stretching lightly and thenget the hyperextension that way,
(19:38):
and then you know, with seated,with flexion too as well, I
mean, gravity is your bestfriend when you're sitting over
the edge.
I used to supine people andjust crank on them, cause I
thought that's what you diduntil I met Lenny and thought
about, if you know, shoot theshit and be casual.
And you know another ACL that Ihad.
Um, he had surgery last Thursdayand I saw him Monday, so five
(19:59):
days post-op.
There was a delay in the CPMgetting there.
The person didn't know how toset it up with instructions, so
I was the first person whowanted to wrap his leg and bend
his knee in five days.
He was just straight the wholetime.
Homeboy was not happy.
He's a good kid, really nicekid, but we barely got him to 35
(20:20):
degrees right.
It took three bouts to pass arange of motion to barely get
him to 90.
He's the one with the LAT andthe meniscus repair.
So obviously more surgery, moreswelling, but we had to.
You know, just talk aboutNetflix and talk about the Red
Sox game and I'm just trying toignore it and like just really
relax and sneak a bit here andhe jumps off the table and then
Ooh, it's all good, and then wego do exercise, then we come
back and do another bout ofmotion in the hour, then we do
another set of this, then wecome back and do another bout of
motion in the hour.
So try your best to know thatit's going to be uncomfortable
(20:41):
but like, make light of thesituation, sit people on the
edge.
You don't just sit there andhammer on their knee bent,
because it's very hard to relaxwhen someone's towering over you
, yanking on your knee andflexing.
Speaker 1 (20:55):
So yeah, yeah, yeah, hyper extension and C deflection
.
Speaker 2 (20:56):
Are you getting CPMs?
For most of your?
Yeah, yeah, most of them um,most doctors want them in the
CPM like eight hours per daybecause of, um, the concerns for
stiffness.
You know, a lot of these peopleare big surgeries, like an LAT,
acl, meniscus, and so they'reworried about motion stiffness,
but they're also worried thatperson's going to push past
maybe a protocol limit so we canset an MPFL reconstruction to
30, right, and not go past that,versus someone who's going to
(21:16):
go to 90 or 60.
So, yeah, most of them aregetting CPMs, yep.
Speaker 1 (21:20):
We don't really get that here.
We get CPMs for, like any ofour OCDs and our knees, but,
like, hardly ever do we get thepatients get CPMs for yeah,
there've been a couple ofpatients where I'm like I would
love to have a CPM.
Speaker 2 (21:34):
Oh yeah, for sure.
Speaker 1 (21:35):
Get them to emotion and I feel like it improves
compliance so much because it'sso easy you just stick your knee
in it and you just go.
Speaker 2 (21:44):
It's like, yeah, this kid that I was talking about.
On Monday he came to PT and Ithink he could feel the aura
that I was like brother, we gotto get on this thing.
You know what I mean, but hewent home and he put himself on
the CPM and set it up and hefell asleep.
He fell asleep for two hours,yeah, so he was just like
chilling out.
I mean, probably there wereoxys involved, obviously, but he
was just chilling there and hegot.
When he came back on Thursday,three days later, he was at
(22:04):
sleep 65, right.
So he doubled his motion byjust daily CPM, consistently
nice and easy, wasn't crankinghis leg, you know.
So he alternated betweenhyperextension, quad sets, basic
CPM, just really really easyopen chain stuff, and he was
much less painful as hisyesterday and um, much more
comfortable with all of PT.
You know, leg raises the nextthing we'll tackle, but um, yeah
, so, um, basic consistentadvice is probably good for that
(22:27):
.
And the last thing that alwayscomes down to is like gate.
You know you want to normalizesomeone's gate as fast as
possible.
So I will say it's a bit murkywhen the surgeons aren't really
like clear about when you canunlock a brace.
In this case, one of the kids,six weeks non-weight bearing,
you know, locked in extensionbecause the meniscus repair.
But the other person, um, whohad the LAT as well, um, you
know the, the surgeons see themone week post-op and six weeks
(22:47):
post-op one week for the surgery, stitches, and then, you know,
another six weeks later for justto check up generally.
