August 4, 2025 • 51 mins
In this episode of the Braun Performance & Rehab Podcast, Dan is joined by Bria Savage to discuss the shoulder labrum in depth, from mechanism of injury to rehab considerations.Dr. Bria Savage is a seasoned physical therapist with six years of experience, including serving as a clinic director for a sports and orthopedic physical therapy clinic. She is certified in bloodflow restriction, dry needling, and as an emergency medical responder for athletes. Bria has also worked as a travel physical therapist, adapting her expertise to diverse clinical settings while fostering excellence in patient care. Her passion lies in sports physical therapy, empowering athletes to achieve peak performance and resilience through innovative, personalized rehabilitation strategies.For more on Bria be sure to follow @drbriasavage and DM her about future ARC courses! You can also find out more about the ARC course by visiting https://www.advancedrehabcertification.com/*SEASON 6 of the Braun Performance & Rehab Podcast is brought to you by Isophit. For more on Isophit, please check out isophit.com and @isophit -BE SURE to use coupon code BraunPR25% to save 25% on your Isophit order!**Season 6 of the Braun Performance & Rehab Podcast is also brought to you by Firefly Recovery, the official recovery provider for Braun Performance & Rehab. For more on Firefly, please check out https://www.recoveryfirefly.com/ or email jake@recoveryfirefly.com***This episode is also powered by Dr. Ray Gorman, founder of Engage Movement. Learn how to boost your income without relying on sessions. Get a free training on the blended practice model by following @raygormandpt on Instagram. DM my name “Dan” to @raygormandpt on Instagram and receive your free breakdown on the model.Episode Affiliates:MoboBoard: BRAWNBODY10 saves 10% at checkout!AliRx: DBraunRx = 20% off at checkout! https://alirx.health/MedBridge: https://www.medbridgeeducation.com/brawn-body-training or Coupon Code "BRAWN" for 40% off your annual subscription!CTM Band: https://ctm.band/collections/ctm-band coupon code "BRAWN10" = 10% off!Ice shaker affiliate link: https://www.iceshaker.com?sca_ref=1520881.zOJLysQzKeMake sure you SHARE this episode with a friend who could benefit from the information we shared!Check out everything Dan is up to by clicking here: https://linktr.ee/braun_prLiked this episode? Leave a 5-star review on your favorite podcast platform
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome back to another episode of the Brown Performance and
Rehab Podcast, powered by Isofit and Firefly Recovery. Isofit is
my go to for all things isometric strength training. For
more on Isofit, be sure to check out isofit dot com.
Episodes like this are made possible by Firefly, the official
recovery provider of the Brown Performance and Rehab Podcast. For
(00:22):
more on Firefly, be sure to check out Recovery firefly
dot com. This episode is powered by doctor Ray Gorman,
founder of Engage Movement. Learn how to boost your income
without relying on sessions. Get a free training on the
Blended practice model by following at Ray Gorman dpt on Instagram. Bria,
Welcome to the podcast. I'm super excited to work with
(00:44):
you today and obviously huge shout out to our many
mutual friends there, whether the be Dylan Dave Tyler, They're
all amazing people and I can't wait to dive into
the shoulder with you today. For people who might not
be familiar with you and the work you do, whether
that be clinically or with our would you mind filing
them in a little bit about who you are and
all the great stuff you've got going on.
Speaker 2 (01:04):
Yeah, So I'm Bria Savage.
Speaker 3 (01:06):
I've been a physical therapist for almost six years now.
I've spent most of my career as a travel physical therapist,
but I do have experience as a clinic director for
orthopedic and sports clinics. I got my bachelors from the
University of Louisiana at Monroe in kinesiology, and then I
got my doctorate from the University of Saint Augustine in Austin, Texas.
Speaker 1 (01:30):
That's amazing. That's amazing, and I feel like you have
in the travel experience as well. You get this taste
of having you know what the differences of the rehab
world look like in many different populations and settings. That way,
I think a lot of people don't realize how different
it can be from state to state, and I've seen
a little bit of that when by own travels that way.
(01:50):
I mean, for example, here in Maryland, I'm able to
order imaging, which is a game changer. But when I
was in some of these other states, I wasn't even
allowed to dry needle, wasn't allowed to be a far
as some of these different tools that make a huge
difference that way, And obviously all of those things impact
our ability to provide our patients with the best outcomes.
And one of the many diagnoses that I see popping
(02:12):
up a lot clinically is issues with the shoulder. A
lot of times it gets called instability, or they get
some imaging done and they show some kind of damage
to the shoulder labrum. Very common in the athletes that
I've seen and worked with that way. Some manage it operatively,
some end up going more of a conservative route at
least for their season. That way. It just tends to
(02:33):
go a lot of different ways. And I don't see
nearly as many people talking about issues at the shoulder
like we do at the knee, and I'm guilty of
that myself. I certainly have a little bit more of
a bias to talk about things like the ACL and
the meniscus more than the shoulder. But these things are
really really prevalent and common out there for starters. When
(02:55):
I say shoulder labor and what the heck is that?
And what comes to mind for you when we say
things like shoulder labrum and shoulder instability that way?
Speaker 3 (03:03):
Yeah, So the lab room is this ring of cartilage
that's in our shoulder socket and it's supposed to act
as like a suction cup in a sense. So it's
increasing the depth of that glenoy fossil which is that
shoulder socket, and it's increasing the surface area for that
head of humors to be able to roll and articulate
with it.
Speaker 1 (03:22):
Right, So it tends to be more of a stability
structure in april in that like duct tape, more than
WD forty if you will. Yeah, because that shoulder, it's
just so unstable in the first place. Right, Like you
hear about different people dislocating the shoulder. I've never heard
of someone dislocating their hip. Not to say it can't happen,
(03:43):
but I haven't seen an athlete do that, just because
of how deep that socket is in comparison to the shoulder,
Like it's really freaking shallow.
Speaker 3 (03:51):
Yeah, because the shoulder, because it's that bottle and socket joint,
it's so mobile and it doesn't have that many structures
to create stability, especially in the front. I mean in
the front, we have our ligaments, we have the longheaded
biceps tending, but we don't have that much. We have
the pecks coming across there, but we don't have much
to really support that front side of the shoulder. So
(04:14):
that's why those antior dislocations are way more prevalent than
you know, any poster dislocations or even inferior dislocations.
Speaker 1 (04:22):
You mentioned the biceps tending there, and I believe anatomically
the long head of the biceps tendon actually attaches to
the labram. And this is something I've had debates about
with many different orthopedic providers in the past, where some
will give a diagnosis of bicipital tendinitis and others will
tell me bicipital tendinitis is not even a thing, and
(04:42):
if there's pain proximately in the you know, that kind
of region in the long head of the biceps, they
say it's more labrum than the soft tissue component itself.
That way, I'm curious what are kind of your thoughts
on that, like anatomically superior labram versus you know, proximal
attachment of the bio if you will.
Speaker 3 (05:01):
Yeah, So when I'm thinking of that, I don't always
just go off of where the pain or tenderness is
because for bicycleal tendonities, which I do get a good
bit of those diagnoses, yes, there's going to be pain
at the a C joint pain at the superior you know,
area of the gleno humoral joint. But also I do
(05:23):
rely on the special tests because they are pretty sensitive,
so they're good to rule out, but.
Speaker 2 (05:28):
They're not as specific.
Speaker 3 (05:30):
So I'm going through the special test to try to
figure out, you know, is this truly biceps or is
this labor.
Speaker 1 (05:35):
Them So you mentioned the special test. What kind of
special test do you like to do or what does
that typical exam evaluation process look like for you? When
someone's coming in with something, you know, whether that be
shoulder labor instability, possible bicep, tendon involvement, what's kind of
your typical exam flow and assessment battery look like.
Speaker 3 (05:56):
Yeah, So when they're coming in, of course I'm taking
a subjective trying to see what was their mechanism of
injury or if they do have a video, can I
see the video. I'm asking them what are their symptoms?
Are they're having night pain, are theyre having crepits.
Speaker 2 (06:10):
Or anything like that.
Speaker 3 (06:12):
I'm looking at their active range of motion and where
a painful arc may be. I like to look at
my internal external rotation and like a supin or laying
down position. So I can keep that scap kind of fixed,
and I'm looking at their internal external rotation at neutral
and in ninety degrees, because we know with most laboral
(06:32):
issues we're gonna have a good bit of external rotation,
but the internal rotation is gonna be pretty limited off
the back. Then I'm looking at their strengths, so I'm
doing my mmts to see where they're weak at, and
then my special test. So there's like the active O'Brien's
compression test, There's some sharer tests there, there's the biceps
(06:54):
load two tests, so all of these type of tests
that I can kind of grind or share that labor
them to see if it's going to increase any symptoms.
Pretty much just how we do McMurray's for the knee.
I'm doing those saying tests for the shoulder to see
if anything is catching, clicking, or popping. And then of
course my palpatience. So I am going through and seeing
(07:14):
where tenderness is. Is it at the AC joint, is
it at the corecoid process, do I get some pec
minor involvement, and is it kind of extending into the
rotator code.
Speaker 1 (07:25):
Good exam flow in my opinion, and It's one of
those things that you don't miss anything, right, you kind
of look at the whole picture. And that's something that
I feel like a lot of clinicians and I feel
like we've all been guilty of it. I've been guilty
of it at times, right, Like you're in a rush
and you've got to cut something out of the exam flow,
even though you might not want to, but it's really
essential to try and get a little bit of everything,
(07:46):
if you will, because I don't think range of motion
and manual muscle test alone tells the full story. But likewise,
I don't necessarily think that reliance exclusively on provocative special
tests is the best strategy either. I think really the
culmination of everything coming together that way. And to your
point on palpati, I've found a lot of times, you know,
(08:07):
someone might come in with pain that would we typically
think along like a labrum distribution or something, but a
lot of times they get really tender when I dig
in posteriorly, especially into some of these posterior soft tissue structures, right,
and so, with the shoulder being so complex and we've
got a lot of nerves in the area, we've got
a lot of muscle muscles in the area. We have
(08:27):
to kind of think beyond just the you know, anatomical
structure of oh it's the labrum, or oh it's the biceps.
There's a lot of other things that can contribute as well.
And there's been times when people come in with that
typical anterior shoulder pain that I actually clean up quite
a bit by treating more along the posterior aspect of
posterior a dell infraspinatus and so on that way. So
(08:50):
I think it's one of those things that having that
thorough assessment process, if you will, really helps to guide
you from your interventions, because you know, with the conversation
of the labrum and an unstable shoulder, it can be
really tricky to manage if you're just kind of throwing
exercises at the wall and not one hundred percent sure
what you're treating.
Speaker 2 (09:09):
Yeah, one hundred percent.
Speaker 3 (09:11):
And then I wanted to mention even after it's during
my follow up visits, when I don't have time during
the initial ebau to look at everything, I do like
to go back and look at their core stability, that
the rascal mobility, and even their glute strength because we
know with the complexity of overhead motions, and especially with
these overhead athletes, a lot of times a glute weakness
(09:32):
could contribute to that. So I always go back and
try to look down the chain too. I think that's
super important.
Speaker 1 (09:37):
Oh, I absolutely love that you do that, and I
love that you bring that up because, as you mentioned,
you know, a lot of times if we're seeing issues
in the labrum or issues in the shoulder, it's going
to be in that typical overhead athlete population, if you will,
whether that be you know, the baseball, softball population, I
would argue volleyball, tennis, u as well, a lot of
(10:01):
these different kind of sports where the arm is overhead
and doing something high velocity, repeated over and over and
over again. And with that in mind, as you mentioned,
it's not just the shoulder producing all that rotational force.
It's other musculature, whether that be spinal engine, hip complex
whatever it is. That way, right, Like, if you watch
(10:21):
someone throw a baseball or swing a baseball bat, it's
not just all arm doing that. It's a lot of
other components contributing to the force that you're VBC displayed
out the arm. So it's more of like I feel like,
in general, if the shoulder's unstable, it becomes this problem
of we're trying to fire a cannon out of a
canoe and it can't handle it.
