26. Dave Tilley, DPT, SCS, CSCS - Part II of II: Gymnastic Injuries, Communication in Rehabilitation & Gymnastic Moves to Incorporate Into Your Routine

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in health care. Before we get into the show, let's talk about this week's sponsor, Deputy. At your practice, what happens when staff call out sick? How much time does it take to find a replacement who can fill in? If you need to cancel appointments because you're short staffed, what does that cost your practice? Deputy is a simple app that's helped more than 250,000 workplaces tackle this problem. Deputy makes it easy to schedule staff in line with patient demand, communicate schedules with your team and instantly find a replacement when someone calls out sick. To learn more and try Deputy app for free, go to drapotcastnetwork.com slash deputy. Welcome to part 2 of our episode with Dave Tilly. Now, if you haven't listened to part 1, I highly recommend going back to episode 25 and checking that out, you will get a better understanding of the foundations of gymnastics and the culture of gymnastics because in this episode, we too will touch on that culture, but just kind of expand on everything that we touched on in that first episode. Now let me first quickly introduce our guest, Dave Tilly is a former collegiate gymnast and has been coaching gymnastics for over 15 years. He has his doctorate in PT and his board certified sports physical therapy, treating patients at champion PT and performance outside of Boston, Massachusetts. Dave is an internationally recognized expert in gymnastics and sports medicine and has consulted in programs from club to the elite level. He has successfully treated some of the world's highest level gymnasts for their injuries. Now in this episode, we go through what those common injuries might be that Dave sees. We even touch on specific patient stories and ultimately has an incredible one. We then move on to talking about communication in the rehab setting. How do us as physicians in the primary care setting discuss things with physical therapists who then now have to discuss things with the surgeons, right? And so we kind of get into this loop. And so how can we make sure that that loop is as close as possible with the most effective and efficient communication? And then if you stay till the end of the episode, we go through some of the best gymnastic workouts that you can do to incorporate into your routine. Enjoy. Yeah, that's really cool to hear, man. That's awesome. They hear that the culture is definitely improving and people like yourself will be at the forefront of that too, especially with your podcast and kind of what you've been preaching out there. But speaking about, you know, I kind of want to shift gears here a little bit in terms of talking about injuries and talking about the physical aspect of gymnastics, right? So let's start off with kind of the injury aspect. What are those common injuries that you're seeing your athletes go through? Yeah, for sure. So in the, I treat a lot of women's artistic gymnastics and men's artistic gymnastics, but I also treat like rhythmic and other people. So you got to kind of divide it up here by, so women's artistic gymnastics, a lot of lower back pain is probably the biggest thing. Spongebob fracture, stress fracture, stuff like that for sets and drum. Sometimes with neurological stuff, I mean, if you look at the literature, ankle sprains is the highest, which I would agree is up there. But I don't think it's like the most high. So Spongebob fractures, I see a lot of like hip micro instability and label issues or capsule label strains, stuff like that. I also see quite a bit of like osteocondroidist descans in the elbow. That's something we work quite a bit with. And then like just general aches and pains are kind of pretty common. For the men's side, what men's artistic shoulders are typically the bigger issues. So cuff, labial issues, personal issues, instability, things like that. The wrists are quite beat up in men's gymnastics because of how much weight being there. So we see a lot of, they call it gymnast risk, but like distal radius, you know, growth split issues, TFCC tears, quite a bit of that. And then I would say lower body, too, as well for the guys, most like ankle problems. They just do like really hard skills. So a taller dome, OCD. Yeah. And then like rhythmic gymnastics is slightly different because it's more about high range of motion. So you see a lot of like, again, like sub spine impingement, label issues in the hip, extreme back bending, spawning fractures. So different category, but you know, similar stuff and then trampoline, tumbling is just impact, you know, back pain, you know, disk issues, stuff like that. Or so can you, I might have missed this. Can you explain like the difference between artistic and rhythmic, then, are they the same exercises and just different styles? Are they completely different routines? Similar element sometimes, but different things. So artistic gymnastics is like again, so like the four events for women, which is a vault bar is being floor, the men's have six events, floor, palm, horse, rings, vault P bar, high bar. So those are like the, you get judged on those events and you each do your score and you get a cumulative score for the elements. It's like what Simone Biles, Sam McCulloch, they're artistic gymnasts. Okay. Like gymnastics, which is much more like ball hoop, some of the things you might have seen more. It's not high force. They usually do it on a floor and they kind of have acrobatic elements mixed in, but it's much more about like extreme range of motion and a lot more dance elements and leaps. So they have their own routine. They do with like a hoop ribbon ball stuff like that. Trampoline and tumbling is they have trampoline, the mini tramp, the giant trampoline, they jump on and do like flips and twists and stuff like that. There's also a double mini tramp, which is an angled mini tramp and a flat mini tramp. So you do a skill off the first one. And then tumbling power tumbling is just like that long strip of like crazy tumbling they do. But then there's like a road to mask stuff. So yeah, artistic and rhythmic are probably the most well known and then trampoline and tumbling is also the texture. Yep. Cool. But the injuries reflect very much the types of forces that are greater than this board. Yeah. And this was so cool about it, right? I mean, anybody who practices muskosco to medicine, I remember talking to our some of the residents when I was teaching us, it was like, you got to understand the mechanism of injury, right? And then most of muskosco to medicine is understanding the mechanism of how it might have happened. Then a provocative maneuver where you try to reproduce that to see if it's positive or not. And then when you're treating or training and modifying training, which I'm going to ask you about in a minute, you try to avoid that motion. So yeah, talk to us a little bit about, I know you've got courses on this. So maybe just a little, a little nutshell about your assessment process, right? You get an athlete, again, you're a physical therapist. So you see them pretty soon out, whether it's post operative period or maybe they're going the non-surgical route, talk to us about an assessment assessment process, what that entails, what's that look like? Yeah. And it's cool for us to talk about this too, because as you saw at champion, we're an out of network direct access provider. So I actually see a lot of people who haven't seen a physician first, and I'm sometimes referring to friends of mine that are docs and stuff like that. So I think for the best way to describe this, probably in a context of a story that will be really helpful. People always was like stress fractures are probably the number one thing, or spondy fractures, or what everyone's going to see on this podcast, who's possibly listening at their position as well. So I think that it's a really good example, because what I think my experience with some physicians, not all, and even PT's, is it's like gymnast equals stress fracture, backbending stopped that, right? And like that's kind of the natural timeline of a thought process. But a stress fracture, a spondy fracture, a spondylolysis is, can happen for a variety of reasons. The extension based pain can happen for a variety of reasons. So in our assessment process, like I have my chunks of what I think is valuable. I'm sure everybody has their semi-process, but like, you know, past medical history, red flags, subjective, you kind of get that stuff, and that tells you that's like 60% of what should be telling you a good conversation, leads you into a good diagnosis. So from there, we do global movement screening of like, you know, touch your toes, bend back, twist, turn, all that kind of stuff. We break those things down into joints, so that I'm saying, okay, like what are the individual joints in that movement pattern doing, either pain or a limited in strength or mobility? So we might break down someone's in a spying example for a stress fracture. They might tell me other things that hurt and then kind of explain those things, and I'm like, all right, let's try to check out your, your stort test, your press up test, your end plate fracture test, like try to rule in which of those forces is the problem, right? Because you can have extreme extension, could be spinous process and pain in bone bruising, which could be very central pain, right? So that's a very extension based mechanism, right? We could have a unilateral, parser neural arch issue, which extension or rotation would be provocative. So a stort test and stuff like that, a prone on elbow extension rotation or shearing test and prone, or we could actually have an end plate and compression issue where the impact forces in extension are causing the fracture, right? So that's it, more of an impact mechanism. So we would do a heel drop test, we would do a seated compression test, right? Because I'm trying to find out the spinous process person versus the parser person, who is unilateral versus the parser person, who's bilateral spine, versus the person who is an end plate fracture or some sort of like, schmoral mode issue. So like all those people are gymnasts that I see all the time, who literally got diagnosed as like gymnast back pain, Spondy, here's a brace good luck, but they're completely different mechanisms, right? So like a completely different treatment protocols. And so once we figure out the category of locally what's causing their provocative pain, whether that's, you know, you can make the argument of a no-susceptive driver and kind of high threat, or you can make the bio, you know, the more path on mechanical model, both probably have overlap here. But I like, okay, I think I know the directional preference if you use McKenzie terms and other provocative movements, or also know some of the asterisk signs as McGill and other people say about what causes their pain. So we're going to give this a delude. Let's figure out what above or below or in their training style stuff is the problem of why this happened, right? So training workload spikes or technical issues or strengthening issues are up there. So you talk about those in the subjective. But then also like, okay, let's look at their tea spine mobility, right? Let's look at their shoulder mobility. Let's look at their hip extension mobility. Let's their ankle mobility because all of those joints I've seen cases where they're contributed factors to the reason why someone doesn't have enough, you know, motion coming from other areas that hurts their spine, limited overhead shoulder flexibility. They extend more from their back, limited tea spine extension rotation, more on their back, limited hip extension from soft tissue or puberty growth or adaptive stiffness. They can extend from their hips, limited ankle mobility. They can't land properly. They get an end plate fracture that causes the spine to hear something like that. So you have to explore those other joints and figure out why it is. And me personally, we go through the strength stuff. Sometimes maybe just super hyper mobile, they bend a lot. So we kind of make a checklist of impairments of like, okay, what's going on from an entire global point of view? I know why their back hurts, what directional preference is going to make them feel better or worse. And then I have these three or five things to work on. And so while the stress fracture heals, and I see people who are literally like day one diagnosis, sometimes it's like ACL. All right. So I'm not going to do too much with the back. It's palliative care to try to make them feel better and kind of get some of that no exception to come down. But we can clearly work on the impairments above or below that are contributing factors to this in the meantime. So we're going to work on your tea spine, your shoulders, your hips, and your ankles. If we find something, and as we go through the normal biological healing timelines, we'll sprinkle in more stuff for the back to slowly rebuild, you know, core stuff or movement patterns. You just kind of go along that process based on the assessment. So I think the stress fracture is a perfect example of people who unfortunately sometimes just lumped gymnasts or baseball players or dancers into one category, not knowing there's so much more that you can do to break an assessment out for that to figure out. And like that's completely different plan to care, completely different return and sport. You mentioned a spondys a few times and I mean, Darshan, I don't know what that is, but for those who might be listening at home who don't know what parts and particular fractures are, stretch fractures are explained how