So in that time though, they'regenerally want to get off a
brace and get off crutches right, they say crutches two to four
weeks weight bearing istolerated for most ACLs and then
unlock the brace when you quote, have quad control, like
involitional quad control.
So I think that the best way tothink about it is, when you're
(23:08):
locked in the brace you want togo from two crutches to one
crutch, you know, in two hourspurts.
So when you first wake up inthe morning, get the knee heated
, get it kind of ready, do someexercise, and then do two hours
on two crutches or on one crutch, and then go to two crutches
for the rest of the day.
The next day add maybe one ortwo more hours, and then
throughout the course of theweek, on Sunday to Sunday, you
go from two hours on one crutchto eventually getting up like
(23:30):
the full day on one crutch andjust being around your house,
maybe at the end of the day ifit's a bit sore, and then you do
the exact same thing with onecrutch, is that when you're at
home.
Try to spend two hours whereyou're doing no crutches but you
have your tabletops around youand your couches, in case you
want to, kind of the day with nocrutches versus you had like
two hours on one crutch or sorry, two hours on no crutches, you
(23:51):
added one crutch at school orsomething like that.
So I find that with like comingout of boots or coming off
crutches, it's better to do twohour stepwise progression to not
make someone's knee prettyangry.
And then in PT you obviouslywant to be the first person who
tests an unlocked situation andwith most ACLs that are weight
bearing, you know you're doingmini squats, you're doing weight
shifts, you're doing open 9050s, you're doing closed chain.
(24:11):
You know stuff a little bit.
So I have three right now thenon weight bearing meniscus.
One is obviously locked, butthere's another one that's two
weeks post op was an ACLmeniscus and he's weight bearing
is tolerated.
They want him to get off hiscrutches in two or four weeks.
So he's doing mini squats andweight shifts and he's pretty
good with hands on the table sothat in a week or two when his
quad is quote, unquote back andfor me that means like you're
(24:31):
doing leg raises in eachdirection.
You have a pretty solid 90 50contraction.
You can do a mini squat prettywell.
Um, you're doing weight shifts,maybe some mini step ups like
that's showing me that you havebasic volitional quad control.
We would unlock the brace maybeto 45, which is what you need
for functional ambulation.
So zero or hyper extension to45 so that when walks he has
like a little bit of a swingwith him.
But you know, god forbid,something happens where he slips
(24:52):
or something happens, his kneesnot going to bend fully to 90.
So that's kind of, you know,probably going to happen for him
at four weeks.
I think the other girl I want tosay it happened at six weeks
because she had a pretty, like Isaid, ami case of mild
sensitivity.
So she was off her brace around, I want to say six weeks.
After four to six weeks we keptthe brace but unlocked it and
she slowly weaned off thecrutches.
(25:12):
So at four weeks she was offcrutches.
But that progression from fourto six weeks it was like unlock
your brace for an hour, walkaround your house, go to the
bathroom, you know, do yournormal stuff, but then lock it
at school and make sure you'resafe when you're, when you're
getting walked by in classes andstuff.
So, yeah, that's the next bigthing and you know that whole.
You know 12 things, right?
There is more or less the firstsix weeks of acute ACL or knee
repair, right?
(25:33):
Um, yeah, any additions on thatCause?
The labor one is the same thing, but just in a different
context.
Speaker 1 (25:38):
Yeah, not really.
I feel like unlocking the bracefor me if they can, kind of
similar ideas.
But as long as they can standon one leg pretty solidly for 30
seconds and they can do adecent step up, Like I like to
see that they can do a step up,just in case like again, like
just being able to, like, almostlike, catch themselves that
they were to step wrong, orsomething.
Being able to do that, I think,is important?
Speaker 2 (25:58):
Yep, for sure, um.
And so here on the uh, I'llslide down to the next one.
Um.
So for hip labrum, I took theexact same kind of uh thoughts I
would say like of thecategories and I tried to, you
know, apply them to what itwould be maybe in a in a labor
repair.
So we won't go into it deep now.
But labor repairs are very, umare variable based on how many
sutures are put in.