Speaker 3 (10:43):
That part, that part literally I don't know how many
times I've tested a gluten need MMT and it's like, oh,
you can't even hold resistance or even looking at a
single egg squat to see can they maintain a pretty
level pelvis? Can they maintain need stability to go through that?
(11:04):
And I'm like, if they can't do those functional movements
like this is definitely contributing to why your shoulder is hurting.
Speaker 1 (11:11):
Right. So, outside a frontal plane hip and a little
bit of a core stability component, are there any other
common death sits you see athletes presenting with that kind
of present in the same time as the shoulder instability
shoulder laborm type things.
Speaker 3 (11:29):
Yeah, So thinking in the transverse plane, any rotation, so
their thoracic rotation sometimes is literally trash.
Speaker 2 (11:37):
It's like, oh, you really can't rotate through there.
Speaker 3 (11:40):
And if you can't rotate through there, your scalpular your
scalpulas can't up really or downly rotate or tilt like
they need to or that almost in this preposition anterior
to where it's like now I'm already going to pinch something.
So I think that thoracic rotation is a super big
one because some of them they really just can't rotate, right.
Speaker 1 (12:02):
How do you like to go about assessing spinal rotation?
And I'll add another one on that as well, how
do you like to look at and assess scap stability
as well?
Speaker 3 (12:12):
So with the spinal rotation, sometimes I'll get them in
child's pose on their elbows and I'll put a hand
behind the head and I'll have them do an active rotation.
Sometimes I'll use the enklinometer to actually measure it, and
sometimes I'm just taking a picture with our company iPad
to show them, hey, you can open up this much
on the left, but on the right, on your actual
(12:34):
throwing side, you're not even moving much. So that's usually
what I'm doing for the thoracic rotation. And then what
was the other one you mentioned, Yes, scalp stability. So
sometimes that looks like just doing forward elevation and abduction
and looking at are the scaps rotating at the same time.
(12:55):
Maybe I'll do a scapular assist test or a scalplar
retraction test. And then I also like to look at
a push up plus so putting them in its tall
plank position and have them do like that pro traction
to see is there a lag on one side? Can
they even get that full range? So that's usually why
I'm looking at there.
Speaker 1 (13:15):
You know, it's so crazy because a lot of these
assessments people are going to listen and they're going to think, wow,
that's pretty simple. You know, homeboy here he benches three
point fifteen for reps. How is that going to tell
me anything about where to intervene on the shoulder labor them?
And it's like it might be simple in nature, and
homeboy might be able to move a little bit away,
but that doesn't mean he's good at these simple things. Right.
(13:35):
A lot of times I see athletes missing these foundational concepts. Right,
they're trying to run a full marathon before they've ever
even completed a five k. Speaking metaphorically here, it's like,
we have to master some of these foundational functional concepts
before we go on and get into the good stuff.
Speaker 3 (13:53):
Right.
Speaker 1 (13:53):
You know, you don't throw someone into sport day one.
You don't throw them into baseball day one, expect them
to throw one hundred miles an hour. A lot of
things they do to prep for that, and even when
they do get to that point, there's an extended prep
in that session, right, kind of a throwing program, throwing routine,
just to get to the point where they're throwing that
explosively and violently, if you will. So, I think the
(14:13):
same concept is true from our assessment standpoint. It's not
so much as getting lost in the weeds. Right, Like
we talk about sports science different times on the podcast,
and I absolutely love that stuff, but we don't need
it to get a good assessment and understanding of what
the heck is going on with an unstable shoulder and
where to go from our intervention standpoint, A lot of
(14:35):
times if we just take the time, use our eyes,
use our hands, we can still get what we need.
Speaker 3 (14:40):
Yeah, one hundred percent. I'm always let's go back to
the basics. Basics, let's go back to the foundation, because
I don't want to have them even when we get
into the rehab part. I'm not trying to train a trick.
I'm trying to give you foundational stability, dynamic stability that's
going to translate into your.
Speaker 1 (14:57):
Sport, absolutely, and the more simple we can make it,
the more likely we are to succeed, in my opinion,
and the more likely our athletes are to actually do
the things that we're asking them to do, because they're
going to understand it.
Speaker 2 (15:11):
Right.
Speaker 1 (15:11):
If you start talking with all these crazy terminology and
different things that way, you know, I found, at least
in my own experience, it ends up doing a little
bit more harm than good. The more simple you can
make the problem, the better off it's going to be,
not just for yourself and potentially other clinicians you know,
working with the patient, but also the athlete themselves. That way, right,
(15:33):
it kind of speaks to what I call the rehab
philosophy of Okham's razor, if you will, Essentially, from a
problem solving standpoint, searching for explanations, going with the simplest
tends to be the best that way in this term.
And it's one of those things too, As I mentioned
or kind of alluded to, I find a lot of
people with these pathologies get very frustrated because a lot
(15:56):
of the times they're told to go with the rehab route,
with a physical therapy route, if you will, that way,
and they do and they don't get good outcomes.
Speaker 2 (16:06):
Right.
Speaker 1 (16:06):
I've seen a number of athletes that are bounced around
from rehab provider to rehab provider, and they get frustrated. Right.
They're not really sure what's going on. They don't feel
like there's a great plan in place, and a lot
of times they feel like the rehab itself is not
overly progressive or challenging. I think everyone's seen those cases
where it's just three sets of ten rubber band factory
(16:27):
for everything, and it's one of those things that I
feel like, in general, this population becomes rather unserved by
the orly served by the traditional rehab model.
Speaker 2 (16:37):
In my opinion.
Speaker 3 (16:38):
What I've found, especially with some of those athletes, so
the research shows that the longer the symptomatic period is
the least likely they are to respond to to conservative
treatment is possible. But the longer they are with pain,
the harder it is to really rehab that without some
type of surgical intervention. But what I found is a
(16:59):
lot of these athletes, they're not coming when they're first
feeling these symptoms. They come after it's like it's killing
me to finish a game, or it's killing me to play,
and so now all those micro traumas have kind of
compounded and that micro trauma has turned into an actual tear,
And so I feel like if they would come a
little bit earlier, they could get a little more a
(17:22):
little more progress. But also I do have a problem
with some of those clinicians who stick with the three
sets of ten model. They're keeping it very beyond simple
and not tailored to that athlete. Because if he can
lay down on the side and do three sets of
ten with a five pound dumb bail with external rotation
and he's like, yep, I'm done, it's like, Okay, how
(17:44):
can I engage that rotator a couple a little bit
more versus just letting it be?
Speaker 2 (17:49):
Right?
Speaker 1 (17:49):
Absolutely absolutely, It's like, how can we challenge what we're
doing and find a way to break the model and
make it better? Right. I think it's one of those
things we should always be challenging ourselves in challengeing our
framework and interventions that we use with people. And obviously
we talked about how the assessment component is going to
have an impact in what we do from an intervention standpoint,
(18:10):
and one of the things I want to kind of
circle back to as well as you mentioned about different
instability moments or different tear patterns that can occur in
the labor, whether that be anterior, posterior inferior. Obviously, I
personally see the more commonly anterior or slap type patterns
that way superior labor or anterior to post heior. That is,
(18:31):
I don't see nearly as many posterior or inferior issues,
but obviously they can happen. What changes on your intervention
approach when the tear pattern or issue is different?
Speaker 2 (18:45):
Right?
Speaker 1 (18:45):
What's different between the slap or anterior versus a posterior
type of instability versus an inferior type of instability if
you will.
Speaker 2 (18:55):
Yeah, so with.
Speaker 3 (18:58):
I guess the posterior, we're looking at possible hell sex
lesions to where maybe the backside got dind it in
a little bit. We may be looking at a bankkart
legion where most of like that posterior inferior area got
torn a little bit. I wouldn't say it's a super
(19:19):
super big difference. Besides, there are some movements that we
want to avoid, like some of that internal rotation or
the horizontal adduction, and sometimes those close close kinetic chain
exercises could be a little too provocative too soon, So
I would say that's probably the biggest thing for me,
Like the intern rotation, horizontal adduction, and then close kinetic chain,
(19:42):
anything pushing.
Speaker 2 (19:44):
I feel like those are the ones that are.
Speaker 3 (19:45):
A little more provocative, and so I don't hit those
so quickly versus your usual slap tear. I'm going straight
for that posterior chain strengthening, posterior cuff strengthening, and then
we are trying to get into like say a sleeper
stretch or horizontal at dutch and stretch, or really digging
into the peg minors. So I think those are probably
the biggest things. But with both I am going to
(20:08):
be strengthening that poster cup pretty heavy.
Speaker 1 (20:10):
I love that. And one of the other things I've
done a lot is, as you mentioned before about the
regional interdependence approach, it's a matter of how can I
find ways to address some of these other components creatively
that still work the shoulder that way. Obviously, you know,
if you're in kind of a private setting like a
cash based model, or if you're in a team based setting,
(20:31):
there's a lot less hurdles and obstacles that come to
you know, treating the hip complex for a shoulder issue.
But if you're in this insurance based world, like many
of us tend to be, we do have a tendency
to need to get creative, if you will, and think
outside the box as far as how we address the
hip and the shoulder simultaneously, if you will, And at
(20:53):
least for me, one of the ones I'll go to
a lot is I'll find different plank row variations per
dog row variation, or I'll also do different things isometrically
as well, where I might have some kind of hip
iso while they're doing something with their shoulder. The other
thing I found a lot of benefit from is doing
loaded carries. And I don't necessarily do these early on
(21:14):
with someone with the unstable shoulder, but it's a matter of, hey,
where can I put the weight, whether that's just general
suitcase carry or some kind of overhead carry, and how
can I load it in a way that maybe addresses
a little bit more than just the shoulder, right, Maybe
I can get into the core stability element or something
along those lines as well. And as you mentioned, that's
not necessarily something I'm going to on day one, but
(21:36):
it's one of those things that I think can certainly
have a bang for your buck value from an intervention
standpoint later down the line.
Speaker 2 (21:42):
Yes, I love those.
Speaker 3 (21:44):
I use them all the time, whether I'm in like
a modified side plank and kind of quelling them drive
that bottom knee into the ground while they're doing some
type of row. I love a good single leg iso
hip thrust while they're doing something.
Speaker 2 (21:58):
With the arm. Any plank rows love it.
Speaker 3 (22:02):
So I'm always, like you, trying to find ways that
I can incorporate it. And I like to keep my
documentation on points so they're going to see things in
there about regional interdependence and how force transfer from the
legs of the torso to the arm. Like I'm hitting
all of that because these athletes need it, and.
Speaker 2 (22:22):
I'll be dog gone if I let insurance hold them back.
Speaker 1 (22:26):
I love that. I love that. I feel the same way.
I'm curious what have been kind of your more like
would have been your most creative ways to dress kind
of full body regional interdependence if you will with the
shoulder that way. I know you mentioned the hip thrust,
and I know you mentioned the plank variation, but if
there have been any other kind of unique variations that
(22:48):
you've cooked up, I would.
Speaker 3 (22:50):
Say, so I like to do dead bugs with like Isopaloff.
Speaker 2 (22:57):
I like to do those.
Speaker 3 (22:59):
I do like to do like a thorastic rotation at
the cable column, but keeping this in the ISO and
have them rotate through kind of engaging those obleaques. I
love anything single legs, so I may have them standing
on in Eric's with like an ISO fire hydrant and
have them throwing a ball at a wall for like
some type of dynamic stability, or sitting on a Swiss
(23:22):
ball with one leg up while we're doing some type
of perturbations or anything with the arms. So now I
try not to get too crazy, but sometimes you know
you have to, expecially with those higher level athletes. It's like, okay,
you're not going to benefit just from a prone ball drop.
I need to give you something a little big, a
little crazier for sure.