you went to your patients, what that is. Yeah. So there's a, you know, when you back then, there's joints that kind of are angled at a 45 degrees. And when you bend forward, they open when you've been, I hope no one's going to see this video. It's okay. But you're doing good job. When you bend forward, those joints open when you bend back, they close on each other, right? So you have more limited extension. When you, when you go back and those joints close, you can't bend any farther. So what happens is the more you bend back over and over and over again, or the more you land with high impact forces, the bones that are connecting those joints to the actual vertebral body can fracture. So they can start to get a, if the joints themselves get irritated, it's a facet syndrome. If you continue to train and have more problems, you can get a stress reaction, which is where there's no actual clear, clear fracture, but you start to get bone, you pediculate dima, and the nerve arch becomes a dima. And then from there, if you keep going, right, you actually get a full fracture where the bone fractures through. And now those joints are starting to slide because there's no longer something keeping them on top of each other and one sliding forward. That's a spondylolysis, which is just the breakage. And then if you actually go even more and you start to have one vertebral body moving over the other, that's a spondylolythesis, which is graded based on the 25% on x-ray. So you're like, okay, how far is this sliding that becomes a problem with like, you know, that's neural impingement and stuff like that. So yeah. You mentioned smore load. How often do you find them being the primary pain generator? Because I'll say, I mean, a lot of times we'll see that those incidental on MRI and we don't do anything about it often. Yeah. I personally don't think they're provocative of pain in a witch that we're going to fix them. But I think they're indicative of a flexion and impact intolerance. Something has already happened. Like the damage has already happened. Okay. So it's usually discogenic or someone who has like a high compression load into your margin. So they can get, you know, discogenic pathology, they can just get soft tissue, just neural overload. We completely are on imaging, but they just have a flexion intolerant pain. And so if I see schmortals, nodes, I'm not trying to treat a schmortals node. I just know that that person's got more of a flexion, possibly intolerance. Makes sense. So, you know, actually, the other thing I wanted to ask you, so Massachusetts has direct access. What other states have that? Do you know, I don't know exactly where the list is, but I think like mass, I think like Virginia, there's a, there's a lot. I think it's like up in the 20s now, they're getting more and more. Yeah, I think it's getting more because, I mean, the piece about this is, if you're direct access, and I just had a very long conversation with one of the Quinnipiac University, like graduating classes about a lot of Monaco cash base, if you're cash base, you have to have a really good understanding of what is in your wheelhouse, and you have to be willing to, you know, send people to the right people, right? Like there's the reason we work so well, and we're friends with a lot of surgeons, because like, I'm the first person to tell you if you need a surgeon, right? Or if you need an MRI, or if you need someone who's not me. And likewise, the physicians that we like to work with are the number one people to tell you, I'm not going to do surgery, you should try PT first. And so, in cash base practice, you have to understand, you know, is this something that I should treat, and I should try to take care of, or should I refer this person out to see somebody else? And I think if you have that under your belt, you can help a lot of people who probably don't need to see physician right away, and they can probably try to go just, you know, like PT, like low back pain is a classic example, right? Like 95% of people probably just have to generalize low back pain that doesn't even need a ton of imaging. It just needs like, you know, a good solid conversation about what makes your back worse and better and how we can help you. And then yeah, if you have a foot drop or bow and bladder problems, like, I'm going to literally rush you to the ER in my own car, like I'm going to get in there and drive you myself. But from the majority of people, like non-specific low back pain, we can probably take a whack of that as general providers first. Well, Dave, there is something called the therapeutic MRI, you know, yeah, no, dude, I would freaking love. I don't know why. I mean, do you think that in some time, I don't know, maybe next 10 years or so, like all 50 states, I would love to work in a state that would direct access. It would make my life so much easier if people were coming in. Totally. Okay, let's send you right back to rehab. You know what I mean? Like, I don't know why. I mean, it's more on the, it's a couple of layers here. And this is one of these I'm so grateful to work for Mike and Lenny because there's a, there's a, there's a business, there's a more important, there's an ethical piece to it. And then there's a business piece of it ethically, we have to do what's right by the patient and help them out or what? You know, it's going to help the person the best, actually having a full conversation, one on one for an hour and doing whatever you need to help that person get better. Okay? So there's that piece of it that like you ethically want to do the best for the person that you possibly can. I know insurance based models that are great that are amazing and do it well. They have 45 minutes to one on one and they, they openly just take a hit financially to give more back to the patient. And what happens is you don't make a lot of money quickly up front because you're not having massive volume of people from insurance companies, but you do ethically live well, but you make it up and with of patients. I get so many referrals from people who come from other places or from other providers to come from doctors or physicians like go to this place because they're going to actually spend time with you and help you develop a program that's going to help you, right? So there's that piece of it. But then financially, you have to realize that up front, you might invest more for your visits, right? So we're out of network where people submit their insurance claims after the fact and get a percentage reimbursed if they have a PPO or something like that. So it's going to be like, okay, here's the money up front. But in the end, it actually works out where sometimes it's much cheaper, right? So like somebody comes to us for an hour session to say it's 140, that's our charge. The other person, right? I see some people one time every week or every other week or every month sometimes. I've treated people for very acute low back pain three times over six weeks via email and text and chat and like Skype and stuff. Just fine. Completely fine. Because they just need education advice. And then like, hey, man, this is going to get better. Don't you worry about it. I've had some people who, you know, they spend 140 the first visit and then 70 for a half hour, check up in two weeks and then 70 for a half hour, check up in two weeks. They spend probably about 300 bucks, right, versus they've gone to other places. They had a $50 copay or $40 copay or $30 copay, right? They spend three times a week for a month. That's 120 a week. That's 240. That's 480. And one month, they're already over what they would spend to go every other week. Now, not all cases are like that, right? Like post op, hip label repair. I had a girl who was a very high level distance runner, high level ACL. It's like, yes, you need me in the acute term to help you because you have, you can't do this on your own. And so I'm very upfront with people that I'm not going to waste your time and I'm not going to waste your money. I will tell you if you need me. So for the first month, that girl came to me twice per week for half hour sessions and it was just like, do everything you need me for and then kind of like just hang out and do the rest of your stuff and we'll keep an eye on you. But like you're here, you know, so she was doing twice a week for four weeks. And then as soon as the four week mark came and she started to get better, it was once a week and then once every other week and then just space it out more and more. So sometimes you're honest with people and you see them up front for surgery and stuff. But the majority of people that I see, I'm seeing once a week, once every other week and I'm just trying to be much more comprehensive and how I help them. Obviously, better pattern recognition skills. I can maybe get away with some of that a new grad wouldn't have that. But I would love for every place to be open access direct access and us to have better education to people because ethically, you feel better. You feel happier as a clinician. The people are getting better, right? They're investing their money. But if I go to a mechanic, right, and I'm like, I need, I need help with my car. And I would like, I'd rather just pay you $250 to fix it for good right now and not worry about my car blowing up when I drive on the highway versus him being like, wow, let's do like session three times a week, I'm going to look at your car for the next month. I'd be like, I don't know if that makes regular two nubs. Now, man, what you mentioned at the outset right there, I think that that's one of the most important things that have come to appreciate over the last couple of years, right? I mean, my co-founder now, we're just having this conversation today. This past Friday in clinic for people who don't know, I'm doing sports medicine, but my primary training is in physical medicine rehab. And a lot of that entails neurological injuries too. You know, one of the things that we see a lot of in training is spinal cord adjuvations. And so this patient who had a spinal cord injury 20 years ago, and he's probably a C4 IJB. And what that really means is this person basically had no sensation kind of below the nipple line. He had very little movement, right? And so he had been seeing chronic pain management for a long time. Now, you know, this individual does not have any sensation in his lower body, right? And so he's seeing pain management and he's telling them for the last couple of months, hey, I'm having bilateral hip pain. Now unfortunately, whoever his pain management doc was like, listen, like you don't have sensation, you should not be having pain down there. And that's just a lack of understanding of how central and pain visualization works. And you know, how you can have and below the level of neurological level of injury, you can have these types of pain syndromes come up about. And our last time, Max Shank was on, we were just talking about, we touched on phantom pain and how that can happen as well. And what was difficult about that situation was, again, this individual did not belong in sports medicine clinic, but just because I'm a pain in our train, it was just kind of the one of those, oh, let's just send to our physiatry colleagues to see what they can do for a function of this individual. And at the time, I didn't do much for the guy. I was like, okay, like I can't, you know, do injections because you also have a sacral de cubitis. Also, you have chronic osteomyelitis and, you know, which for those who don't know this infection to the bone, this is not a good idea for me to do an injection in your hip. I don't think that's going to help you. But I probably spent about 35 to 40 minutes. I mean, this guy was in tears because he came, I was the last guy to see him and he was like, listen, you're not going to help me who is. And it was just simply therapeutic listening. Well, one of the people I was working with, one of the assistants had mentioned afterwards was like, oh, you don't really do anything for that patient, did you? And I was like, no, actually, I did. I think, in fact, I mean, I did a couple of injections that day, which are absolutely my favorite thing to do. I'm learning to be a proceduralist, right? But the most powerful thing I did that day was spend those 30, 40 minutes with that individual, right, just held his hand, say, hey, listen, man, I'm going to help you. We're going to try to get you better. This is not going to be easy. You've been dealing with for a long time, but I know your pain is real, right? I hear you. I see you. I believe your pain is real. Like, I understand this. And it's probably the most impactful thing I did that day. And interestingly, the later that day, I saw a 17-year-old who had an ankle injury three weeks prior, and now she was developing acute CRPS. And she had had CRPS after a scaphoid fracture when she was 13 years old. So she's got the risk factors. And again, we all know, I mean, how difficult of an issue that can be and how long it takes to bounce back from that. And today, I got on the phone with her mom, and her mom was like, you are the first doctor who, like, we feel comfortable with. And they dream 90 minutes away. And I'm just a chump. I didn't really do, literally didn't do anything. I was like, listen, we need to get a sympathetic block. And that's going to help us. I'm sorry, I can't do that for you, but I will try to refer you to. But it's literally just spending an extra five minutes talking to an individual, kind of what you guys do. Like, you guys are all exceptionally glad I've had the opportunity to actually be a patient and actually see you guys. And, you know, just that therapeutic listening is so incredibly powerful. And Darce knows as, you know, we've had