(26:18):
Do they have any boneinvolvement?
So did they have like a pincherlesion debrided or a cam lesion
debrided, which would be anosteoplasty.
So acetabular osteoplasties withcapsular closures are treated a
bit more like a cartilagesurgery than a labor repair
surgery, because you have topull down and delaminate some of
the cartilage to repair it.
So they're a lot more cautiouswith weight bearing versus
somebody who just had a laborrepair with no osteotomies at
(26:40):
all.
They're going to be probablyweight bearing is tolerated, but
they probably will have a brace.
So pain is the exact same thing, right?
Meds, ice, reduce your swellingaround the hip.
There's you can't see it asmuch in the hip versus a knee,
but there's obviously a lot ofswelling going on.
So look at the incisions.
They usually have three portalholes to make sure they're clean
, they're not rubbing on theirskin or their underwear or
something like that if they'rewearing running shorts.
And then regular motion too aswell.
(27:01):
Is that you know the the kneeprecaution situation is that if
you have a meniscus repair orsomething, you don't go past 90
with flexion but you can havefull hyper extension with a hip
label repair.
You oftentimes are limited to90 degrees of passive motion.
Obviously don't cross your legs.
So no ir past a certain 10degrees but then no er for 40
degrees because you don't wantsomebody to have, you know, too
much stress on the labral tissue.
(27:21):
So passively when you're doingmotion you want to do to those
tolerances and you want to kindof work in the mildly abducted
yard plane, because that's howthe scap or the acetabular plane
kind of lines up, normally thesame way that like a scaption
plane in the shoulder we don'treally range in close flexion
because of the impingementpossibly in a rotator cuff.
So we put them slight abductedjust to kind of clear more space
.
So I do all my passive range ofmotion there.
(27:44):
And then also the version ofhyperextension, propped and knee
flexion is circumduction andlog rolling for somebody who's
labor-opera, becausecircumduction and log rolling
aren't closing the femoral neckon the tissue that was repaired,
but it's moving the hip jointin circles or moving the
synovial fluid around quite abit right.
So you want to have regularmotion.
They can't circumductthemselves.
But in PT a lot of your work iscircumduction, log rolling,
(28:05):
basic tolerance to flexion, irlightly on their back, log
rolling, basic tolerance,deflection, er, ir lightly on
their back and then within theirprotocol they'll probably have
those restrictions of how long.
It's typically four to sixweeks, based on kind of how
involved the surgery was.
But it's the exact same thingas like a knee has like patellar
mobility and this and that youknow a quad head or a hip has
some quad and adductor softtissue.
That's probably pretty helpful.
It has circumduction, it haslog rolling and stuff.
(28:27):
And then after a couple ofweeks you know they're on there.
Um, they have a hip brace that'skind of locked in to prevent
them from abducting or abductinginside neutral, but that kind
of lasts for you know, up tofour weeks and the exact same
progression will happen.
If they're just a labor repair,they're going to be, weight
bearing is tolerated and it'sthe exact same crush progression
.
You know two hours and then gofrom two to one.
Make sure you're not limping.
Uh, you don't want to hyperextend your hip too far, um,
(28:50):
because it passes zero becauseof that.
So you have to take very shortsteps.
You can't, like, take a longstride with your leg behind you,
because that will pull on someof the anterior tissue.
Um, they oftentimes have noactive hip flexion as well, um,
but the the version of, uh, youknow, propped hyper extension
for the knee is prone lying inthe hip.
So a lot of surgeons want thesepeople on their stomach for
five to 10 minutes throughoutthe day multiple times, just to
(29:11):
prevent the risk of any scarringin the anterior tissue where
they put the portals through andstuff like that.
So lying on your stomach is thesame as prop hyperextension to
get that motion back.
And then they generally usequad rocking as the main way to
get patient controlled flexionback, in the same way that if
you're sitting on the table athome you would put your own
other good knee behind your badknee and use that to kind of
bend your knee or a CPM.
(29:32):
So the analogous CPM is is quadrocking make sure your knees
are apart and make sure yourhips are slightly turned out.
So we're clearing that space.
Um, but literally all the exactsame things.