Speaker 1 (23:43):
For sure, sometimes we got to get crazy. And it's
one of those things that I find, going back to
what we talked about before, a lot of times we
tend to over complicate the evaluation and assessment, yet under
complicate or miss the boat a little bit, the actual
intervention strategy. Right, we get so complex and so detailed
(24:05):
in the actual assessment itself, and then we go to
give them interventions and it's three sets at ten this,
three sets attend that, And obviously we can do a
lot better. I think everyone knows the simple interventions, but
it takes a little bit more to understand and grasp
the concept around some of those more advanced interventions. And
(24:25):
I know one of the big things that comes up
a lot when I'm talking with individuals with ARC is
just overall, what is the capacity of the tissue, whether
that be that day, that week, that month, whatever it
is that way, So I'd imagine having some kind of
tool to assess what is their tissue capacity and tolerance
to movement and load at that specific point can really
(24:47):
help guide your intervention strategy for that day one and
then two. The more you understand what the tissue can
handle and can't handle, the more clear your intervention route
is going to become.
Speaker 3 (25:00):
Yes, And I think as I've been conversing with Tyler,
I've learned a lot about his model of that tissue
capacity umbrella. So underloading it you're going to cause harm.
Overloading it, you're going to cause harm. So if you
want to be a good clinician, You're going to find
what is that threshold and we're trying to move that
(25:20):
threshold a little bit more each time. So definitely looking
at tissue capacity, whether I'm looking at using like a
moloc to get their strength and saying, okay, if this
is your strength, what is you know, your one rep
max and you know, can we go sixty five to
seventy five percent of that? You know, things like that,
(25:41):
and saying, what is the true goal of my intervention
right now? Am I trying to mobilize through a certain range?
Am I really trying to increase some strength and hypertrophy?
Am I looking at more so endurance? So being able
to understand what you're doing and why you're doing it,
I think helps with and you know, creating a better
(26:02):
tissue capacity for that individual.
Speaker 1 (26:05):
Yeah. No, absolutely absolutely, And it's also one of those
things that I think we need to understand when we
do intervene. As you mentioned, what are we doing mobility stability?
Are we doing more of a neuro type of pattern
as well? Because one of the things I personally didn't
take as seriously as I should have in school was
that neuroscience course. Right, I think everyone looks at it
(26:27):
and they're like, well, you know, I'm gonna work with athletes.
I don't need that. And then you get into the
world and you're like, shoot, I need to go back
to those notes. I need to touch up that sort
of thing and understanding that role of kind of the
neuromuscular stability element there as well. The other piece I'll
say is understanding the different types of contractions and making
sure that you do hit all of the different types
(26:50):
of contractions in your rehab approach. Right, Are we producing force?
Are we reducing force? Are we hitting some actual true eccentrics?
Are we hitting some isometrics? Right? Going through the variety
of different types of contractions that we can see, but
different types of motions we can see that muscular group
and that joint doing and insuring we didn't miss anything right,
(27:12):
because yeah, you know, we might get them back to
the point where they're throwing one hundred miles and now
we're paying free. But if we miss something, they're going
to end up back on our table in six weeks,
and ideally that's what we're trying to prevent here.
Speaker 3 (27:23):
Yeah, I definitely agree with hitting all those types of contractions,
So I've been leaning more into some of those, like
yielding isometrics.
Speaker 2 (27:32):
I think that is one of those underused.
Speaker 3 (27:34):
Tools, or even just trying to incorporate the eccentric training
in a different way, whether I'm having them do a
bandited shuffle with the dumbbell and throwing a punch to
see can you slow down the momentum of that weight.
You know, I'm trying to find ways that I can
incorporate all of those contractions.
Speaker 2 (27:50):
But yeah, I think that's so important and.
Speaker 1 (27:52):
To your point too on the yielding ISOs and some
of the other things, right, Like a lot of them
require minimal to know equipment.
Speaker 2 (27:58):
So literally times.
Speaker 1 (28:00):
People come to me and they're like, well, you know,
I work with athletes, but I don't have access to
a power rack in barbell, so I can't load them.
And it's like, you can still load them, you just
have to get creative and think outside the box outside
of yielding ISOs. How old do you like to get
creative to put high force or put different kind of
loads through the shoulder that way, when you might be
I call it balling on a budget, you know, working
(28:22):
in a spot where maybe we don't have access to
everything we normally want.
Speaker 3 (28:26):
Yeah, so you can give me a wall, a med ball,
and some type of slip floor with a towel, and
I'm going.
Speaker 2 (28:34):
To make something happen.
Speaker 3 (28:35):
Whether I have them in a plank position and have
them do like literally floor slides. Can you keep that
stable medball pushes, being able to sit with your back
against the wall and just throw that med ball, push
it as hard and as far as you can things
like that.
Speaker 2 (28:52):
I mean it takes literally three things.
Speaker 3 (28:57):
Doing ball circles with a med ball on the wall,
your shoulder, maintain that.
Speaker 2 (29:02):
So anything that I could do the equipment, Hey, I'm
here for it.
Speaker 1 (29:07):
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(29:51):
dan to at Ray Gorman DPT on Instagram and receive
your free breakdown on the model for sure. For sure,
it's thinking outside the box and one of the things
I like to do whenever we have some free time
in the clinic, which is not common, but it's nice
when it comes around. Yeah, grab stuff and play around
and just kind of, I don't know, create a movement
playground if you will. Right, it's like, go out there,
(30:12):
try things, see how it feels, see how it works,
and if it sticks, if the idea is good and
you feel like it's valuable, and yeah, try it with someone.
Start small. Don't just know, replace your entire rehab program
with all this new stuff, but maybe throw it in
in addition to what you've been doing and see how
it goes that way. Obviously, exercise is great, but one
(30:33):
of the other things, going back to the tissue component
as well, is the clinician's ability to use their hands
to get things calmed down and open up this window
of opportunity for us to get load through it, to
move the needle forward with exercise that way. And I
know that's one of the many things that comes up
a lot when I'm talking with people involved in ARC,
(30:53):
as well as some of the crafty creative things you
all do, whether that be curved cups or different things
that way for this kind of shoulder region. What have
been kind of your go to strategies with your own
hands that way or with the different kind of tissue tools,
if you will, to calm things down, maybe take it
from like a ten to or three and open up
that window of opportunity for us to get load through
(31:15):
the shoulder.
Speaker 2 (31:16):
If you will.
Speaker 3 (31:17):
Yeah, I definitely don't neglect my mobs. I like to
do my shoulder modes and different planes. So I may
start off with those grade one, grade two mobs AP
joint modes while they're just laying down with it in neutral.
Speaker 2 (31:31):
Then let's see ken you tolerated.
Speaker 3 (31:32):
Going at forty five degrees going to ninety degrees in
abduction maybe in a scalpular plane, getting those AP modes
sometimes inferior modes I do enjoy doing soft tissues, So
I love my little release techniques because that PEC monitor
it'll be tender on them.
Speaker 2 (31:49):
But once I get in there and kind of scrub
it a.
Speaker 3 (31:51):
Little bit, they're like, oh, that hurt, but that feels
good now a good subscap release.
Speaker 2 (31:57):
Whether they're laying on their.
Speaker 3 (31:59):
Side with the painful side that I can get my
fingers in there and little just grab under the scapula,
or if I have them laying on their side with
the painful side down, have them retract a little bit
and scrub on the inside there as well to get
to those midge traps, run boards and that media border
of the scapula. So I'm always doing some type of
(32:21):
release technique for the posterior muscles and then trying to
free up their posterior capsule because that's usually what starts
getting a little contracted after a shoulder injury.
Speaker 1 (32:33):
Yeah. No, I love that you brought that up, and
I love how you mentioned we don't neglect the mobilizations.
A lot of times I hear people say, well, you know,
it's a problem of instability at the shoulder. It moves
too much, right, we have too much WT forty nine
en f duct tape and they just completely throw the
manual to the wayside as a result. And as you mentioned,
that posterior capsule plays such an essential element to the
(32:57):
whole concept of the shoulder into the ability that way, right,
if we're too tight posteriorly, knowing that we have thinking
back to biomechanics and that concave convex role for a second, Right,
we have the concave glenoid and we have the convex
humoral heads. The role and glider opposite one another because
we have convex surface moving on concave. So as a result,
(33:20):
if we have restriction posteriorly, we're gonna end up with
more issues anteriorly as a result. So I love that
you bring that up, and I love how you mentioned
just not being afraid to dig in there a little
bit and break stuff up and release stuff. I know
a lot of people kind of debate this whole soft
tissue world and soft tissue theory, and I think it's
one of those things if you've never felt the benefits
(33:42):
and effects of it, it's very easy to critique. But
once you kind of get into some of these situations yourself,
you realize just how much of a difference it can make.
It changes the conversation rather quickly.
Speaker 2 (33:55):
Yeah, one hundred percent.
Speaker 3 (33:56):
So, and there are even articles out there that show
that there is some type of benefit with including manual therapy.
There has to be more research down to see how
much and what exactly, but it shows there is some benefit,
especially to increase the athletes or the client's tolerance to
the exercise. So I definitely don't like to neglect the
male therapy side, but I also educate them that hey,
(34:20):
this is going to bring you some short term relief
so that we can get a little more into the.
Speaker 2 (34:23):
Strength and endurance.
Speaker 3 (34:25):
But you know, it's it's necessary, but that doesn't mean
I need to go home with you and do.
Speaker 2 (34:30):
These mobs every single day on you, you know.
Speaker 3 (34:34):
Or I teach them how to do their own mobes
with like one of those big like power road bands
and you know, hook it on some fick surface and
show them, Okay, put your arm through here, rotate this way,
allow it to glide you to a certain degree. So
if they're like, no, that really works, Okay, let me
show you how to do it on your own with
a band you can get.
Speaker 1 (34:54):
It's funny. I do the same thing. Right, the manual
almost becomes part of your examination and evaluation, and it's like, hey,
I can do this thing and in ten minutes, look
at the improvement we got. Whether that's hey, the pain
is down, the range of motion is whatever, it is.
That way, if I can make some kind of positive
change that quick, I'm giving them home versions of those
exact same things, And obviously it might not be quite
(35:16):
as effective. But you know, I think it's important to
note with any kind of rehab, especially the shoulder, we're
not necessarily swinging for home run chots here. We're not
trying to get this thing better in one or two visits.
It does take a little bit of time. And that
goes back to what you mentioned before. Right, these are
typically not one single moment that causes a mechanism of injury.
(35:36):
A lot of times it's that repetitive microtrauma. It accumulates
over time. Right. I can't undo you know, fifteen years
of baseball's effect on the shoulder in one to two hours. Unfortunately,
it takes me a little bit longer to get there.
And maybe maybe I'm just not as good of a
clinician as I could be. Maybe someone else can fix
it in an hour and it's never an issue. But
(35:57):
I really think because the problems come on over a
long time, we have to be a little bit more
long minded in our rehab approach. And that's not necessarily
them in the clinic, you know, for you know, twelve
months out of the year, that might be hey, look,
you know, we're gonna work this for a month and
a half or two months, and then after that time,
(36:18):
here's what you have to do on your own, here's
how you progress it. And educating them on kind of
how to steer their own ship if.
Speaker 3 (36:24):
You will, Yeah, one hundred percent. And I think even
doing like those pre and post test type deals, when
you do menu and they do see a change, even
the mental aspect, it gives them a positive outlook on therapy.
Speaker 2 (36:39):
It gives them a.
Speaker 3 (36:39):
Positive outlook like, oh, this actually worked, and it creates
a little more buy in to say, let me trust
this clinician a little bit more.
Speaker 2 (36:47):
So.
Speaker 3 (36:47):
I think even just from the mental aspect of your patient,
it helps.
Speaker 1 (36:52):
Absolutely, it definitely helps. And I think that's the other
piece that people neglecting this whole process as well as
you know, we use the physical therapy a lot, But
some of these things also have a bit of a
mental component to them as well, Right, And if you've
gott an athlete who's had shoulder issues for multiple years,
they've been in and out of clinics, and you know,
(37:12):
nothing's really helping them, and they're just trying to push
through it and play through it. It's not just the
physical component that we're addressing here. There's also a mental
element to it as well. That way, and I think
you know, knowing that it's it has to be a
little bit more of a holistic rehab approach, if you will,
a little bit more than just again the three sets
of ten rubber band factory and a ten minute evol conversation.