individual after individual come on, Dr. Josie Patel, every single person talk about the power of listening and how that might be, honestly, the best thing that we do. As providers. I could not agree more. I'm so happy you brought it up. Like, bro, I've had four people in the last month, I'm not sure if it's just because we see a lot of people who have gone to multiple providers and have had a tough time. But four people in the last like six weeks who have cried during the intake process of the subjective. They just, like, they feel as though one, they're hopeless, right? Like, we see a lot of like ACL repairs that have had three, four, five physical therapists and they can't get back to support. They have problems or people would, I see a lot of people with back pain who just have like multiple people over and over give them like exercises and tell them this and tell them that. And like, it just doesn't get better. Or like you said, they don't understand what's wrong with them, right? And they need someone to give them a simple, a simple explanation based off really good high level signs. And I think that's what's sometimes missing is you either get someone I've made this mistake as a young provider who is insecure about wanting to sound smart. So you flex on that person and drop terminology like crazy or you go the other way and you're so, you're so lay, the person's like, okay, well, that's not helping me explain things like that. So I think a lot of the times that people who I think respond the best of that are people who you listen to their entire story and you really try to figure out what's going on and you're honest with them and you say, so, so I don't know if we're going to get all of this to be better, but I'm going to give you the best possible explanation that I can to help you out and the best possible thing. And there's five other people in this room, girls and guys that can help you out if I'm not the person for you and we can figure out how to help you. And I think just that person being able to tell their story in part of it is vent, part of it is actually feeling as though they're heard. And then for you to be like, okay, well, based out the science I know, here are some really easy explanations for this. And then honestly, it's just easy interventions. Like the lot of these people with like a really, really aggressive back pain, you just like think about like, okay, what are the lifestyle factors, what are some of the things they're doing? Like, it's flexing in time. Well, you have an hour drive to work, you sit for your desk job, you maybe come home and you don't really do the best to warm up for your workout and then you go and you deadlift, right? And it's like, okay, well, you notice those are all very common factors and you explain it to them in a way like, oh, yeah, well, that makes sense. And it's like sitting's not bad for you. It's just that you got to like do some things that avoid that or reverse it. And then you start that conversation about, okay, let's do two or three exercises, like cat camels, press ups and some sit with a towel roll and you're lower back and maybe get up and do some walks throughout the day. Let's just do that for a week. Just let's do that every day for a week. No fancy exercises. Just let's get that over that hump and you just start that trust building, right? And so the person's like, Goddamn, this person actually listened to me. Made a 40 minute conversation about what was wrong. They sound like they know what they're talking about. They drew me a cool diagram with the thing that went up and down and it looks like I made sense and you just leave it at that and you're like, all right, here's my email, shoot me an email in seven days and let me know how you're feeling. And it's like, oh, cool. You know, so I think like people having an understanding is really important. Back to the mechanic examine examination for medical providers. Imagine I know nothing about my car, zero, right? Like I'm not a mechanical person. My dad can change breaks. I just never got that skill set nor do I want to do it, right? But like, imagine I go to my, I go to my mechanic last week and I go, well, it's skipping on the highway and it can't change gears for some reason. I'm worried that something's wrong. And imagine if in that moment, he's like, okay, we looked at your car. The reverse carburetor and the spark plug takes it's changed to hearing it, puts oil through the pressure. And so this this flux dynamometer is not going to work. But I'm like, I have no, I just don't want to die in the highway, bro. That's all I care about. I just don't want to blow up on the highway, right? Like I trust you sound real smart. But like, can you help me with my help? Can you fix it or not, David? Yeah. And imagine what happens. And if that person was like, you know, actually, someone can fix it. But I don't have the parts. I'm not the guy for that. My friend downtown has the parts. He's a great mechanic. I'll get you in to see him. Don't worry about this visit. I'll refer you. Like think about in a medical provider, well, we would do that. Like my back hurts when I sit for too long and I deadlift it and it feels bad. Well, disc have hydraulic pressure when they push the nerve back in the reverse and the ventral nerve comes out and he's like, yo, my back hurts, man. Just fix me. Okay. Well, I'm not good with back. But my colleague is down the road. And I think you could help you out. Imagine how much better the mold of medicine would be if that's what we went through with like nice simple explanations. And if you can fix it, cool. If you can't fix it, man, don't do it. If you refer to somebody else, yeah, no, no, that was very weird side. But no, I love that, man. I mean, listen, man, you're talking about skipping. My car is actually making, I never mind. I really just bought it by some of mine. That's the best part about it. And but you know, you talked a little bit about coming back to injuries. You talked about your such a process, which obviously is extremely thorough. And it's really awesome. And earlier, we touched on how these athletes, I mean, the training loads for astronomical, right? Relatively speaking, a lot of the other sports. And it's necessary. It's a highly, highly skilled base sport, right? These are very technical movements. I require a lot of scale, a lot of advanced techniques that we talked about. And Olympic lifting is another one, right? That's kind of very similar that you kind of just have to keep, keep honing on the movement. So you're kind of just grooving on those, those motor patterns, making sure that those signals are firing their appropriate way. And if you get a new visual who does, because you have direct access, they come to you because whether they have it a cuter, a chronic injury, and they're finally wanting to get a checked out. I don't think a conversation with them. And you tell me if I'm wrong, it's going to be like, we're just going to completely cut your training load in half. I can't imagine that's going to go well. So yeah, I suspect, and as you kind of touched on, is you're understanding the kinematics and how the system moves together and integrated and how what needs to work on you. You're going to give a little more TLC to one part of the body. But you're probably using a lot of tools in your tool belt to kind of assist the recovery process, right? To speed up that reatt process, if you can, or if not to modify the training load loads and without injuring the patient further, what are some of those tools that you like to use? For sure. Yeah, I think this is why again, the subject of it's so important, because you have to understand the provocative stuff and back that up with an aval, but every sport, and this is not just for sports, but just every thing in general, nobody want, if you love something, the last thing you want to hear is that you can't do that thing, right? So like runners are probably the craziest example, right? Runners just want to run all the time, right? Baseball pictures, right, throwing gymnasts with doing stuff, you know, or think about like an average just everyday dad or mom who blows off steam for 45 minutes in a gym by working out and lifting weights like they very much need that to be to be healthy and stuff. So you have to kind of, again, by building relationship and trust with someone in this objective interview and understanding that and kind of getting connection, you have to find a way to pull back slightly on the thing that they're doing that's provocative, but then and give them something to do instead of that so they don't feel as though they're losing out on their activity, right? And so let's take the general fitness serve, for example, because I think that's more common with everyone's going to see, I just want to go about my day and lift some stuff up. If you're once in a while and when I go home and play with my kids and I want to blow my back out, right? That's that's my goal in life. So you tell that person like, oh, like what do you do for your training? Like, oh, I deadlift and I squat and I do some stuff like that. And then it really hurts on dead things, something's on squatting. I don't feel comfortable when I sit in my car after I after I do a dead lift it's like, okay, well, clearly conventional deadlift and then back squatting is probably the provocative factor combined with maybe some lifestyle stuff. Let's try to, again, like we talked about earlier, let's try to get a bad your chair at work. Let's try to get a towel roll ball ball, all that stuff modifying those things to maybe take away some of the sensitization. And then let's maybe go for a, a version of a hinge exercise that's going to still kind of work your legs and the way you want it. And it's not going to take you out of the gym and kind of work on a squat that's still going to help you, but just not do the exact thing. So let's, let's go out, let's do an assessment. Let's figure out sensitivity wise where you're at. If you're super sensitive and you're super, super flared up, we just got to take a little bit of a step back and find some other things for you to do for a couple of days, probably a week or so. But most people aren't in that category. It's like, okay, you're just like those things are provocative. So let's go try to do a single leg weighted hip lift. Let's go try to do some sort of hamstring, physio ball curl. Let's go try to do a single leg RDL. Let's go try to do a split or a, um, um, uh, sumo stance deadlift. Let's try to do a step up. Let's try to do a split squat. Let's find all these different things that maybe are leg strength, but not back intensive. And then supplement some things with some core, some loaded carries, or some sled work. Let's kind of find a version of training your post year chain in a hinge fashion that you can do. And then maybe it's the depth of your squat because your ankles are super stiff, right? So let's, let's do a low bar back squat, right? With lighter weight or let's front squat you. So it's more upright while we work on those ankles. Let's do that for two weeks and we can work on these impairments together. And then we'll slowly build you back up into a program that allows you to deadlift in the proper volume. Let's look at your program, your training, your periodization. And of course that requires you have a necessity of understanding transmission, but it's that process of like, yes, deadlifting and squatting probably is not a great idea right now, along with sitting for six hours of your day. So let's modify those things, dial them back. But here's 14 things that we can test and do together and back to cash based practice and out of network practice. I couldn't do any of those things if I was working in insurance based clinic, right? Number one, if I had a script for back pain and then I looked at someone's shoulders and tea spine and hips and treated the things that were problematic. While the back calm down, I wouldn't get insurance coverage because like, you're not working on their back. Like don't you need a separate script for their hips, a separate script for their ankles. You're not dealing with that. But also I couldn't spend 40 minutes of my aval going out and working up to a weight that starts to feel provocative for them or watch them squat or watch them deadlift or watch them run or swing a golf club or pitch like all that kind of stuff. And so I think that's the problem though is that you have to have the space in the environment to do that. But then you have to have the critical thinking skills to go through that process and know like, okay, here's the seven things I can do instead of a squat. And here's a progression ladder of force that's going to expose them back up to what they want to do. So you have to have the trust subjectively wise, but then you have to have in your head what can happen from a programming point of view and active and modification point of view. Yeah. And I think at the outset again, you had mentioned just that conversation of having with the athlete, hey, like we're going to complete shut you down. Of the effects that's going to have with their identity that's basically what that they're doing all the day. I mean, it's just not going to go well. And I think recently on one of your actually Mike's podcasts, maybe you guys had somebody had a question about, I forget if it was a Achilles tendonosis or tendonitis and some individual put them in a boot. Some doctor put them in a boot for six weeks with the steris. Yeah. It's the stupidest thing ever. Yeah. If it's, I mean, Alyssa was tear. I don't really know what the background was. But, but you know, what's it? Was it a full tear? Was it a tendonitis? No, it was tendonitis. It was severed. I think it was severed disease. Oh, I