Is a checklist for the knee?
It's the exact same approach toa hip, it's just about what
surgery, what's the jointdiffering?
You know, shoulder has its ownset, elbow has its own set,
ankle has its own set, wrist hasits own set.
You know it'd be a two and ahalf hour episode to go through
(29:54):
them all, but the principles arethe same that if you do the
work we said about reading andunderstanding, talking to
surgeons, taking courses, you'llget to a point where, between a
protocol and your own knowledge, you feel pretty confident with
you know, the first, definitelythe first couple of weeks that
are terrifying for new grads orpeople who have not seen a lot
of post-ops, but up to the pointwhere when you're off crutches,
then it becomes more about like, okay, how do we start a
(30:18):
strength program?
You know, how do we startprogressing?
Speaker 1 (30:20):
Make sense Yep.
Any questions?
No, we pretty much do all thesame things.
I think crutch training is moreimportant with the hips than it
is.
Speaker 2 (30:26):
Totally, but more sensitive than yep because it's
hard to do stairs without usingyour hip a little bit yeah for
sure.
Speaker 1 (30:34):
Yeah, so I just like to prevent any sort of like
inflammation or irritation atthe like interior hip with like
your hip flexors, because theycan like just they get
overworked, especially if I havea lot of kids that are like
going to school and they'redoing their schools are just so
spread out and they're doingwalking and I'm like I don't
want you in a wheelchair, butlike yeah too, and um on the.
Speaker 2 (30:55):
The same kind of point of the quad turning back
on in the knee is that theglutes and the glute med are of
the hip so, like lots of glutesets, lots of lateral abduction
raises, if they can't toleratethat, just line your back and,
do you know, pass, or supineslides on a towel in and out.
There's lots of modificationsand when you do start somebody
back with active hip flexion,that's probably best done in
side lying or in somethingthat's a little bit less intense
(31:17):
than anti-gravity.
So, yeah, I have a patient.
I have two labral repairs rightnow and one of them is like
literally on it.
She's cleared to do a hipflexion fully, but she can't do
a full anti-gravity to 90 hipflex because it's just like
hasn't done it.
She had a huge repair so theydidn't let her for six weeks.
If you didn't use your arm forsix weeks it'd be hard to do a
bicep curl.
So just lie on sideline and, doyou know, she's perfectly fine
to do it in sideline.
(31:37):
There's gravity taken away.
Speaker 1 (31:39):
Yeah definitely I do a lot of isos yeah, oh yeah,
tons of isos, for sure, I haveaddiction and then with hip
flexion I just try to minimize.
I honestly don't do a lot ofhip flexion and initially if
they're weight bearing, becauseI know that they're doing a lot
of like stress with walking andwalking in normal stairs when
you get off your crutches is hipflexion.
Speaker 2 (31:57):
You know it's like you have to use hip flexion,
which is why the the crutchprogression of like six weeks is
often lines up with the activehip flexion of six weeks as well
.
We can't climb a stair without,you know, somewhat involving
your hip flexor.
I think it's more along thelines of like loaded hip flexion
they're worried about.
Sure, yeah, um, cool, so we'llkeep this one to 30 minutes and
uh, yeah, hopefully that washelpful.
Um, I think I, I knew, I knowthat I wish I had something
(32:19):
along the lines of like a basicsystematic approach and, like I
said, if you just tackle maybeone month on each joint, you and
your homies at the clinic, andkind of get yourself together on
a good like, okay, here's theimmediate must do things, and
then here's the next yellow flagthings.
Then here's the next end of thestage goal by six weeks or
something like that.
But, yeah, hopefully that washelpful.
Yeah, all right, we'll see youguys in the next one.
Bye, bye.
Popular Podcasts
NFL Daily with Gregg Rosenthal
Gregg Rosenthal and a rotating crew of elite NFL Media co-hosts, including Patrick Claybon, Colleen Wolfe, Steve Wyche, Nick Shook and Jourdan Rodrigue of The Athletic get you caught up daily on all the NFL news and analysis you need to be smarter and funnier than your friends.
On Purpose with Jay Shetty
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