(37:34):
That way, you know, how can we provide best not
just for this athlete, but for this person as a whole,
after we've gotten understanding of what they've been through and
how they landed in front of us on that specific day.
Speaker 2 (37:45):
Yeah, it's the whole biocycle social model.
Speaker 3 (37:48):
We get taught that in school, but when we get
into practice sometimes it goes out the window. Usually we're
pretty good on the bio part, but the psycho social
it's we have to think about what are these people
telling them, So what are other people telling them?
Speaker 2 (38:02):
Do they have coaches, you know, bringing down their next thing?
We need you back, we need you back.
Speaker 3 (38:05):
Are their parents who trying to push them to get
this you know d one scholarship?
Speaker 2 (38:09):
But here they are playing through injuries.
Speaker 3 (38:12):
So I think we have to look at the whole
thing and address that, especially in like the subjective evil part.
You know, So, how are you feeling? Honestly, like, besides
the pain, how are you feeling? No, I'm not trying
to be a therapist, but this gives me a little
more insight into what language I need to use around you,
what language may be a little more harmful to their
therapy versus you know, what may be a little more helpful.
(38:34):
So that's one thing. I'm looking at the whole thing
as best as I can.
Speaker 1 (38:39):
It Also, at least in my experience, has helped me
to decide if I'm even the right provider for that person,
because one of the things I don't feel like I
got enough when I was in school. And maybe this
is just my experience, but I don't feel like I
was taught enough about you might not be the right
person for someone, And a lot of times we start
(39:01):
coordinating the rehab if you want to call it rehab,
with head coach, pitching coach, at S and C. We
get other people involved, sometimes mental health providers, whatever it is.
But sometimes I'm not the one that they need to see.
Sometimes it's hey, look, they need adjustments to their actual
practice load, or they need adjustments to their actual pitching mechanics.
(39:24):
And while I like to think I'm good at some
of these different sports like baseball, I'm not the guy
you're going to call to correct your pitching mechanics. If
you're looking for a D one scholarship, I know my place,
and I have no issue stepping back letting someone else
help you with that and kind of addressing what needs
to be addressed there ultimately. With complex issues like the shoulder,
you know, I always joke we call it the shoulder
(39:45):
complex because it is really freaking complex. You look at
how many muscles are in that area, how many just
attached to the scapula alone, right half of the joint.
There's a lot going on here. And I think as
long as you approach these situations not just from an
exercise standpoint, but overall from a personal standpoint with high
respect levels, for others and low ego levels, You're going
(40:07):
to do right by the people in front of you.
Speaker 3 (40:09):
Yeah, I would have to agree that. I don't think
we were taught that. Hey, you just may not be
the right person. So as I've been practicing and you know,
getting a little more, getting a little more experience, I've
learned that and I've understand Hey, put your pride acide. Yeah,
you may know the bio mechanics of this and that,
but ultimately, what's going to help this person the best? Now,
(40:30):
if I am working in the area that you know,
resources may be limited and the next provider you know,
might be sixty miles away, then I'm going to do
my research.
Speaker 2 (40:39):
I'm going to reach out and I'm going to let
you know.
Speaker 3 (40:42):
Other people within the care note, Hey, I need your help.
So yes, I am collaborating with their athletic trainers and
their strength and conditioning coaches. Especially, say, if it's off
season and they really can't get into a facility and
I'm the only thing they have at that moment, I'm calling, hey,
what is your picture coaches now? Number I need to
talk to them because at the end of the day,
(41:04):
is what gets this athlete better? And can you put
your pride side and know that, hey, yeah, you may
be a good clinician, but this just may not be
the case for you. And if it is not the
case for you and you still have to work on it,
can you reach out and get the help that you
need so that you can help this athlete or this patient.
Speaker 1 (41:23):
Absolutely, and that's essential throughout the entire rehab process as well,
right from day one all the way up into the
return to sport era as well. Right you know, I
think there's a lot of conversations lately about outcomes of
different surgical procedures, and I think one of the reasons
that we might not see the outcomes that we want
to is we ultimately fail in the return to sport element,
(41:45):
whether we don't have a process for testing and assessing
readiness or we don't have some kind of process to
actually return them to sport. I think a lot of
times people think they get cleared to go back and
play their sport and they're going to pick up off
right where they left off. And I think it's, in
my opinion, more of a progression, right, you know, just
like you didn't get to return to sport overnight, you
(42:08):
don't get back to the desired level of sport performance
the first time you step back into you know, your
playing pitch. That way, it takes time to get there.
What's been your own approach for return to sport for
the shoulder labor? How do you like to do some
of these different testing, assessments and batteries, whether that be
post operatively or not up and they're just trying to
(42:29):
get through a season that way, where do you like
to go from an assessment standpoint and how do you
like to kind of progress them back to their sport
if you will.
Speaker 3 (42:36):
Yes, I have to credit this to my sports mentor,
doctor Anda Gray. She really helped me with return to
sport testing for the shoulder, so just how we do
it for the acl meniscus. She showed me ways to
return to sport for the shoulder. So that looks like
for me doing like a wide balance test with the
shoulder to see and compare it with you know, the
(42:57):
affected and unaffected limb. It looks like doing a med
ball throw with your back against the wall and seeing
how far they can throw it. It looks like the
endurance tests where they're doing like a shoulder tap with
their arms a certain width part. So those are the
three main ones that I do. And I also, like
I said, go back to using the malac, getting their
(43:19):
strength at neutral at ninety here, even at ninety here,
to see what those numbers look like compared to the
unaffected side and if they're in like that ten to
twenty percent difference. So those are usually my go tos.
And then also doing the quick mental assessment, you know,
how are you feeling, and using those questionnaires as well,
(43:42):
because insurance loves.
Speaker 2 (43:43):
Though, so I have to get them in.
Speaker 3 (43:45):
But using those as well, so I think for me,
I've been able to do a little bit better at
that return to sport part. I'm giving them interval throwing programs.
I know a lot of the protocols. Have you do
the throwers ten program and then when you get a
little bit further there's an events throws ten. But you
know those interval programs. And I understand now with the
(44:06):
research coming out, they don't really know how hard or
how fast they're throwing gets. So it's more so can
you throw this many pitches at this distance? And then
are you doing it off the mound or with my quarterbacks?
Are you throwing you know so many yards without pain
and then how long is it taking you to recover
and having them actually document that. So I'm trying to
(44:28):
be a little more objective in my return to sport
versus just going off the feeling and okay, you pass
the NMT, you pass.
Speaker 2 (44:34):
Range of motion. No, what are those other things that
kind of contribute to it?
Speaker 1 (44:38):
Absolutely, I love that you outlined it like that. It's
a combination of everything coming together subjective and the objective. Obviously,
we need the objective data and we need it in
a lot of different positions. As you mentioned, you know,
it's not just stuff by the side. It's hey, you know,
can we get into some of these other locations that
they're going to be in when they're throwing that way?
(44:58):
If you will? And I like your kind of phase
progression back. I know you mentioned the throwers ten that way,
and obviously you know the exercise component and the you know,
return to throwing component that way, or at least in
my mind, I always think of kind of the Kevin
wilk working contributions to it that way and his progressions
that way. It's a great roadmap, it's a great framework,
(45:19):
but it's also the kind of thing that you have
to understand it and not just kind of say like, well,
here's your program, here's your plan. Have that it's understanding
the progression, why the progressions are there, but also how
do you individualize step one to step two to step
three for the individual in front of you, because you
know they might not fit the framework that was outlined.
(45:42):
You know, step one to step two might go from
fifteen fastballs to thirty fast balls thrown off a mound,
but they might need to go fifteen to twenty, twenty
to twenty five, twenty five to thirty. Someone else might
be able to go fifteen to fifty rights. It's individualizing
everything to the person in front of you.
Speaker 2 (46:00):
Yeah. Absolutely.
Speaker 3 (46:01):
I always tell them that these return to Sport protocols
or these programs, there are guidelines. Can you necessarily skip steps?
Not necessarily, but you can kind of advance a little
bit quicker through them. But I'm always talking about the
soreness rules as well. It's like, Okay, how long of
a break did you take and then did you only
have soreness at the end of the day, was there
(46:21):
no soretness? Did it take you two to three days
to recover? Because if it did that lets us know
we overdid it. We got to scale back until you're
able to do this without soreness, you know, impeding you
the next two to three days.
Speaker 1 (46:33):
As we kind of individualize that approach to return to sport,
I also think we need to get more people involved
in it as well, going back to that multidisciplinary comment
we made a little bit ago, right, It's not just
or at least for me, I don't like to be
the one single person that comes to this return to
sport and decision, if you will, I like to actually
get everyone else involved and have a conversation around, hey,
(46:56):
what are you seeing do you feel like they're ready?
You know, athletes obviously included in that, but also like
can we get coaching staff involved or throw involved, ats
and c involved?
Speaker 2 (47:06):
Right?
Speaker 1 (47:06):
Can we get everyone together and kind of come to
more of a team based decision than trying to go
at it on our own, because I think the more
eyes we have on it, the more accurate or idealer
decision will be, if you will, For lack of a
better way to put it, right, instead of just basing
it off of what I see in the clinic, which,
whether I like it or not, it's a very controlled environment,
(47:28):
and there's only so much I can do to make
it chaotic. You know, I can base it off of
what they're actually doing from a practice standpoint, a sports standpoint,
and what other people have actually seen with their own
eyes while they're doing their sport.
Speaker 3 (47:41):
Yeah, most definitely, especially when you're thinking of an insurance
based model as well. By the time we're getting to
those later phases, insurance is like, look, you've seen him
this many times, it's time for him to go. So
by the time it gets to the return to sport,
I may only be seeing them one time a week,
and so they're already back in the weight room with
their strength and conditioning coaches, you know, before they're back
(48:03):
on the field. And so I think it's so important
that I have to talk to those athletic trainers and
those strength and conditioning coaches and you know, their regular
coaches are pitching coaches or whoever, because you're going to
start seeing this person way more and I want to
make sure we're all on the same page. This is
what I'm seeing in the clinic, what are you seeing
with them out there?
Speaker 2 (48:24):
You know?
Speaker 3 (48:25):
So I like to make sure that whole most disciplinary
approach is there, because I never want.
Speaker 2 (48:31):
To be that outside pt who just like yeah I
got this.
Speaker 3 (48:34):
It's like no, this is this a whole family that's
trying to get this person back to sport, back to function.
Speaker 1 (48:41):
So yeah, absolutely, absolutely, I love that. I love that
for I realized we could probably talk about this all
day long that way. Is there anything we missed as
we were chatting, or any other kind of closing thoughts
or closing remarks you might have.
Speaker 3 (48:55):
If any closing remarks, especially to anyone that's going to
listen to this, I would just summarizing, really emphasize using
a holistic approach. I would really push that regional interdependence,
especially with like post op in those first few weeks
that you can't do so much with the shoulder besides,
(49:16):
you know, passive and active assist range emotion, being able
to say, hey, let's still strengthen the glutes, let's still
strengthen the core, let's get some trunk stabilization in some ways.
So get creative to make sure you're still pushing that
regional interdependence, Tailoring everything to your specific patient or athlete,
(49:37):
keeping your eye on the mental component, making sure you're
using positive language, not language it's going to harm them
or affect them in any way. But also being very
transparent and being very real with you know, your client,
giving them timelines, but telling them, hey, these are subjective,
so you know, just being a good clinician literally, just
(49:59):
be a good clinic.
Speaker 1 (50:00):
And on top of that, never stop learning, right, always
be willing to go out there and learn something new
that way, And obviously you and the entire team at
or have a phenomenal course and resource to make that happen.
Where can people find out more about you at Yes, So.