see. But, you know, how many times I'll see people or somebody will follow up with me and they've seen somebody before and they're like, yeah, I had an ankle injury or maybe it was just a sprain or maybe a wrist something like that. But they were completely not training whatsoever. And we've talked about this day and before we talked, I've talked about this with the race before. It just drives me bananas. Just the whole concept of like, I mean, just training around a single extremity, lower extremity, upper extremity injuries like the easiest thing in the world. You have every single other joint thing, million things you can do. And it's just a lack of understanding on, you know, on our part, or my colleagues part, and I'm sure just people in the physical therapy room will have a similar, you know, and meets in me seven years ago. You know, that's correct. Well, we were all there at one point. I mean, and you know, actually, you know what? That's part of the reason we're doing this podcast, right? And part of the reason you do your show is to help educate. But so some of the stuff that we're talking about that both of us are really passionate about is this concept of bridging the gap, right? So we talked a lot about the rehab aspect of the middle aspect, medical aspect of it. But let's keep going down the continuum. Let's talk about getting the individual back to performance, right? Back to return play. As you approach that, how does your mindset and that conversation with the athlete change that you're saying, okay, let's not accelerate. Like let's not hit that gas pedal too fast that you're so close, but you're not quite there yet. And then also when they do get there, what are the maintenance things that you need to continue doing? Because I mean, I'll use shoulder example as an easy one or somebody comes in, just quote unquote, impingement, right? Rotator cuff impingement, uh, subroquement per side is whatever you want to call it. They come in. They have some issues. We do some targeted culture and things. They get better. They stopped doing the home exercise program. They come back. Especially like my shoulder hurts. Again, give in injection. Like, well, did you do the exercises? Yeah. Did you get better? Yeah. Did you continue the exercises? No. Go to the friggin exercise, right? So how do you have that conversation with your athletes? Yeah. For sure. And I think it's actually funny because the way you're familiar with that question was good. Is that this is actually the problem that I think happens in our side of the fence on rehab with underloading. Like, if you look at like the basics of histology and physiology, it's just you need the proper dosage of stress and adaptation to produce a response, right? And I think we use the analogy and the clinic a lot about like using aspirin, right? So like aspirin is good for a headache, right? If you, if you have a headache, too is probably good. But if you take zero or 40, you're probably going to have some problems, right? So like we have the, oftentimes athletes have the 40 aspirin problem, whether overdosing themselves, it's how they end up to you, but physical therapists and physical medicine providers have the zero aspirin thing is that we're doing, you know, yellow therapy and external rotations for four weeks and straight leg raises with a one pound ankle weight and make, all right, let's run. You know, like, and that happens all the time in ACL stuff. Like I have so many people on Lenny does as well who come to us and it's like, you know, maybe they did have a complicated surgery. They had like a meniscus stuff with an ACL graph. They had some, some component factors and it's like, okay, for six weeks, yep, we're going to go slow. We're going to get the motion back. We're going to the basics, blah, blah, blah. It's great. And then they do like the same kind of boring strength stuff for from six to 12 weeks. And they're physiologically, biologically, the graph is safe, quote, unquote, and the doctors like, all right, three months in the timeline, we're clear to run and it's like, what in the world are we doing? You know what I mean? Like that's crazy. You're going to ask someone to do that. They might not tear the ACL, but they're going to be a raging fertility tendonitis because you haven't loaded them at all. So you have to know as a provider, you have to know how to properly dose someone to be challenging enough, right? You have to like, you know, there's the Tim Gabbett's concept of like the floor, the ceiling, and the ramp, right? So like you have to pull the ceiling, you have to temporarily pull down the top to your stuff, which is the thing they're doing, right? So like running or overhead lifting or I don't know reaching into the cabinet or reaching their seatbelt when they have a rotator cuff strain. So you got to pull that down to modify the sensitivity of the tissue, then you have to build it up, like actually doing a proper progression of load, linear loading, right? Like basic stuff, like actually doing dumbbell weights that are challenging and making it a demanding. You have to know what a proper dosage of exercise is and a proper dosage is not, but also a proper response. Soreness is normal in an exercise, right? Like when you go for a run after a long time for the first time, your quads are sore. For two days, it thumps, right? So like you can have that with your cuff, you can be able to sore. You have to know what appropriate dosage of that and appropriate responses are to understand your progression moving forward. And I think in the return to sport conversation, that's what I see often the most is if there are four phases of healing that we try to teach athletes through. There's damage control, right? And this ranges from like what, two to six weeks, depending on like what, what injury you have, but there's the first phase of damage control, and this is what I tell patients exactly. There's a second phase of just being normal human again. Go up the stairs, pick up your milk, pick your backpack up, sit in class, right? So once that goes by maybe no two to six weeks, there's be a general athlete again, just be a normal athlete, someone who can run, jump, skip, throw, push, pull, carry, lunge, squat, like all that kind of stuff. And after that third phase, you can be your sport again. You could be a gymnast, a baseball player, a cross-fitter, an Olympic lifter, whatever else it is. And so the reason I say this is because in the very beginning, from the first day of the evolve, the first day post-op ACL, I teach people about that timeline to know what to expect the entire time. So that when we get to three months ACL repair, they're not just like, can I run? It's like, well, we talked about the timelines and the markers and our strength indexes or our swelling indexes still have some work to do. But if you lay that out for people to return to sport processes so much better because they know what's coming, they can understand the fluidity, how it's not a hard benchmark you have to meet. Right? And I think a really good example that I had recently is I, like I said, I treated this hip labor repair. She's a very high level collegiate runner. She had a huge camp, pincher, depreement, four-anker repair, condral fragments inside of her hip, like as a doozy. She was a really big one. At the same time, I was treating a girl with a perioste tabular osteotomy, massive surgery, but they were rehabbing at the same time together. So the girl who was a very high level gymnast was watching the runner progress at a very fast rate because her timeline appealing was a little bit faster, right? She did great. She didn't have nine screws and her bones from the PAO, but she was in the gym working out starting stuff around the two month mark when this other girl was still doing very basic exercises. She was getting upset. But I was educating them both on the timeline is those four stages, but for you, it's going to be every four weeks you might move up for you. It's going to be every eight weeks you move up because you have giant bony screws put in. So like education process is that gymnasts who I was working with had a very common approach to her return to sport. I was like, it's going to take you a long time to get back to your sport because of the doozy of the surgery you had. Whereas this girl over here literally you're going to see her running on the wood way treadmill when you come in and you're going to probably be frustrated. But you have to set up that in advance from the day one of post-op and pre-op. I was teaching people about that, right? And then with that actual, the hardcore mechanics of return to sport, you have to dose the same way you would dose an exercise, right? How do we dose exercise, right? Volume intensity, frequency, duration, like all sorts of parametrics we can have, parametrics that's not a word. It sounded sick though. But you have those things and you dose those in the same way. So like for those two of people, I'll keep running with that example on the pun intended, is the runner, right? We talked about what's the criteria to say we're okay to start a return to sport program. Well, you should be able to jump and skip and bounce and run into single leg strength work and squat and deadlift to show us you have tissue capacity to do that. For the other athlete, the gymnast, like what do we need to make sure you're good for basic gymnastics, the same kind of stuff. Run, jump, skip, kicking your leg front inside because that's going to come along with gymnastics. And each of them had a volume intensity frequency stuff mapped out. So for the runner, we're going to start two times a week on a 30-on, 30-off program of walk jog with an RPE. We're going to track and we're going to dose you and then see how you respond every two days after that running. We're going to journal about that and see how your pain levels are. Make sure you're okay if it's good. Another week will go by. We'll do that again for two weeks as a basic tissue adaptation. And then we'll bump it up in two more weeks and that will go a minute on one minute off or two minutes on one minute off. And we'll work your volume up and we'll work your intensity and we'll put in a third day. And for frequency, we'll add that up a little bit, right? As a same time, we're increasing her strength as we go. But we dose the days a week. She's running. How many times she does it? What are her pain responses? Over the course of four to eight sessions of two weeks, like two weeks at this, then two weeks at that. And that maps out over three weeks. We're trying three months versus the other athlete, right? I know what she needs to do. Same thing. Frequency intensity, repetitions, all that stuff. We're going to go the number, the difficulty of your skills and I know this is a gymnastics provider. This could be interval pitching 30 feet, 60 feet, 75 feet, 90 feet higher, farther distance, more stress on your shoulder, your elbow. So in gymnastics, we have, again, basics and then levels of skills that move up. So I know that these skills are less force. We're going to do these force skills for your hip and jumping and landing three days per week. You're going to do 10 of them each. You're going to do them on softer surfaces because it's less force. And we're just going to do that. We're going to see how you feel after two days and we'll progress the next one than every two weeks. We'll go to a harder surface. We'll go more repetitions. We'll do harder skills. And then once that's good for two weeks, we'll go to the next set, right? And you just dose those things all the way back up. But the return to sport process has principles of frequency, intensity, duration, all that kind of stuff and symptom monitoring, but they have the same kind of ideas about workload fluctuation, which is just like we said, you can't under load them, but you can't overload them. You have to stress them a little bit, monitor response, what's a normal response, what's not okay? We're good. Let's move forward. Like you just keep playing that song and dance a little bit. And the biggest piece of advice I give around returning sports to the doctoral students we have is never promise anybody anything. Don't say like in four weeks, you're going to be good to go or in six weeks, you're going to be good to go because you and I, and everybody know, right, five label repairs in the shoulder are going to have five different responses to the initial rehab piece because of old injury, lifestyle factors, you know, tons of other stuff, anywhere from pain, signs, the biomechanicals. So you have to spell that out over the course of the long treatment. Once you build that trust with them, they'll be ready to kind of, you know, injure your way around different things that pop up or kind of come back and come forward. I love them. And it's so individualized and extremely comprehensive, obviously. And that's my favorite part, right? Every single patient, it's not cookie cutter. It's, it's highly individualized. You're working with a patient. It's a two-way street. And that's why it's always like, hey, communication is super important with the athlete, with the patient. Let's work together, right? And then you're kind of, the patient's kind of navigating and giving you that feedback. You know, you mentioned earlier that a lot of the, the surgical colleagues that we have will often say, okay, this is an ACL or, you know, after what are four months and I, recently had a conversation with somebody who was like, yeah, I don't even let my ACLs run after a certain amount of time or before a certain amount of time. And I mean, I get the concept behind it, right? I mean, you, the graft, it's going to take some time before it kind of assimilates to the body. And, and you, you don't want to push the athlete too soon, especially the younger ones who just, they're, the bony healing response isn't, isn't as good. How do you, other than the individuals, the, the, your, your physician colleagues that you already have a good rapport with, good established relationship with the ones, let's just say maybe when you first came to Boston or a new dot comes in, how do you educate them and say, um, actually, there was something such like a dose response. I mean, is it, is it giving the aspirin analogy? I find that, you know, we, I mean, it's not just exclusive to surgeons, ego can be a thing. And again, it's actually not even exclusive to physicians, but how do you educate your physician colleagues? Yeah, this is great, because I was actually going to ask you guys this question too, because I'd like to have some back and forth here, because this is a huge problem for new grads who struggle with contacting physicians and trying to talk to them, not even about, like, I think we should do something differently. It's just about like, can I get a protocol? Like, can I even get, like, understand the radiology reporter, an MRI reporter, an upper port? But, um, yeah, I think it's tough, because from our point of view, like the hardest thing for us to do is physical therapists or any, like, AT Cairo sports Cairo, you can make the argument for any rehab provider. The hardest thing for us to do is to try to follow some sort of idea or principle based on the best science, when we don't know what actually happened, right? So, like, the lack of communication in physicians sometimes is really tough. But on that being said, is that we try our best, and this is not just me trying to read a lot of research, we try to pride ourselves on being an evidence-based facility, where we try to follow the best current literature on a variety of topics of what we try to do. And we know, we treat a lot of ACL tears between myself, Mike, Lenny, Lisa, everybody, else, Dan. We see a lot of people for ACL tears. So we have a pretty decent idea about what the literature says on timelines and what to do and what not to do. And I think what's tough sometimes is, I'm not sure whether physicians just continue to use the same protocols, or they maybe don't understand some neuroscience, I really don't know. But we'll have some times when, like, somebody will come, for example, and they'll be, like, no weight bearing for four weeks. No men is just repair, no nothing, just, like, locked in a brace for four weeks. Or don't start PT until four weeks. And we're like, it's gonna be really tough, you know what I mean? It's gonna be really, really challenging to help that person get better. And I will say devil's advocate that PT's who listen to this or physical medicine provide as you listen to this, pardon my friend, but you have to know your ship. You can't get somebody day two after ACL and start ranging them past 30 degrees if they have an MPFL too or something like that. You can't not know the surgery or not know the in-depth nature of the tissue, right? Because if I think that's what happens a lot of the times is that surgeons kind of gamble a little bit and say, I know rehab is important, go there early, but they get a PT unfortunate, who's running around to four other patients and they don't have it something going on or they don't understand the anatomy well. They don't understand the procedure well and they range a label repair week one into ER for their hip and they flare them up and they jack their hip up, right? And then that person's furious goes back to the surgeon and is like, yo, my hip is killing me and the surgeon's like, well, what happened to PT? And they're like, well, they moved my hip like this. And the surgeon's like, you know, so like, I see both sides of the coin. And I've made that mistake before as I was uneducated. But I think this brings up the issue of like the communication between the physician or the doctor, the surgeon, whoever in the PT is so important. But also, each person has to equally understand and respect the current literature around the other person's party. Like physicians need to understand that if you respect the tissue and understand it. Yes, you can come to us day one post-op ACO and we can do a lot of stuff to help you manage your pain and get the swelling out and just do basic range of motion. Like there's a lot of stuff we can do education wise. Vice versa, we as physical therapists need to know, okay, the surgeon actually did a medical repair or the surgeon did some sort of, you know, ALL or something like that. That's going to make it a little bit more dicey to work with. You have to know how that changes the rehab and stuff. And in terms of how do you talk to docs around about question is, I bring this up because of a really good story. So we, I'm not going to name the hospital a physician on us up. Here's some very reputable hospitals here in Boston. Yeah. And so I saw two patients who are three days apart from ACO repairs, one of which who got a younger, newer doc who we know well and got a great, what we would think is a great evidence based protocol early weight bearing, open chain and closed chain in the right range of motion, stem on the quads, BFR, like a lot of great stuff. We got the exact same person from a different physician who literally is the next office down from the person who gave us this first surgery, don't weigh bear, don't wait bear for two weeks, no open chain exercises, no lunges ever, no squats past 45 degrees. And we were like, how does this happen? How does the person who is literally having lunch with the same surgeon and did the exact same surgery give us two different repairs? They're both straight up ACLs, no meniscus, no bone bruise, no nothing. So maybe we don't know, but we read the radiology reports. We read the opera ports to the nail. I didn't see anything that would make a protocol is different. Why is this dude giving us such a progressive evidence based one when this other guy is not? And that's what's challenging for us is like, in that situation, I'm literally treating the other girl while Lenny is working on the girl who has a different protocol. And I'm like, she's like, I just checked through and something different than I am. I'm like, I don't know. Why is that girl? There's some different. And like, that's an extreme example within one practice, but that happens all the time within different people's and different groups. And so from there, right, like, how do you handle that as a provider? So I've had this with other situations, not the ACL because I had the girl who was maybe more progressive, but you have to try to approach that situation from a very defenseless, not defenseless. I'm very like selfless point of view that this is not about me. This is not about me jumping down the surgeon's throat and saying, why don't you doing something? Because maybe I'm an idiot and I don't know the learned research, maybe there's something that's not going on. But I typically tell the students and I do this is I will reach out to the physician themselves if I have the email or their assistant, I'll say, hey, can I hop on the phone with you or hey, can I shoot you an email and you can refer this to the doctor. And I usually say something to the line of like, hey, my name is blah, blah, blah. I'm treating this patient. They give me medical release. I'm just over viewing the protocol and I have a couple questions that I think you have some more expertise in here. I'd love to know your ideas about the situation. So one of which is we're pretty, we do a lot of BFR at our clinic. We're pretty good to the research. We think it's great. Here's some things that we've done in the past with other patients that have been very helpful. Do you think that would be something good or is there something else you want us to do? Right. So that's a common question we have. But also is like on the weight bearing open chain stuff, it's like, you know, we've found another patient that it's been helpful to do some open chain exercises early for quad stimulation and stuff like that use the stem. But you obviously did the surgery and I think that you would know her much more than me. Do you think that's okay based on your expertise? So you spin it a little bit to be like, you know, I'm not like, yo, moron, you didn't read this new study. Why can't they do BFR? You know, I'm not going to jump down someone's throat like that. But I'm also going to try to maintain that relationship with that person. And I don't see a lot of the times. They go, oh, yeah, no problem. Go ahead. I'm just going to quick text back. I'm like, yeah, that sounds fine. So like the protocols are unfortunately sometimes used for multiple things, but you always have to approach it with the thing of empathy. You always have to approach it with a thing of, you know, I'm trying to do what's best for the patient and my ego is not involved here. And honestly, man, sometimes I don't get an email back. I don't get a phone call back. And it's just like they don't want to be bothered. And the reason I had this long piece of it, because I actually want to ask you guys this because so many PTs contact me and other people and say physicians are inaccessible completely. Like I talk to a lot of physicians, thankfully, because we have like cell phone numbers and stuff. And I can call them. And I'm like, so many times I'm like, yo, this person is not doing well when you need MRI. And I think they probably need a quarter zone shot or something like to help them get through because this has been like six weeks, eight weeks, ten weeks where like we're trying everything, man. And it's just not working out. But I can't get anybody in the line. I wonder from your point of view, why do you guys think physicians are sometimes so resistant? I mean, one being busy as hell, that's not, you know, that's off the table completely because that's a real thing. But like, I mean, a four, a four line email sometimes is not that hard to send out or just sending the radiology report or the operative for like I'm curious your thoughts. Right. Yeah. Yeah. I mean, it's, it's the culture. And I think, you know, I think ultimately we'll have more experience with the outpatient side than I will. Right. So me being a PGY2 is more the inpatient. But even now, trying to call a surgeon, right, for somebody that just had a laminectomy, right? And they have sutures and I need to figure out, hey, when can I take these sutures out? And I'm calling day after day after day, just trying to get into the surgeon and still no call back a week later, right? And how much of that is due to just the fault in the medical system in the sense that everyone has a different electronic medical record. Like it's impossible to like even just get notes from our colleagues, right? And the discharge summaries that we get are just so different, you know, from hospital hospital. Some might be very inclusive of everything that we need to know, whereas some are just so blank. And it's true. I mean, it's what you bring up is a very good point, right? But even MDDO to MDDO, right, physician to physician has this issue. How are we ever going to solve the issue when it comes to a doctor in a physical therapist or a doctor and a health coach or, you know, a dietitian, right? I mean, and the way I see it moving is kind of these two camps and all too much. I don't know if you think this is well, but, you know, me and all too much have this idea of we kind of want to build almost like wellness centers in our minds, right? That work as a team, right? I don't think this has to be a zero sum game, where I'm telling the patient one thing and then you're telling it another and they contradict and in the end, the patient's going to lose this, right? We're just going to go on to our next patient, but as you bring up that kind of ethical side of things that that needs to be at the forefront. And I think it's more possible to do that when you collaborate with other, you know, leaders in healthcare. But to answer your point, at least from the inpatient side of things, I don't have a good reason or answer, but it's been equally as tough. I'll say it's difficult, you know, first one, obviously, I'm not a surgeon, so I have a non-surgical musculoskeletal bias. I mean, I went into physical medicine rehab because I thought that you could treat most musculoskeletal medicine not operating, which again, that's just a fact. I will say at least from some surgeons, because I do work with them pretty closely, the ones who get burned on something, like the example that you gave of, like, their patient got ranged day two after and then the patient came back and they had a negative outcome. Then they're like, that's it, no more, no more after this, you know what I mean? I once got burned 11 years ago and since then, this is my new protocol because this is the more conservative option that's safer. But I think the bigger part of it is, Dave, is it's the fear of the unknown. We don't, we're not taught, right? You have so eloquently described like all these intents and comprehensive protocols in such a short period of time and you know what's interesting about this is I'll see these people and in my, like, so I have different smart phrases, right? I quickly type in AR, PT, whatever, like in our thing and I want the knee for the hip and blah, blah, blah. And they're relatively generic, but I know what typical areas they need to be addressed because I don't want to write evaluate and treat because I feel like that's ass and I'm like, that's nothing, but I want to give, I want to give you guys a blueprint of what I saw and then obviously understanding that you guys are experts in the physical therapist and they're going to make their own assessment, a more functional