Speaker 3 (50:17):
For me personally, if you want to go to my Instagram,
I have two at doctor Sabria Savage that's b Ria
Savage and then at the Savage PT you'll find information
on me. If you want to go to www. Dot
Advance Rehab Certification dot com, you can see all our
course dates to elevate your game elevator rehab game and
(50:41):
really learn how to be a better clinician. To segrity
and all that great stuff, to capacity tissue umbrella that
I mentioned before.
Speaker 2 (50:49):
We'll learn all of that in the art classes.
Speaker 1 (50:52):
Absolutely love that. We'll link to all of that in
the description below as well. That way, if you didn't
quite catch it. You can just click there. This was amazing.
I really appreciate your time, and I'm looking forward to
continued conversations with.
Speaker 2 (51:04):
You in the future. Yes, I appreciate you. Thank you
for having me.
Speaker 3 (51:08):
This has been a great conversation. I appreciate how advanced
and modernized you are with it, so thank you.
Speaker 2 (51:16):
I appreciate it.
Welcome back to another episode of the Brown Performance and
Rehab Podcast, powered by Isofit and Firefly Recovery. Isofit is
my go to for all things isometric strength training. For
more on Isofit, be sure to check out isofit dot com.
Episodes like this are made possible by Firefly, the official
recovery provider of the Brown Performance and Rehab Podcast. For
(00:22):
more on Firefly, be sure to check out Recovery firefly
dot com. This episode is powered by doctor Ray Gorman,
founder of Engage Movement. Learn how to boost your income
without relying on sessions. Get a free training on the
Blended practice model by following at Ray Gorman dpt on Instagram. Bria,
Welcome to the podcast. I'm super excited to work with
(00:44):
you today and obviously huge shout out to our many
mutual friends there, whether the be Dylan Dave Tyler, They're
all amazing people and I can't wait to dive into
the shoulder with you today. For people who might not
be familiar with you and the work you do, whether
that be clinically or with our would you mind filing
them in a little bit about who you are and
all the great stuff you've got going on.
Speaker 2 (01:04):
Yeah, So I'm Bria Savage.
Speaker 3 (01:06):
I've been a physical therapist for almost six years now.
I've spent most of my career as a travel physical therapist,
but I do have experience as a clinic director for
orthopedic and sports clinics. I got my bachelors from the
University of Louisiana at Monroe in kinesiology, and then I
got my doctorate from the University of Saint Augustine in Austin, Texas.
Speaker 1 (01:30):
That's amazing. That's amazing, and I feel like you have
in the travel experience as well. You get this taste
of having you know what the differences of the rehab
world look like in many different populations and settings. That way,
I think a lot of people don't realize how different
it can be from state to state, and I've seen
a little bit of that when by own travels that way.
(01:50):
I mean, for example, here in Maryland, I'm able to
order imaging, which is a game changer. But when I
was in some of these other states, I wasn't even
allowed to dry needle, wasn't allowed to be a far
as some of these different tools that make a huge
difference that way, And obviously all of those things impact
our ability to provide our patients with the best outcomes.
And one of the many diagnoses that I see popping
(02:12):
up a lot clinically is issues with the shoulder. A
lot of times it gets called instability, or they get
some imaging done and they show some kind of damage
to the shoulder labrum. Very common in the athletes that
I've seen and worked with that way. Some manage it operatively,
some end up going more of a conservative route at
least for their season. That way. It just tends to
(02:33):
go a lot of different ways. And I don't see
nearly as many people talking about issues at the shoulder
like we do at the knee, and I'm guilty of
that myself. I certainly have a little bit more of
a bias to talk about things like the ACL and
the meniscus more than the shoulder. But these things are
really really prevalent and common out there for starters. When
(02:55):
I say shoulder labor and what the heck is that?
And what comes to mind for you when we say
things like shoulder labrum and shoulder instability that way?
Speaker 3 (03:03):
Yeah, So the lab room is this ring of cartilage
that's in our shoulder socket and it's supposed to act
as like a suction cup in a sense. So it's
increasing the depth of that glenoy fossil which is that
shoulder socket, and it's increasing the surface area for that
head of humors to be able to roll and articulate
with it.
Speaker 1 (03:22):
Right, So it tends to be more of a stability
structure in april in that like duct tape, more than
WD forty if you will. Yeah, because that shoulder, it's
just so unstable in the first place. Right, Like you
hear about different people dislocating the shoulder. I've never heard
of someone dislocating their hip. Not to say it can't happen,
(03:43):
but I haven't seen an athlete do that, just because
of how deep that socket is in comparison to the shoulder,
Like it's really freaking shallow.
Speaker 3 (03:51):
Yeah, because the shoulder, because it's that bottle and socket joint,
it's so mobile and it doesn't have that many structures
to create stability, especially in the front. I mean in
the front, we have our ligaments, we have the longheaded
biceps tending, but we don't have that much. We have
the pecks coming across there, but we don't have much
to really support that front side of the shoulder. So
(04:14):
that's why those antior dislocations are way more prevalent than
you know, any poster dislocations or even inferior dislocations.
Speaker 1 (04:22):
You mentioned the biceps tending there, and I believe anatomically
the long head of the biceps tendon actually attaches to
the labram. And this is something I've had debates about
with many different orthopedic providers in the past, where some
will give a diagnosis of bicipital tendinitis and others will
tell me bicipital tendinitis is not even a thing, and
(04:42):
if there's pain proximately in the you know, that kind
of region in the long head of the biceps, they
say it's more labrum than the soft tissue component itself.
That way, I'm curious what are kind of your thoughts
on that, like anatomically superior labram versus you know, proximal
attachment of the bio if you will.
Speaker 3 (05:01):
Yeah, So when I'm thinking of that, I don't always
just go off of where the pain or tenderness is
because for bicycleal tendonities, which I do get a good
bit of those diagnoses, yes, there's going to be pain
at the a C joint pain at the superior you know,
area of the gleno humoral joint. But also I do
(05:23):
rely on the special tests because they are pretty sensitive,
so they're good to rule out, but.
Speaker 2 (05:28):
They're not as specific.
Speaker 3 (05:30):
So I'm going through the special test to try to
figure out, you know, is this truly biceps or is
this labor.
Speaker 1 (05:35):
Them So you mentioned the special test. What kind of
special test do you like to do or what does
that typical exam evaluation process look like for you? When
someone's coming in with something, you know, whether that be
shoulder labor instability, possible bicep, tendon involvement, what's kind of
your typical exam flow and assessment battery look like.
Speaker 3 (05:56):
Yeah, So when they're coming in, of course I'm taking
a subjective trying to see what was their mechanism of
injury or if they do have a video, can I
see the video. I'm asking them what are their symptoms?
Are they're having night pain, are theyre having crepits.
Speaker 2 (06:10):
Or anything like that.
Speaker 3 (06:12):
I'm looking at their active range of motion and where
a painful arc may be. I like to look at
my internal external rotation and like a supin or laying
down position. So I can keep that scap kind of fixed,
and I'm looking at their internal external rotation at neutral
and in ninety degrees, because we know with most laboral
(06:32):
issues we're gonna have a good bit of external rotation,
but the internal rotation is gonna be pretty limited off
the back. Then I'm looking at their strengths, so I'm
doing my mmts to see where they're weak at, and
then my special test. So there's like the active O'Brien's
compression test, There's some sharer tests there, there's the biceps
(06:54):
load two tests, so all of these type of tests
that I can kind of grind or share that labor
them to see if it's going to increase any symptoms.
Pretty much just how we do McMurray's for the knee.
I'm doing those saying tests for the shoulder to see
if anything is catching, clicking, or popping. And then of
course my palpatience. So I am going through and seeing
(07:14):
where tenderness is. Is it at the AC joint, is
it at the corecoid process, do I get some pec
minor involvement, and is it kind of extending into the
rotator code.
Speaker 1 (07:25):
Good exam flow in my opinion, and It's one of
those things that you don't miss anything, right, you kind
of look at the whole picture. And that's something that
I feel like a lot of clinicians and I feel
like we've all been guilty of it. I've been guilty
of it at times, right, Like you're in a rush
and you've got to cut something out of the exam flow,
even though you might not want to, but it's really
essential to try and get a little bit of everything,
(07:46):
if you will, because I don't think range of motion
and manual muscle test alone tells the full story. But likewise,
I don't necessarily think that reliance exclusively on provocative special
tests is the best strategy either. I think really the
culmination of everything coming together that way. And to your
point on palpati, I've found a lot of times, you know,
(08:07):
someone might come in with pain that would we typically
think along like a labrum distribution or something, but a
lot of times they get really tender when I dig
in posteriorly, especially into some of these posterior soft tissue structures, right,
and so, with the shoulder being so complex and we've
got a lot of nerves in the area, we've got
a lot of muscle muscles in the area. We have
(08:27):
to kind of think beyond just the you know, anatomical
structure of oh it's the labrum, or oh it's the biceps.
There's a lot of other things that can contribute as well.
And there's been times when people come in with that
typical anterior shoulder pain that I actually clean up quite
a bit by treating more along the posterior aspect of
posterior a dell infraspinatus and so on that way. So
(08:50):
I think it's one of those things that having that
thorough assessment process, if you will, really helps to guide
you from your interventions, because you know, with the conversation
of the labrum and an unstable shoulder, it can be
really tricky to manage if you're just kind of throwing
exercises at the wall and not one hundred percent sure
what you're treating.
Speaker 2 (09:09):
Yeah, one hundred percent.
Speaker 3 (09:11):
And then I wanted to mention even after it's during
my follow up visits, when I don't have time during
the initial ebau to look at everything, I do like
to go back and look at their core stability, that
the rascal mobility, and even their glute strength because we
know with the complexity of overhead motions, and especially with
these overhead athletes, a lot of times a glute weakness
(09:32):
could contribute to that. So I always go back and
try to look down the chain too. I think that's
super important.
Speaker 1 (09:37):
Oh, I absolutely love that you do that, and I
love that you bring that up because, as you mentioned,
you know, a lot of times if we're seeing issues
in the labrum or issues in the shoulder, it's going
to be in that typical overhead athlete population, if you will,
whether that be you know, the baseball, softball population, I
would argue volleyball, tennis, u as well, a lot of
(10:01):
these different kind of sports where the arm is overhead
and doing something high velocity, repeated over and over and
over again. And with that in mind, as you mentioned,
it's not just the shoulder producing all that rotational force.
It's other musculature, whether that be spinal engine, hip complex
whatever it is. That way, right, Like, if you watch
(10:21):
someone throw a baseball or swing a baseball bat, it's
not just all arm doing that. It's a lot of
other components contributing to the force that you're VBC displayed
out the arm. So it's more of like I feel like,
in general, if the shoulder's unstable, it becomes this problem
of we're trying to fire a cannon out of a
canoe and it can't handle it.
Speaker 3 (10:43):
That part, that part literally I don't know how many
times I've tested a gluten need MMT and it's like, oh,
you can't even hold resistance or even looking at a
single egg squat to see can they maintain a pretty
level pelvis? Can they maintain need stability to go through that?
(11:04):
And I'm like, if they can't do those functional movements
like this is definitely contributing to why your shoulder is hurting.
Speaker 1 (11:11):
Right. So, outside a frontal plane hip and a little
bit of a core stability component, are there any other
common death sits you see athletes presenting with that kind
of present in the same time as the shoulder instability
shoulder laborm type things.
Speaker 3 (11:29):
Yeah, So thinking in the transverse plane, any rotation, so
their thoracic rotation sometimes is literally trash.
Speaker 2 (11:37):
It's like, oh, you really can't rotate through there.
Speaker 3 (11:40):
And if you can't rotate through there, your scalpular your
scalpulas can't up really or downly rotate or tilt like
they need to or that almost in this preposition anterior
to where it's like now I'm already going to pinch something.
So I think that thoracic rotation is a super big
one because some of them they really just can't rotate, right.
Speaker 1 (12:02):
How do you like to go about assessing spinal rotation?
And I'll add another one on that as well, how
do you like to look at and assess scap stability
as well?