assessment, which is not what I'm making in the office and they'll do that. But on our side, we're not taught exercise and dosing of exercise, we don't understand what that means, you know? And so it's, it's much harder to like, okay, so if you call and you say, hey, listen, BFR is actually very, very safe and here are all the studies. I'm happy to share the literature with you. But if you don't know BFR, like, oh, no BFR, oh, blood clots, oh, this, so crazy stuff. And this is a conversation that I have with my individuals who aren't as well versed in orthobiologics, you know, like the one case of a tumor after happened, oh, but cancer in orthobiologics and there was a couple of cases of, you know, septic arthritis because somebody was using amniotic tissue stuff. I mean, you know, and then that makes a mainstream and, you know, there's a few bad apples. It kind of goes back to, it comes back full circle in our conversation with gymnastics and how 95% of the coach is good, but then the 5% kind of ruin it for the batch, right? And then what's the other interesting thing about is is a lot of people beat this evidence based drum is like, okay, well, we don't have any systematic reviews and meta analyses to support this. But when it comes to our own anecdotal evidence, we're so like, you know, that's what drives most of the practices I find is people will say, well, the literature shows this and this is what they show us, but this one time I had a bad outcome or this, this in my experience, this has a good outcome or I'll hear this. I know that you guys have kind of touched on talking about musculoskeletal ultrasound and you guys are probably familiar with this. We do a lot of diagnostic, right? That's what sports medicine does and and there's a good amount of literature supporting how, you know, palpation guided injections versus musculoskeletal guided injections. I ultrasound got it, excuse me. And when you have guidance, like, you're just going to be better, but I can't tell you how many providers let's tell me, oh, yeah, I just, I know, I know I'm in there because I've done 10,000. I'm in there every single time. But then literature is actually shows that you have people at different levels of expertise and, you know, like for instance, AC joint, how superficial is the AC joint? Literally anybody who's in musculoskeletal medicine can palpate it, but I think there was a really good study published maybe in 2011 that less than 50% of time, even well versed physicians were hitting that to the AC joint. So it's multifactorial, like most things are, but I would say the biggest piece is the fear of the unknown because we don't have a good understanding of it. So your solution to hitting up that clinician and saying, look, here's kind of what the literature shows were, very evidence-based stroking the eagle. I mean, can never go wrong with that a little bit. I mean, I think that that's really awesome, but I mean, that's part of the hope here is like we continue to have in these conversations. I mean, you're like the fourth or fifth individual we're having a conversation about, you know, how to establish these rehab protocols with because I mean, that's what's lacking. That's the foundation of that pyramid or rehab, and that's what we need to focus on. Yeah, it's very helpful and I appreciate you guys and put, I think my take and I think maybe hopefully what summarizing this is that I think there's a void right now. We're still in this void of like how to really get people back to what they want to do. There's a lack of evidence on the advanced stage of rehab through to like the actual get back side of rehab. I think of largely because of insurance and stuff and the way the medical model is set up. But I think that when I talk to physicians who I have a relationship with and we kind of go, I think we're all looking at the same problem from different vantage points. And this might be a terrible story slash analogy, but there's this joke that one of my colleagues once told me is that like, this giant elephant, right? And like one person at the front, one person at the back, one person at the side. And like, you ask that person like, what's an elephant? Like it's like, oh, it's just trunk. It's this crazy thing. You ask somebody to back like, what's this? This is fluffy tail. It's wild. I don't know if the tail is fluffy. But as somebody else like underneath, like what's an elephant and I go, it's crazy, like ceiling like thing, right? So everyone has this different approach to what they think the problem is and we're all scrambling to try to figure out how to help these people with that void, which is that advanced rehab through to return to sport. And I think that the thing that we need more of, which I think what Mike and Lenny paved the way for personally with me was working with like James Andrews, Kevin Wilk, Kyle Fleasing, who's a bio mechanist too, and then them to it to be like, all right, we all need to treat this Tommy John, Dr. Andrews, what do you think from the moment they have a tear to the surgical repair? You do all of that to where this point stops. All right, Kevin, you take over right here with me and Lenny, we're going to write all of the overlapping rehab protocols all the way to return the sport and then Kyle at the biomechanics side when they're throwing and what are you looking for? So you have this massive continuum of care of what happens when you tear your TJ to when you throw again after TJ, right? You have this giant extended continuum of care. And I think that's what we need more of. And I just, we just finished a paper that's submitted currently right now on OCD, osteocontritis, desiccans and the elbow for gymnasts for this exact same thing that I took from the elbow for Lenny and Mike, which is like, okay, the surgeon I work with, how do you diagnose and say who needs surgery versus who does it and what MRI things, what treatment things, what mechanical symptoms, what grade, all that. Okay, then when you do the surgery, explain for all the other surgeons how you do the surgery and I know nothing about that, what's scalpel to use, the dial, I have no clue. But then, okay, now after we're going to be right here after they get surgery done, how long do you want them to wait before they come to see me and why and what can I do while they're still banged up in their sling, but they're in their brace, right? So what's over that here and when they're cleared from the surgeon to return to sport, I'll take care of all this kind of stuff. It's going to gymnastics coach to help out with biomechanically what needs to happen to make sure their technique is better or their workload training is better. I think that personally is the answer or one of the answers to a lot of these solutions, because you could do that for everything, right? From some sort of physical injury to many other problems and I think the more we have those five experts come together on a certain issue and make a clinical practice guideline or a best practices or a consensus statement for what we know right now is continuum of care. I think that is where a lot of these things will kind of get wishy-washy because you guys and all I know is that some people are not going to pick their phone up. Some people are not going to want to care, but you know, that girl with EAO, the perfect example was a PAO has really limited literature on how to get back for the rehab protocols or even like kind of all over the place. I did a big lit review. I read like surgical textbooks from like Dr. Kelly and stuff and I was like, oh, a lot in here for after they get done their surgery. So me and the surgeon from Boston, we were like, he's like, okay, well, this is what I think with the protocol that I wrote because that's what I have. What do you think? Okay, we could do some BFR here. Okay, but he was like, okay, but no so as work for six weeks because I had taken them so I was like, oh, I didn't know that. Sorry. Thanks for letting me know. So we had this very fluid conversation. We were talking the phone every Friday and it was crazy because there was no literature on how to help this person, which you did great in the end. But it was because of that surgeon admitting like, yeah, it's tough. There's not a lot of literature on how to do these PAO rehabs. I know I needed surgery really well, but I need some help here. And so let's figure out something that works. And there's an example of everything you could do for that, right? Injection to massive injury to Nana. I think that's where it's kind of got to go. So long rant there. But that's my, I've been thinking on that one a lot. Yeah, no, I love that, man. And you know, I'd also even be curious about that the second physician who's literally in the same practice or down the hall is like, what's their thought process? Like, I mean, are they truly colleagues? Was it one practice or was it two separate practices? It was one practice. Yeah, I mean, I don't know. It sounds like maybe you had a better relationship with the first one, the one that you were treating. I would ask and be like, you know, is this like kind of like is every surgeon have, most surgeons have their own practice. But like, you know, was that other second surgeon was that somebody who was fresh out and maybe there's don't have quite as experience. And it's always, you know, took kind of, it was, it was weirdly the other way. The surgeon that I was working with with my patient had just moved from Texas or somewhere else and was like on the younger side. And maybe in his 30 to 40s, whereas the other gentleman was I think like 50s and 60s and older, a little interesting. So I don't know if it was like, this is the protocol that he kind of started with and didn't want to like update it too much or change it much. Maybe he knows a lot more in the literature, but just like, it hadn't quite gone into the protocol being changed. I don't know. I don't know. I got nothing for you. I have no idea. It was so bizarre, man. It was one of the more awkward situations I've ever been. I feel, because I feel terrible for the athlete though, because that athlete's like, what the, why did I draw the short straw here? Literally. Literally. Yeah, she's like, why is she doing squats? And I was like, I don't know. I should do squats. Oh, man. That's awesome. Generally, I would say things are better. Things are getting better where surgeons are actually much more communicative and it's actually pretty, it's pretty rad to have some surgeons like cell phone numbers. And other note for people listening to this, don't abuse the people who you have contact with. I think that's another thing that I see a lot of young grads do is they're like reaching out for like some of the stupidest stuff ever. Like, you know, it's not an emergent problem or it's not a, you know, very concerning question. You're just trying to chat with them about like, hey, what, what do you think about this thing? And it's like, dude, I have so much stuff to do. Like if I was a surgeon, I'm like, I'm like, literally running. I can tell when the surgeons are texting me or emailing me between surgeries because it's like broken like spanglish kind of like brutal cap. Yeah. Exactly. Yeah. So I like know that. But I'm like, it's very clear about when I do reach out to someone or I refer someone, like they need them and I go like, you know, like I try to grab their attention. Like patient, like H dot R ACLR concerning blank, you know, or like concerning blank. And like, it's like cut to the crap, man. Like, I'm seeing this person. These are the four things I need to know about. What do you think about this? Thank you. Like two lines. It's not elaborate. Like, hello, I was wondering how your day was going. And I had this, you know, it's just like get to the job and like go and abuse the email if you have it at that cell phone. That's actually a really important point. This reminds me of a conversation I recently had with one of my actually my program director. He was talking about how, you know, with COVID, there's we all came up with post-COVID protocols. I've returned to play. There's a whole process, you know, we have different algorithms of when to get a knee-kidgy, when to get cardiology, all that kind of stuff involved in more than once. Different athletic screeners, we work with a ton of them. I mean, most of them are awesome. But we'll ask, hey, this individual had COVID X amount of time ago. And, you know, what should we do now? Like, and the response has been like, well, are they symptomatic? Do they have COVID? No, no, they had it a long time ago. Like, follow the freaking protocol. Like, the protocol was created for a reason. We sat there like, you know what I mean? The question was like, are they safe to continue to like a return to play a protocol? Like, that's what it was created for. Like, that's the kind of thing that like, we'll have that, you know, kind of like, the burnout type thing. No, maybe that's the worst word I'm looking for. When you have like, click fatigue or whatever, darsht, right? I mean, you just kind of just to click things on that type of thing. So, a lot of times, actually, when I'll refer patients to physical therapy, they'll just kind of send me these at the initial intake. Well, just these generic things that don't really mean much to me about like the, you know, what the functional stuff is. And I'll kind of quickly review them. And I'm not getting anything substantial, you know, and if I get too many of those in my inboxes, I don't want to say that we're busy, like a physician's busy, because that's a shitty excuse. Everybody's busy. You're busy. I'm busy. We're all busy. So, that's not a good excuse. But I think that like, again, to your point about what's the key information? If we're really trying to provide the best care for this patient, let me communicate just the key information. And I mean, I suspect some of this is challenging. Again, I'm still early in my career that when you're working in a cash-based model versus when you're working with insurance, or working part of a large system, or whatever it might be, sometimes you have to just jump through the hoops. And I don't know how much of it is. And I mean, maybe in the future, it wouldn't matter, because it's taking away from good care, good quality care. You know, this concept that you talked about is picking up the phone and calling, talking to therapists, one of our first guest, David Ote, who's actually a personal trainer or a strength and conditioning coach. And he works with Dr. John Russ and maybe you know him. And he works with the PPSE minute. He talks about how, as a trainer, he would call the surgeon, be like, oh, this guy had a total hip replacement. What was your approach? It's freaking awesome, man. I mean, you remember this, as clinicians, we do signouts to each other all the time. We do it in the hospital. We do signouts and it was like, okay, this was like next level signout, right? We're starting to do signouts among disciplines. And so I thought that was really awesome. And I would love it if we do it. And it should have worked both ways. But I think if we're getting a lot of the bullshit ones, anybody would get fatigue from them, and be like, all right, this is what is going on, you know? Yeah, yeah. For, there's only two times I reach out to a surgeon. One is a referral and one is a trouble shooting or like a clarification thing. And on the referral one, it's like, in the subject line, I'm just like, like blank, blank referral, concerning for this, right? And like, it immediately kind of catches their eye. But like, I'm very quick. I'm like, aval this person, let's use the spine example, right? Because I say that one lot. I just like, high level gymnast, I aval them, positive blank, blank, blank, concerning for this. Worried about stress fracture? Can I send to you for MRI? And I'll usually include their assistant on that email as well. And that's usually all of it. It's just like, okay, yep, this person, or I'll say like, tried four to six weeks of PT, not getting better, has some neurological stuff or has some concerns for a bony abnormality. And like, I'll send them right away. And it's usually all you need. It's like two or three lines. And then the clarification one, it's usually like the same thing in the email. It's like concerning for blank. And then I'll send it to like, ACL, you know, saw this person, she's four weeks ACL, lacking 10 degrees of extension, trying long load, not going well, lots of into your pain, concerned for psychopelation. Do you think it's worthy of a MRI? And I'm just like, very quick and very referred to the point. But again, I'm not like, I think surgeons know when you're not doing your own work and homework to look things up and figure it out on your own versus when you actually need them, right? So sometimes, I think I've seen people, and I've made this mistake when I was really, really fresh out, was like, I wasn't willing to look up all the literature on something and go through all of it and get it on myself, because I was a little lazy at that point. And so the email was like three paragraphs of like, what do you think about this? And this and should we try this? And the guy should probably like, I'm not an angel. And that's it all. Because this is crazy. I can't take 30 minutes out of my life to put this to the east. So yeah, yeah, exactly. Yeah, or like they have good intentions. Like, okay, I'll get it answered that, but then they like, oh god, I don't have 30 minutes to sit down and write this back. So you have to be very succinct with like, when you refer people and why you refer people to stuff like that. And surgery, it's funny, because honestly, even in like, my life outside the hospital now, when I talk to people and they're talking to me, I'm just like, you know, three words. Please just like, what is it? Right? I feel so bad. I'll touch my wife and I'll be like, this is all I do every day. I just need like three sentences. High yield. What's going on? It's terrible. But yeah, it's funny, because I'm less with it. Yeah, so used to that now. I just just say, sorry, interrupt. It's unless it's a planned time, when you know it's a long block of time. You know what I mean? Like if we're exchanging details fast, let's just get it over with. But like if you do want, I'm like, down to have a long conversation. It's like two hours. Like just let me know. Right, right. So I can get in the right. Because that's what happens to. I feel bad in the clinic sometimes, because again, people are paying us 140 for an avow. Some people are driven three hours to see me. People like flying into see me. I'm like, this is ridiculous, right? But like, I'm not trying to be blunt here. But I'm like, yo, let's get to it. You know what I mean? Like I'd love to hear the story of when you were three, how you fell and hurt your knee. And it might contribute to this now. But like, I'm trying to help you, man. We got a long assessment today. So like, I'm not trying to cut you off. I want to hear you all. But like, we only got an hour, man. Let's roll. Yeah, it's about that balance. And like, to your point, I kind of thought about this too. When you were talking about how, you know, the surgeon will go to like phase one. And then you'll kind of come in phase two. And then there's so many phase three. You know, there's there's a book called Mastery by a Robert Green. And he kind of talks about the difference, you know, between being a generalist and being a specialist. And I think, you know, in the last decade or so, more and more people have trying to evolve into becoming a specialist into a field. Because we look at tech, right? Silicon Valley entrepreneurs, all these things. The ones who have, quote unquote, made it are the ones who are super specialized in something now. And I think, again, we bring up the pendulum. We need to start going the other way a little bit, right? And kind of being a generalist. And stepping back and saying, okay, well, what else can I learn from all these other specialties, right? And not getting just so narrowed in into one thing. And I think having that kind of mentality sometimes actually helps in the end, right? Like, you can still be a specialist in some way, but you can also combine these different fields together and kind of create your own or just even have more expertise. Yeah, Josh, I couldn't agree more. And that's one of the biggest pieces of advice we give to a lot of new grads that come into the champion. A lot of them do their last rotation with us before they go to like sports, residency or stuff. And so many people want to do cash-based practice right now. So many people want to specialize in baseball or jump right into a sport. And I think that myself, I can't speak to Mike and Lenny and them, but like myself and Dan and Particular, we spent two years or three years in generalized practice doing general low back pain, general back pain, general neck pain, general shoulder pain. And it forced us to master the joints themselves. And so I think that by understanding the generalist point of view, I learned so much about pain science then and so much about McKenzie and SFMA and all these systems that were great, but that allowed me to become really good at gymnastics. Because if I mastered the joints first, right? And I think it's in August to some of your guys mastering the systems of understanding the biological systems, you can then become a specialist in one of those systems or one of those things. And so a lot of new grads are super passionate and fired up, which is awesome, but they want to go right to cash-based practice and only work with baseball players. And I'm like, bro, you're poking holes in your boat because you don't know how to treat a post-op shoulder, just a general shoulder week one. You're like an ACL day one when someone's coming off their nerve block and they're not the happiest campers. And it's not all puppies and rainbows. And so I think I wish that more people would when the talk I gave to these new grad students I told them, I was like, if you want to go into cash-based practice and be a specialist, just like kind of eat dirt for two years and just get reps in because you've got to get practice in pattern recognition. You've got to see a thousand shoulders before you really start getting a high level pattern recognition and that will allow you the high referral rate from insurance companies and stuff is great sometimes because you get a lot of wax at it to try to do a fresh about all the time. So I would encourage people, like you said, to swing that pendulum back into being a generalist. I'm not sure what the analogy is for you guys in terms of the physician side, but like be a generalist and really know a lot about the basics. And then from there, you can run down one rabbit hole you're passionate about. Yeah, I think that's what fellowship is really for. But even then, I think there's even sub-fellowships now that you can really do in our field. But for me, I just, I love being a generalist. And I've thought long and hard about it. And it's something that I really enjoy is having more breath instead of completely just having that depth. And I think it's just, it's made my life honestly more exciting just kind of have my hands in a lot of different things. But you know, to use their own, but I think again, it's important to have that understanding that between specialization and generalist. Yeah, that's been a blessing and a curse with gymnastics because everything gets hurt. Like it was so hard on gymnastics because they have so many injuries. But like Mike and Lenny are phenomenal physicians, but they just see a ton of those elbows. It's just a way like, you don't treat a ton of low backs and hips. Like I treat so many low back people in the clinic because I think that Mike and Lenny, maybe not now, this spread out more. But earlier, I treated a lot of low back in the clinic when it was just me, Mike and Lenny, because that wasn't their specialty. But like, I think now that they get more into it, they're better. But like it's just the sport itself comes with a lot of, you know, three joints versus gymnastics is like hip knee ankle back elbow wrists. Absolutely. Well, I wanted to shift gears, but before I do, ultimately, Dave, anything else he has want to add into this conversation right now about rehab and whatnot. Cool. That's great, Blum, just vibing. Yeah, absolutely. So let's go back to the gym gymnastics side of things here because I don't think we could end this podcast without talking about kind of why I think, so I am fascinated by gymnastics, right? Like I just think the flexibility, the strength, the mobility, just the balance, everything is there, right? We actually just had Mack shank on recently and he went through this phase of where he was saying, oh, well, gymnastics must be the answer. And he's obviously doing like the straddles and the handstands, which you guys can all do, which is absolutely nuts and hopefully one day, but we'll see. But talking about these non gymnasts, right? These 20, 30, 40, 50 years old, the regular gym goers. Why is it important if it is important to incorporate some sort of gymnastics and second part of that is what should they be incorporating? Yeah, it comes to a circle because we talked about, you know, why so many young kids shoot gymnastics, right? Because it's got a lot of things in it that are just, you know, their own kind of body manipulation. So like you just noted, it requires some flexibility, it requires some dynamic stability, some strength, a lot of perception or control. But also there's the non physical parts that requires, you know, consistent practice, it considers discipline, it requires a lot of, you know, failure and uphill learning and stuff like that. So there's kind of two dimensions to it. But I think that the, one of the biggest things you can do as a person is trying to be healthy is understand how to control your own body and how to control your own, your levers and your own, like, you know, positions of core work and stuff like that. So my buddy Dave Durrani is huge into this because he owns Power Monkey Fitness and he works with like a lot of adults who want to do gymnastics in their start in their 40s, 50s, 60s. So he's trying to help these people learn the basics of foundations, gymnastics, stuff like that. He has an overlap in very high level, competitive CrossFit athletes and games athletes because of the nature of, he was an Olympian and he's very, very talented. But I think that that's like the, the biggest sell that I have for you feel is like, who wouldn't benefit from a little bit of flexibility, a little bit more strength, a little bit of dynamics stability, and a little bit of coordination and perception and balance with one or two exercises, right? So you get that with some of these basic gymnastics training skills and stuff like that. In terms of what they should do, I personally feel that starting with some of the basic gymnastics core work is probably the best way to go. So just understanding, can you be flat into a line and engage your entire body? A lot of gymnastics is about like high, high tension threshold. So when you see gymnasts especially with an Olympics, the reason they make things look so easy is because they have like maximal contraction and tension to make their levers very, very rigid so they can manipulate the equipment more. But they also understand how to explosively turn on and turn off different shapes. So from a hollow to an arch is how they create some of