Speaker 3 (12:12):
So with the spinal rotation, sometimes I'll get them in
child's pose on their elbows and I'll put a hand
behind the head and I'll have them do an active rotation.
Sometimes I'll use the enklinometer to actually measure it, and
sometimes I'm just taking a picture with our company iPad
to show them, hey, you can open up this much
on the left, but on the right, on your actual
(12:34):
throwing side, you're not even moving much. So that's usually
what I'm doing for the thoracic rotation. And then what
was the other one you mentioned, Yes, scalp stability. So
sometimes that looks like just doing forward elevation and abduction
and looking at are the scaps rotating at the same time.
(12:55):
Maybe I'll do a scapular assist test or a scalplar
retraction test. And then I also like to look at
a push up plus so putting them in its tall
plank position and have them do like that pro traction
to see is there a lag on one side? Can
they even get that full range? So that's usually why
I'm looking at there.
Speaker 1 (13:15):
You know, it's so crazy because a lot of these
assessments people are going to listen and they're going to think, wow,
that's pretty simple. You know, homeboy here he benches three
point fifteen for reps. How is that going to tell
me anything about where to intervene on the shoulder labor them?
And it's like it might be simple in nature, and
homeboy might be able to move a little bit away,
but that doesn't mean he's good at these simple things. Right.
(13:35):
A lot of times I see athletes missing these foundational concepts. Right,
they're trying to run a full marathon before they've ever
even completed a five k. Speaking metaphorically here, it's like,
we have to master some of these foundational functional concepts
before we go on and get into the good stuff.
Speaker 3 (13:53):
Right.
Speaker 1 (13:53):
You know, you don't throw someone into sport day one.
You don't throw them into baseball day one, expect them
to throw one hundred miles an hour. A lot of
things they do to prep for that, and even when
they do get to that point, there's an extended prep
in that session, right, kind of a throwing program, throwing routine,
just to get to the point where they're throwing that
explosively and violently, if you will. So, I think the
(14:13):
same concept is true from our assessment standpoint. It's not
so much as getting lost in the weeds. Right, Like
we talk about sports science different times on the podcast,
and I absolutely love that stuff, but we don't need
it to get a good assessment and understanding of what
the heck is going on with an unstable shoulder and
where to go from our intervention standpoint, A lot of
(14:35):
times if we just take the time, use our eyes,
use our hands, we can still get what we need.
Speaker 3 (14:40):
Yeah, one hundred percent. I'm always let's go back to
the basics. Basics, let's go back to the foundation, because
I don't want to have them even when we get
into the rehab part. I'm not trying to train a trick.
I'm trying to give you foundational stability, dynamic stability that's
going to translate into your.
Speaker 1 (14:57):
Sport, absolutely, and the more simple we can make it,
the more likely we are to succeed, in my opinion,
and the more likely our athletes are to actually do
the things that we're asking them to do, because they're
going to understand it.
Speaker 2 (15:11):
Right.
Speaker 1 (15:11):
If you start talking with all these crazy terminology and
different things that way, you know, I found, at least
in my own experience, it ends up doing a little
bit more harm than good. The more simple you can
make the problem, the better off it's going to be,
not just for yourself and potentially other clinicians you know,
working with the patient, but also the athlete themselves. That way, right,
(15:33):
it kind of speaks to what I call the rehab
philosophy of Okham's razor, if you will, Essentially, from a
problem solving standpoint, searching for explanations, going with the simplest
tends to be the best that way in this term.
And it's one of those things too, As I mentioned
or kind of alluded to, I find a lot of
people with these pathologies get very frustrated because a lot
(15:56):
of the times they're told to go with the rehab route,
with a physical therapy route, if you will, that way,
and they do and they don't get good outcomes.
Speaker 2 (16:06):
Right.
Speaker 1 (16:06):
I've seen a number of athletes that are bounced around
from rehab provider to rehab provider, and they get frustrated. Right.
They're not really sure what's going on. They don't feel
like there's a great plan in place, and a lot
of times they feel like the rehab itself is not
overly progressive or challenging. I think everyone's seen those cases
where it's just three sets of ten rubber band factory
(16:27):
for everything, and it's one of those things that I
feel like, in general, this population becomes rather unserved by
the orly served by the traditional rehab model.
Speaker 2 (16:37):
In my opinion.
Speaker 3 (16:38):
What I've found, especially with some of those athletes, so
the research shows that the longer the symptomatic period is
the least likely they are to respond to to conservative
treatment is possible. But the longer they are with pain,
the harder it is to really rehab that without some
type of surgical intervention. But what I found is a
(16:59):
lot of these athletes, they're not coming when they're first
feeling these symptoms. They come after it's like it's killing
me to finish a game, or it's killing me to play,
and so now all those micro traumas have kind of
compounded and that micro trauma has turned into an actual tear,
And so I feel like if they would come a
little bit earlier, they could get a little more a
(17:22):
little more progress. But also I do have a problem
with some of those clinicians who stick with the three
sets of ten model. They're keeping it very beyond simple
and not tailored to that athlete. Because if he can
lay down on the side and do three sets of
ten with a five pound dumb bail with external rotation
and he's like, yep, I'm done, it's like, Okay, how
(17:44):
can I engage that rotator a couple a little bit
more versus just letting it be?
Speaker 2 (17:49):
Right?
Speaker 1 (17:49):
Absolutely absolutely, It's like, how can we challenge what we're
doing and find a way to break the model and
make it better? Right. I think it's one of those
things we should always be challenging ourselves in challengeing our
framework and interventions that we use with people. And obviously
we talked about how the assessment component is going to
have an impact in what we do from an intervention standpoint,
(18:10):
and one of the things I want to kind of
circle back to as well as you mentioned about different
instability moments or different tear patterns that can occur in
the labor, whether that be anterior, posterior inferior. Obviously, I
personally see the more commonly anterior or slap type patterns
that way superior labor or anterior to post heior. That is,
(18:31):
I don't see nearly as many posterior or inferior issues,
but obviously they can happen. What changes on your intervention
approach when the tear pattern or issue is different?
Speaker 2 (18:45):
Right?
Speaker 1 (18:45):
What's different between the slap or anterior versus a posterior
type of instability versus an inferior type of instability if
you will.
Speaker 2 (18:55):
Yeah, so with.
Speaker 3 (18:58):
I guess the posterior, we're looking at possible hell sex
lesions to where maybe the backside got dind it in
a little bit. We may be looking at a bankkart
legion where most of like that posterior inferior area got
torn a little bit. I wouldn't say it's a super
(19:19):
super big difference. Besides, there are some movements that we
want to avoid, like some of that internal rotation or
the horizontal adduction, and sometimes those close close kinetic chain
exercises could be a little too provocative too soon, So
I would say that's probably the biggest thing for me,
Like the intern rotation, horizontal adduction, and then close kinetic chain,
(19:42):
anything pushing.
Speaker 2 (19:44):
I feel like those are the ones that are.
Speaker 3 (19:45):
A little more provocative, and so I don't hit those
so quickly versus your usual slap tear. I'm going straight
for that posterior chain strengthening, posterior cuff strengthening, and then
we are trying to get into like say a sleeper
stretch or horizontal at dutch and stretch, or really digging
into the peg minors. So I think those are probably
the biggest things. But with both I am going to
(20:08):
be strengthening that poster cup pretty heavy.
Speaker 1 (20:10):
I love that. And one of the other things I've
done a lot is, as you mentioned before about the
regional interdependence approach, it's a matter of how can I
find ways to address some of these other components creatively
that still work the shoulder that way. Obviously, you know,
if you're in kind of a private setting like a
cash based model, or if you're in a team based setting,
(20:31):
there's a lot less hurdles and obstacles that come to
you know, treating the hip complex for a shoulder issue.
But if you're in this insurance based world, like many
of us tend to be, we do have a tendency
to need to get creative, if you will, and think
outside the box as far as how we address the
hip and the shoulder simultaneously, if you will, And at
(20:53):
least for me, one of the ones I'll go to
a lot is I'll find different plank row variations per
dog row variation, or I'll also do different things isometrically
as well, where I might have some kind of hip
iso while they're doing something with their shoulder. The other
thing I found a lot of benefit from is doing
loaded carries. And I don't necessarily do these early on
(21:14):
with someone with the unstable shoulder, but it's a matter of, hey,
where can I put the weight, whether that's just general
suitcase carry or some kind of overhead carry, and how
can I load it in a way that maybe addresses
a little bit more than just the shoulder, right, Maybe
I can get into the core stability element or something
along those lines as well. And as you mentioned, that's
not necessarily something I'm going to on day one, but
(21:36):
it's one of those things that I think can certainly
have a bang for your buck value from an intervention
standpoint later down the line.
Speaker 2 (21:42):
Yes, I love those.
Speaker 3 (21:44):
I use them all the time, whether I'm in like
a modified side plank and kind of quelling them drive
that bottom knee into the ground while they're doing some
type of row. I love a good single leg iso
hip thrust while they're doing something.
Speaker 2 (21:58):
With the arm. Any plank rows love it.
Speaker 3 (22:02):
So I'm always, like you, trying to find ways that
I can incorporate it. And I like to keep my
documentation on points so they're going to see things in
there about regional interdependence and how force transfer from the
legs of the torso to the arm. Like I'm hitting
all of that because these athletes need it, and.
Speaker 2 (22:22):
I'll be dog gone if I let insurance hold them back.
Speaker 1 (22:26):
I love that. I love that. I feel the same way.
I'm curious what have been kind of your more like
would have been your most creative ways to dress kind
of full body regional interdependence if you will with the
shoulder that way. I know you mentioned the hip thrust,
and I know you mentioned the plank variation, but if
there have been any other kind of unique variations that
(22:48):
you've cooked up, I would.
Speaker 3 (22:50):
Say, so I like to do dead bugs with like Isopaloff.
Speaker 2 (22:57):
I like to do those.
Speaker 3 (22:59):
I do like to do like a thorastic rotation at
the cable column, but keeping this in the ISO and
have them rotate through kind of engaging those obleaques. I
love anything single legs, so I may have them standing
on in Eric's with like an ISO fire hydrant and
have them throwing a ball at a wall for like
some type of dynamic stability, or sitting on a Swiss
(23:22):
ball with one leg up while we're doing some type
of perturbations or anything with the arms. So now I
try not to get too crazy, but sometimes you know
you have to, expecially with those higher level athletes. It's like, okay,
you're not going to benefit just from a prone ball drop.
I need to give you something a little big, a
little crazier for sure.
Speaker 1 (23:43):
For sure, sometimes we got to get crazy. And it's
one of those things that I find, going back to
what we talked about before, a lot of times we
tend to over complicate the evaluation and assessment, yet under
complicate or miss the boat a little bit, the actual
intervention strategy. Right, we get so complex and so detailed
(24:05):
in the actual assessment itself, and then we go to
give them interventions and it's three sets at ten this,
three sets attend that, And obviously we can do a
lot better. I think everyone knows the simple interventions, but
it takes a little bit more to understand and grasp
the concept around some of those more advanced interventions. And
(24:25):
I know one of the big things that comes up
a lot when I'm talking with individuals with ARC is
just overall, what is the capacity of the tissue, whether
that be that day, that week, that month, whatever it
is that way, So I'd imagine having some kind of
tool to assess what is their tissue capacity and tolerance
to movement and load at that specific point can really
(24:47):
help guide your intervention strategy for that day one and
then two. The more you understand what the tissue can
handle and can't handle, the more clear your intervention route
is going to become.
Speaker 3 (25:00):
Yes, And I think as I've been conversing with Tyler,
I've learned a lot about his model of that tissue
capacity umbrella. So underloading it you're going to cause harm.
Overloading it, you're going to cause harm. So if you
want to be a good clinician, You're going to find
what is that threshold and we're trying to move that
(25:20):
threshold a little bit more each time. So definitely looking
at tissue capacity, whether I'm looking at using like a
moloc to get their strength and saying, okay, if this
is your strength, what is you know, your one rep
max and you know, can we go sixty five to
seventy five percent of that? You know, things like that,
(25:41):
and saying, what is the true goal of my intervention
right now? Am I trying to mobilize through a certain range?
Am I really trying to increase some strength and hypertrophy?
Am I looking at more so endurance? So being able
to understand what you're doing and why you're doing it,
I think helps with and you know, creating a better
(26:02):
tissue capacity for that individual.
Speaker 1 (26:05):
Yeah. No, absolutely absolutely, And it's also one of those
things that I think we need to understand when we
do intervene. As you mentioned, what are we doing mobility stability?
Are we doing more of a neuro type of pattern
as well? Because one of the things I personally didn't
take as seriously as I should have in school was
that neuroscience course. Right, I think everyone looks at it
(26:27):
and they're like, well, you know, I'm gonna work with athletes.
I don't need that. And then you get into the
world and you're like, shoot, I need to go back
to those notes. I need to touch up that sort
of thing and understanding that role of kind of the
neuromuscular stability element there as well. The other piece I'll
say is understanding the different types of contractions and making
sure that you do hit all of the different types
(26:50):
of contractions in your rehab approach. Right, Are we producing force?
Are we reducing force? Are we hitting some actual true eccentrics?
Are we hitting some isometrics? Right? Going through the variety
of different types of contractions that we can see, but
different types of motions we can see that muscular group
and that joint doing and insuring we didn't miss anything right,
(27:12):
because yeah, you know, we might get them back to
the point where they're throwing one hundred miles and now
we're paying free. But if we miss something, they're going
to end up back on our table in six weeks,
and ideally that's what we're trying to prevent here.
Speaker 3 (27:23):
Yeah, I definitely agree with hitting all those types of contractions,
So I've been leaning more into some of those, like
yielding isometrics.
Speaker 2 (27:32):
I think that is one of those underused.
Speaker 3 (27:34):
Tools, or even just trying to incorporate the eccentric training
in a different way, whether I'm having them do a
bandited shuffle with the dumbbell and throwing a punch to
see can you slow down the momentum of that weight.
You know, I'm trying to find ways that I can
incorporate all of those contractions.
Speaker 2 (27:50):
But yeah, I think that's so important and.
Speaker 1 (27:52):
To your point too on the yielding ISOs and some
of the other things, right, Like a lot of them
require minimal to know equipment.
Speaker 2 (27:58):
So literally times.
Speaker 1 (28:00):
People come to me and they're like, well, you know,
I work with athletes, but I don't have access to
a power rack in barbell, so I can't load them.
And it's like, you can still load them, you just
have to get creative and think outside the box outside
of yielding ISOs. How old do you like to get
creative to put high force or put different kind of
loads through the shoulder that way, when you might be
I call it balling on a budget, you know, working
(28:22):
in a spot where maybe we don't have access to
everything we normally want.
Speaker 3 (28:26):
Yeah, so you can give me a wall, a med ball,
and some type of slip floor with a towel, and
I'm going.
Speaker 2 (28:34):
To make something happen.
Speaker 3 (28:35):
Whether I have them in a plank position and have
them do like literally floor slides. Can you keep that
stable medball pushes, being able to sit with your back
against the wall and just throw that med ball, push
it as hard and as far as you can things
like that.
Speaker 2 (28:52):
I mean it takes literally three things.
Speaker 3 (28:57):
Doing ball circles with a med ball on the wall,
your shoulder, maintain that.
Speaker 2 (29:02):
So anything that I could do the equipment, Hey, I'm
here for it.
Speaker 1 (29:07):
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dan to at Ray Gorman DPT on Instagram and receive
your free breakdown on the model for sure. For sure,
it's thinking outside the box and one of the things
I like to do whenever we have some free time
in the clinic, which is not common, but it's nice
when it comes around. Yeah, grab stuff and play around
and just kind of, I don't know, create a movement
playground if you will. Right, it's like, go out there,
(30:12):
try things, see how it feels, see how it works,
and if it sticks, if the idea is good and
you feel like it's valuable, and yeah, try it with someone.
Start small. Don't just know, replace your entire rehab program
with all this new stuff, but maybe throw it in
in addition to what you've been doing and see how
it goes that way. Obviously, exercise is great, but one
(30:33):
of the other things, going back to the tissue component
as well, is the clinician's ability to use their hands
to get things calmed down and open up this window
of opportunity for us to get load through it, to
move the needle forward with exercise that way. And I
know that's one of the many things that comes up
a lot when I'm talking with people involved in ARC,
(30:53):
as well as some of the crafty creative things you
all do, whether that be curved cups or different things
that way for this kind of shoulder region. What have
been kind of your go to strategies with your own
hands that way or with the different kind of tissue tools,
if you will, to calm things down, maybe take it
from like a ten to or three and open up
that window of opportunity for us to get load through
(31:15):
the shoulder.
Speaker 2 (31:16):
If you will.
Speaker 3 (31:17):
Yeah, I definitely don't neglect my mobs. I like to
do my shoulder modes and different planes. So I may
start off with those grade one, grade two mobs AP
joint modes while they're just laying down with it in neutral.
Speaker 2 (31:31):
Then let's see ken you tolerated.
Speaker 3 (31:32):
Going at forty five degrees going to ninety degrees in
abduction maybe in a scalpular plane, getting those AP modes
sometimes inferior modes I do enjoy doing soft tissues, So
I love my little release techniques because that PEC monitor
it'll be tender on them.
Speaker 2 (31:49):
But once I get in there and kind of scrub
it a.
Speaker 3 (31:51):
Little bit, they're like, oh, that hurt, but that feels
good now a good subscap release.
Speaker 2 (31:57):
Whether they're laying on their.
Speaker 3 (31:59):
Side with the painful side that I can get my
fingers in there and little just grab under the scapula,
or if I have them laying on their side with
the painful side down, have them retract a little bit
and scrub on the inside there as well to get
to those midge traps, run boards and that media border
of the scapula. So I'm always doing some type of
(32:21):
release technique for the posterior muscles and then trying to
free up their posterior capsule because that's usually what starts
getting a little contracted after a shoulder injury.
Speaker 1 (32:33):
Yeah. No, I love that you brought that up, and
I love how you mentioned we don't neglect the mobilizations.
A lot of times I hear people say, well, you know,
it's a problem of instability at the shoulder. It moves
too much, right, we have too much WT forty nine
en f duct tape and they just completely throw the
manual to the wayside as a result. And as you mentioned,
that posterior capsule plays such an essential element to the
(32:57):
whole concept of the shoulder into the ability that way, right,
if we're too tight posteriorly, knowing that we have thinking
back to biomechanics and that concave convex role for a second, Right,
we have the concave glenoid and we have the convex
humoral heads. The role and glider opposite one another because
we have convex surface moving on concave. So as a result,
(33:20):
if we have restriction posteriorly, we're gonna end up with
more issues anteriorly as a result. So I love that
you bring that up, and I love how you mentioned
just not being afraid to dig in there a little
bit and break stuff up and release stuff. I know
a lot of people kind of debate this whole soft
tissue world and soft tissue theory, and I think it's
one of those things if you've never felt the benefits
(33:42):
and effects of it, it's very easy to critique. But
once you kind of get into some of these situations yourself,
you realize just how much of a difference it can make.
It changes the conversation rather quickly.
Speaker 2 (33:55):
Yeah, one hundred percent.
Speaker 3 (33:56):
So, and there are even articles out there that show
that there is some type of benefit with including manual therapy.
There has to be more research down to see how
much and what exactly, but it shows there is some benefit,
especially to increase the athletes or the client's tolerance to
the exercise. So I definitely don't like to neglect the
male therapy side, but I also educate them that hey,
(34:20):
this is going to bring you some short term relief
so that we can get a little more into the.
Speaker 2 (34:23):
Strength and endurance.
Speaker 3 (34:25):
But you know, it's it's necessary, but that doesn't mean
I need to go home with you and do.
Speaker 2 (34:30):
These mobs every single day on you, you know.
Speaker 3 (34:34):
Or I teach them how to do their own mobes
with like one of those big like power road bands
and you know, hook it on some fick surface and
show them, Okay, put your arm through here, rotate this way,
allow it to glide you to a certain degree. So
if they're like, no, that really works, Okay, let me
show you how to do it on your own with
a band you can get.
Speaker 1 (34:54):
It's funny. I do the same thing. Right, the manual
almost becomes part of your examination and evaluation, and it's like, hey,
I can do this thing and in ten minutes, look
at the improvement we got. Whether that's hey, the pain
is down, the range of motion is whatever, it is.
That way, if I can make some kind of positive
change that quick, I'm giving them home versions of those
exact same things, And obviously it might not be quite
(35:16):
as effective. But you know, I think it's important to
note with any kind of rehab, especially the shoulder, we're
not necessarily swinging for home run chots here. We're not
trying to get this thing better in one or two visits.
It does take a little bit of time. And that
goes back to what you mentioned before. Right, these are
typically not one single moment that causes a mechanism of injury.
(35:36):
A lot of times it's that repetitive microtrauma. It accumulates
over time. Right. I can't undo you know, fifteen years
of baseball's effect on the shoulder in one to two hours. Unfortunately,
it takes me a little bit longer to get there.
And maybe maybe I'm just not as good of a
clinician as I could be. Maybe someone else can fix
it in an hour and it's never an issue. But
(35:57):
I really think because the problems come on over a
long time, we have to be a little bit more
long minded in our rehab approach. And that's not necessarily
them in the clinic, you know, for you know, twelve
months out of the year, that might be hey, look,
you know, we're gonna work this for a month and
a half or two months, and then after that time,
(36:18):
here's what you have to do on your own, here's
how you progress it. And educating them on kind of
how to steer their own ship if.
Speaker 3 (36:24):
You will, Yeah, one hundred percent. And I think even
doing like those pre and post test type deals, when
you do menu and they do see a change, even
the mental aspect, it gives them a positive outlook on therapy.
Speaker 2 (36:39):
It gives them a.
Speaker 3 (36:39):
Positive outlook like, oh, this actually worked, and it creates
a little more buy in to say, let me trust
this clinician a little bit more.
Speaker 2 (36:47):
So.
Speaker 3 (36:47):
I think even just from the mental aspect of your patient,
it helps.
Speaker 1 (36:52):
Absolutely, it definitely helps. And I think that's the other
piece that people neglecting this whole process as well as
you know, we use the physical therapy a lot, But
some of these things also have a bit of a
mental component to them as well, Right, And if you've
gott an athlete who's had shoulder issues for multiple years,
they've been in and out of clinics, and you know,
(37:12):
nothing's really helping them, and they're just trying to push
through it and play through it. It's not just the
physical component that we're addressing here. There's also a mental
element to it as well. That way, and I think
you know, knowing that it's it has to be a
little bit more of a holistic rehab approach, if you will,
a little bit more than just again the three sets
of ten rubber band factory and a ten minute evol conversation.
(37:34):
That way, you know, how can we provide best not
just for this athlete, but for this person as a whole,
after we've gotten understanding of what they've been through and
how they landed in front of us on that specific day.
Speaker 2 (37:45):
Yeah, it's the whole biocycle social model.
Speaker 3 (37:48):
We get taught that in school, but when we get
into practice sometimes it goes out the window. Usually we're
pretty good on the bio part, but the psycho social
it's we have to think about what are these people
telling them, So what are other people telling them?
Speaker 2 (38:02):
Do they have coaches, you know, bringing down their next thing?
We need you back, we need you back.
Speaker 3 (38:05):
Are their parents who trying to push them to get
this you know d one scholarship?
Speaker 2 (38:09):
But here they are playing through injuries.
Speaker 3 (38:12):
So I think we have to look at the whole
thing and address that, especially in like the subjective evil part.
You know, So, how are you feeling? Honestly, like, besides
the pain, how are you feeling? No, I'm not trying
to be a therapist, but this gives me a little
more insight into what language I need to use around you,
what language may be a little more harmful to their
therapy versus you know, what may be a little more helpful.
(38:34):
So that's one thing. I'm looking at the whole thing
as best as I can.
Speaker 1 (38:39):
It Also, at least in my experience, has helped me
to decide if I'm even the right provider for that person,
because one of the things I don't feel like I
got enough when I was in school. And maybe this
is just my experience, but I don't feel like I
was taught enough about you might not be the right
person for someone, And a lot of times we start
(39:01):
coordinating the rehab if you want to call it rehab,
with head coach, pitching coach, at S and C. We
get other people involved, sometimes mental health providers, whatever it is.
But sometimes I'm not the one that they need to see.
Sometimes it's hey, look, they need adjustments to their actual
practice load, or they need adjustments to their actual pitching mechanics.
(39:24):
And while I like to think I'm good at some
of these different sports like baseball, I'm not the guy
you're going to call to correct your pitching mechanics. If
you're looking for a D one scholarship, I know my place,
and I have no issue stepping back letting someone else
help you with that and kind of addressing what needs
to be addressed there ultimately. With complex issues like the shoulder,
you know, I always joke we call it the shoulder
(39:45):
complex because it is really freaking complex. You look at
how many muscles are in that area, how many just
attached to the scapula alone, right half of the joint.
There's a lot going on here. And I think as
long as you approach these situations not just from an
exercise standpoint, but overall from a personal standpoint with high
respect levels, for others and low ego levels, You're going
(40:07):
to do right by the people in front of you.
Speaker 3 (40:09):
Yeah, I would have to agree that. I don't think
we were taught that. Hey, you just may not be
the right person. So as I've been practicing and you know,
getting a little more, getting a little more experience, I've
learned that and I've understand Hey, put your pride acide. Yeah,
you may know the bio mechanics of this and that,
but ultimately, what's going to help this person the best? Now,
(40:30):
if I am working in the area that you know,
resources may be limited and the next provider you know,
might be sixty miles away, then I'm going to do
my research.
Speaker 2 (40:39):
I'm going to reach out and I'm going to let
you know.
Speaker 3 (40:42):
Other people within the care note, Hey, I need your help.
So yes, I am collaborating with their athletic trainers and
their strength and conditioning coaches. Especially, say, if it's off
season and they really can't get into a facility and
I'm the only thing they have at that moment, I'm calling, hey,
what is your picture coaches now? Number I need to
talk to them because at the end of the day,
(41:04):
is what gets this athlete better? And can you put
your pride side and know that, hey, yeah, you may
be a good clinician, but this just may not be
the case for you. And if it is not the
case for you and you still have to work on it,
can you reach out and get the help that you
need so that you can help this athlete or this patient.
Speaker 1 (41:23):
Absolutely, and that's essential throughout the entire rehab process as well,
right from day one all the way up into the
return to sport era as well. Right you know, I
think there's a lot of conversations lately about outcomes of
different surgical procedures, and I think one of the reasons
that we might not see the outcomes that we want
to is we ultimately fail in the return to sport element,
(41:45):
whether we don't have a process for testing and assessing
readiness or we don't have some kind of process to
actually return them to sport. I think a lot of
times people think they get cleared to go back and
play their sport and they're going to pick up off
right where they left off. And I think it's, in
my opinion, more of a progression, right, you know, just
like you didn't get to return to sport overnight, you
(42:08):
don't get back to the desired level of sport performance
the first time you step back into you know, your
playing pitch. That way, it takes time to get there.
What's been your own approach for return to sport for
the shoulder labor? How do you like to do some
of these different testing, assessments and batteries, whether that be
post operatively or not up and they're just trying to
(42:29):
get through a season that way, where do you like
to go from an assessment standpoint and how do you
like to kind of progress them back to their sport
if you will.
Speaker 3 (42:36):
Yes, I have to credit this to my sports mentor,
doctor Anda Gray. She really helped me with return to
sport testing for the shoulder, so just how we do
it for the acl meniscus. She showed me ways to
return to sport for the shoulder. So that looks like
for me doing like a wide balance test with the
shoulder to see and compare it with you know, the
(42:57):
affected and unaffected limb. It looks like doing a med
ball throw with your back against the wall and seeing
how far they can throw it. It looks like the
endurance tests where they're doing like a shoulder tap with
their arms a certain width part. So those are the
three main ones that I do. And I also, like
I said, go back to using the malac, getting their
(43:19):
strength at neutral at ninety here, even at ninety here,
to see what those numbers look like compared to the
unaffected side and if they're in like that ten to
twenty percent difference. So those are usually my go tos.
And then also doing the quick mental assessment, you know,
how are you feeling, and using those questionnaires as well,
(43:42):
because insurance loves.
Speaker 2 (43:43):
Though, so I have to get them in.
Speaker 3 (43:45):
But using those as well, so I think for me,
I've been able to do a little bit better at
that return to sport part. I'm giving them interval throwing programs.
I know a lot of the protocols. Have you do
the throwers ten program and then when you get a
little bit further there's an events throws ten. But you
know those interval programs. And I understand now with the
(44:06):
research coming out, they don't really know how hard or
how fast they're throwing gets. So it's more so can
you throw this many pitches at this distance? And then
are you doing it off the mound or with my quarterbacks?
Are you throwing you know so many yards without pain
and then how long is it taking you to recover
and having them actually document that. So I'm trying to
(44:28):
be a little more objective in my return to sport
versus just going off the feeling and okay, you pass
the NMT, you pass.
Speaker 2 (44:34):
Range of motion. No, what are those other things that
kind of contribute to it?
Speaker 1 (44:38):
Absolutely, I love that you outlined it like that. It's
a combination of everything coming together subjective and the objective. Obviously,
we need the objective data and we need it in
a lot of different positions. As you mentioned, you know,
it's not just stuff by the side. It's hey, you know,
can we get into some of these other locations that
they're going to be in when they're throwing that way?
(44:58):
If you will? And I like your kind of phase
progression back. I know you mentioned the throwers ten that way,
and obviously you know the exercise component and the you know,
return to throwing component that way, or at least in
my mind, I always think of kind of the Kevin
wilk working contributions to it that way and his progressions
that way. It's a great roadmap, it's a great framework,
(45:19):
but it's also the kind of thing that you have
to understand it and not just kind of say like, well,
here's your program, here's your plan. Have that it's understanding
the progression, why the progressions are there, but also how
do you individualize step one to step two to step
three for the individual in front of you, because you
know they might not fit the framework that was outlined.
(45:42):
You know, step one to step two might go from
fifteen fastballs to thirty fast balls thrown off a mound,
but they might need to go fifteen to twenty, twenty
to twenty five, twenty five to thirty. Someone else might
be able to go fifteen to fifty rights. It's individualizing
everything to the person in front of you.
Speaker 2 (46:00):
Yeah. Absolutely.
Speaker 3 (46:01):
I always tell them that these return to Sport protocols
or these programs, there are guidelines. Can you necessarily skip steps?
Not necessarily, but you can kind of advance a little
bit quicker through them. But I'm always talking about the
soreness rules as well. It's like, Okay, how long of
a break did you take and then did you only
have soreness at the end of the day, was there
(46:21):
no soretness? Did it take you two to three days
to recover? Because if it did that lets us know
we overdid it. We got to scale back until you're
able to do this without soreness, you know, impeding you
the next two to three days.
Speaker 1 (46:33):
As we kind of individualize that approach to return to sport,
I also think we need to get more people involved
in it as well, going back to that multidisciplinary comment
we made a little bit ago, right, It's not just
or at least for me, I don't like to be
the one single person that comes to this return to
sport and decision, if you will, I like to actually
get everyone else involved and have a conversation around, hey,
(46:56):
what are you seeing do you feel like they're ready?
You know, athletes obviously included in that, but also like
can we get coaching staff involved or throw involved, ats
and c involved?
Speaker 2 (47:06):
Right?
Speaker 1 (47:06):
Can we get everyone together and kind of come to
more of a team based decision than trying to go
at it on our own, because I think the more
eyes we have on it, the more accurate or idealer
decision will be, if you will, For lack of a
better way to put it, right, instead of just basing
it off of what I see in the clinic, which,
whether I like it or not, it's a very controlled environment,
(47:28):
and there's only so much I can do to make
it chaotic. You know, I can base it off of
what they're actually doing from a practice standpoint, a sports standpoint,
and what other people have actually seen with their own
eyes while they're doing their sport.
Speaker 3 (47:41):
Yeah, most definitely, especially when you're thinking of an insurance
based model as well. By the time we're getting to
those later phases, insurance is like, look, you've seen him
this many times, it's time for him to go. So
by the time it gets to the return to sport,
I may only be seeing them one time a week,
and so they're already back in the weight room with
their strength and conditioning coaches, you know, before they're back
(48:03):
on the field. And so I think it's so important
that I have to talk to those athletic trainers and
those strength and conditioning coaches and you know, their regular
coaches are pitching coaches or whoever, because you're going to
start seeing this person way more and I want to
make sure we're all on the same page. This is
what I'm seeing in the clinic, what are you seeing
with them out there?
Speaker 2 (48:24):
You know?
Speaker 3 (48:25):
So I like to make sure that whole most disciplinary
approach is there, because I never want.
Speaker 2 (48:31):
To be that outside pt who just like yeah I
got this.
Speaker 3 (48:34):
It's like no, this is this a whole family that's
trying to get this person back to sport, back to function.
Speaker 1 (48:41):
So yeah, absolutely, absolutely, I love that. I love that
for I realized we could probably talk about this all
day long that way. Is there anything we missed as
we were chatting, or any other kind of closing thoughts
or closing remarks you might have.
Speaker 3 (48:55):
If any closing remarks, especially to anyone that's going to
listen to this, I would just summarizing, really emphasize using
a holistic approach. I would really push that regional interdependence,
especially with like post op in those first few weeks
that you can't do so much with the shoulder besides,
(49:16):
you know, passive and active assist range emotion, being able
to say, hey, let's still strengthen the glutes, let's still
strengthen the core, let's get some trunk stabilization in some ways.
So get creative to make sure you're still pushing that
regional interdependence, Tailoring everything to your specific patient or athlete,
(49:37):
keeping your eye on the mental component, making sure you're
using positive language, not language it's going to harm them
or affect them in any way. But also being very
transparent and being very real with you know, your client,
giving them timelines, but telling them, hey, these are subjective,
so you know, just being a good clinician literally, just
(49:59):
be a good clinic.
Speaker 1 (50:00):
And on top of that, never stop learning, right, always
be willing to go out there and learn something new
that way, And obviously you and the entire team at
or have a phenomenal course and resource to make that happen.
Where can people find out more about you at Yes, So.
Speaker 3 (50:17):
For me personally, if you want to go to my Instagram,
I have two at doctor Sabria Savage that's b Ria
Savage and then at the Savage PT you'll find information
on me. If you want to go to www. Dot
Advance Rehab Certification dot com, you can see all our
course dates to elevate your game elevator rehab game and
(50:41):
really learn how to be a better clinician. To segrity
and all that great stuff, to capacity tissue umbrella that
I mentioned before.
Speaker 2 (50:49):
We'll learn all of that in the art classes.
Speaker 1 (50:52):
Absolutely love that. We'll link to all of that in
the description below as well. That way, if you didn't
quite catch it. You can just click there. This was amazing.
I really appreciate your time, and I'm looking forward to
continued conversations with.
Speaker 2 (51:04):
You in the future. Yes, I appreciate you. Thank you
for having me.
Speaker 3 (51:08):
This has been a great conversation. I appreciate how advanced
and modernized you are with it, so thank you.
Speaker 2 (51:16):
I appreciate it.
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Fudd Around And Find Out
UConn basketball star Azzi Fudd brings her championship swag to iHeart Women’s Sports with Fudd Around and Find Out, a weekly podcast that takes fans along for the ride as Azzi spends her final year of college trying to reclaim the National Championship and prepare to be a first round WNBA draft pick. Ever wonder what it’s like to be a world-class athlete in the public spotlight while still managing schoolwork, friendships and family time? It’s time to Fudd Around and Find Out!