that, that power on explosive or facial power. So learning that concept of one core, control and core strength that gymnastics has a lot of, but also to understanding how to regulate neural kind of threshold work, which is like max effort versus not. I think a lot of people get this in powerlifting because powerlifting expresses maximal intent, right? Like explosive med ball work, maximal intent. I think gymnastics is a very safe and good way to tap into maximal intent without like, you know, concerns of a heavy, heavy load and stuff. So you can just lay in your back and try to like, you know, squeeze your legs together, lock your quads out, point your toes, keep your core on shoulders and a maximal body tension. But it's a really good skill to have to understand that. But I also think that some of the shapes in the ranges of motion that gymnastics may expose someone to are very much challenging from a flexibility point of view but also a control and strength point of view. So like yoga is awesome. I love yoga. But sometimes it's like not the highest amount of like stress in terms of like challenging wise until you get into more advanced poses. So gymnastics, like the beginning stuff can be really, really challenging. So I would encourage people to do some sort of like core work, so hollow arch work. I personally think everyone can benefit from some sort of inversion just to learn, like feel what it feels like to be like, you know, just a basic head upside down position of like putting your hand down and leaning your butt over your head. So I like those things a lot. And I also think some of the basic tumbling elements, like if you can get into adult gymnastics class and just do like some very basic hand placements for cartwheels and jumping and, you know, just basic kick the handstands. It's really cool to use your body in that way. It's just so unique, right? It's so unique. Unfortunately, soccer is like baseball and running sometimes, which is also kind of like some other sports. But there's nothing like gymnastics because of what it asks your body to do. So yeah, probably core, some basic flexibility and shaping stuff, then some basic time. Yeah, I think that translation to, you know, into older age as we start to lose balance when we might tumble, take a fall as Max talks down or proves us of getting comfortable with the ground, right? And I think that's super cool. And I was telling a bunch of this to you. I used to break down. So that's why I was like super fascinated by just kind of like the gymnast thing. Like doing headstands. It's fun too. I think when you learn body control, you start to master your own body. That's when you start to really realize the true greatness, you know, of the human body. Yeah. Yeah, absolutely. Man, I can do it. Very cool. All right. Any last thoughts, Dave? I have a couple questions here for you. Go for it. No, man. I think we've got a lot of it. Yeah, this has been awesome. This has been fantastic, man. So I want to know what is what is next for you? What is next for shift movement? Yeah. So I, I'm definitely kind of got more of my hands dipped in the research world right now. I think we're, I'm lucky that I'm Dr. Ellen Casey, who is the women's team physician for the women's national team is a friend and we're a research partner. So doing some work through HSS, we just had a paper published on Achilles, tear risk factors and collagen masks, which is rad. And then we're doing a follow up study on looking at training loads. And so a big project of mine, I don't know if we said this, but I think there's three really big things. We have to work on gymnastics. One is a moral and ethical code. Two is a better education system. I mentioned that, but three is a workload monitoring system that's specific to gymnastics and wellness monitoring. And so one of those two things I can help out with, like that research stuff and like some of the education, like the moral ethical thing is a lot of people's work to do. But yeah, so I've been working with Tim Gabbett the last four years to try to design a very specific gymnastics monitoring system that might be more of like mixed kind of internal external RPE signal. So it involves waiting factors based on the events they do during a day. So like Vault bars being floor, multiplying that by time, then multiplying that by a waiting factor, which the coaches give, which Tim gave me the idea for. And you kind of get an arbitrary gymnastics load measurement. So we did a pilot study in girls that I coach, worked out pretty well. We started a pilot with two division ones college teams that went really well, then COVID broke it off. But it's got a lot of potential to be really, really great. So we're combining the second tier of the Achilles tear study with the workload study. And we're going to submit in the IRB now to prospectively look at the competitive season for college and 10 teams. And look at the workloads across the competitive season and get an idea of what normative data looks like for that. But then also superimposed, should they occur Achilles issues or Achilles ruptures will be able to retrospectively look back at the workload data and see if there was something that came out from that. It might not be a situation. I mean, out of the acute to chronic workload ratio is getting quite a bit of a heat right now. And it's kind of as all things do cycling, but workloads and periodization and monitoring is very important. So that's the study that most of my time is going to right now. So that's what we're doing. I have an amazing team, Sarah, Becky and Taylor, who kind of have helped me with podcasts and where people want to merge apparently from shifts and we're launching some T-shirts in their clients because people have asked for it. So yeah, man, we're just trying to help the community. We're very unique in the position that I feel grateful for, which is people value my opinion and I think I have something important to say. So I try to listen to the community and help them with their problems and give back to what I can. If people keep listening to me talk, then I'll keep trying to help out the best I can. So yeah, man, research, treating the clinic, trying to have a personal life. That's what I want to do. We could sign you up for a part two, then. That's what you're saying. Let's do it, man. Let's go tonight. Hey, because I just pulled it up. This is hot off the press, huh? This paper. Yeah, it is, man, sports, health, bro. We got it in sports. That's awesome, man. Congrats. Yeah, we'll like this in the show. And as the title is a factor associated with Achilles tendon rupture and women's collegiate gymnastics. Do you want to quickly, I mean, people can read the paper, but do you want to talk about exactly like what you found and what was impressive in this study for you? Yeah, it's interesting because, so the last podcast I did, it was in press, so I couldn't talk about it, but now that's public that I can. So yeah, we looked at a, we did a cross-sectional study where we just survey data. I have, fortunately, have a lot of connections in the, you know, world of research and stuff like that and sorry, gymnastics research. So essentially reached out to all my friends and hey, can you guys give this to your team? It's a survey that essentially said, you know, how many hours did you train when you were little? What skills did you do? What was the, when did you reach elite? When did you specialize? Did you have any ankle problems? Like tons of demographic stuff but then tons of just like trained risk factors, things that we thought might be probability. I was thinking severed disease, past injury history, elite status when you were young, early specialization, all that kind of stuff. And so we essentially sent it out to, as many people as we could, and we got like, I think like 500 people or so were like actually ruled in. It's like doing the survey, being the right criteria. And I think like the 18 to 20, like five or six cap, we wanted to help people who were captured recently from college. So it asked all those things at the end of the survey, it said, oh, by the way, have you torn your Achilles? And if they tore their Achilles in college, it opened up another sub category that said, okay, like what were you doing? What were you training hours? Were you a specialist? Did you do four events or not? So essentially we just found a way to look at those things side by side. When we compared out of the 500 people we had at 560, I think it was 100 of reported Achilles ruptures that happened in this demographic. So we compared those to the rate of the group that didn't report in Achilles tear, because the rates that we found in literature was like, I think like women's gymnastics, Ellen Calcutta is like 16 times higher of Achilles rupture rate than like women's soccer and like 32 times basketball. So it was like, there's a lot here. So we looked at those risk factor side and said, okay, not what's causable, it's correlated with people who reported in Achilles tear. Obviously there's recal bias, there's all sorts of other stuff. But yeah, we found that interestingly what we didn't find, I found was more interesting than what we did find. So what we didn't find, number one is that BMI was not associated with that, which is a huge thing because there's a lot of coaches who are like, oh, if we didn't gain that freshman 15 and you wouldn't tear your Achilles, which is such bullshit. So we wanted to kind of hopefully prove that wrong. So yeah, BMI was not one past ankle injuries or a severed disease or Achilles tendonitis was not. And so when I talked to Jill Cook about this who was a world leading expert in tendon issues, she was like saying, well, maybe the collagen is getting, you know, not developed from either training loads or nutritional factors or prior ankle injuries. We have a degradation of the tendon that shows up in college and then finally eventually reaches its failure tissue loading limit. So I thought that severed disease is issues would be one, but that was not a risk factor. The theory that might have been against that was that maybe those kids that were injured didn't have as many training hours because they couldn't take the impact. So if they had like a year where they were banged up with Achilles issues or stuff, they wouldn't tumble as much. So maybe that's the reason why they didn't have a wear and tear. But what we did find is that we found that people who were reported high level tumbling skills or vaulting skills when they were younger, who reported high level or hard tumbling skills in college, which is kind of a no-brainer. Those who did elite when they were younger so the highest level of gymnastics. Those who were all the rounders, which was very interesting because I thought it was gonna be specialists. People just did floor and vault because the higher tumbling, floor 90% of the tear is one floor, back tumbling on floor. So I thought that people who were floor specialists or vault specialists would have been more prone to tear their Achilles, but we found it was all rounders. So people do all the events, which suggests a cumulative workload issue, not a skill specific workload issue, which was very curious. And then we also found people who reported retinoid medication use when they were younger, which you guys would know more than me, but I believe that for acne mostly is what they use it for, I believe. Yep, and then people who were self-reported as African American, which is another very interesting thing is that there was a higher proportion than people who reported as African American. A lot of theories around there that are one of our co-authors went into around different genetic factors. We're not really, I'm not the expert in that, so I can't really explain more, but yeah, we found those things. So identified as African American retinoid all around elite when they were younger and then very hard challenging passes when they were younger or in college. And so I was fortunate to give a keynote for the entire Women's Collegiate Gymnastics Association. So all the colleges that were there, we had a long conversation about like do we have to, you know, maybe the density of season is a problem, maybe we're doing too many meets in a short period of time. We have to maybe, there's still not a great usage of evidence-based strengthening with lifting weights and that culturally is still not accepted in some places. So like preparing attendance for those, like we had a good conversation about workload management and periodization and some strengthening stuff. So it was cool. Yeah, but that's launching the next study, which is hopefully with the volumes of workloads and stuff like that. I love that, man. That's awesome. Yeah, it's fun. I was very lucky to be a part of that. There's a lot of smart people there. Yeah, that case is actually pretty awesome. I interviewed with her and she's very knowledgeable. Yeah. She's awesome, man. She's a shining beacon of light and gymnastics for me from the medical point of view. She's incredible. Super cool, man. Well, I'm excited to follow your journey. Our listeners probably are as well. Where can they find you and keep up with your work? Excuse me, I appreciate it. Yeah, so anything shift related is social media. Just shift. Again, my amazing team is a lot of the social media stuff. So all the cool graphics and videos. We try to put out like a YouTube video per week. We have a podcast every week, the shift show where I talk with people and we put out a ton of content. We interview anybody from the last episode. It was a Dinesha Francis, who was a limping. Like I said, we talked to students with girls been on. I had a lot of other ranging of people on who just try to like have interesting conversations with. So if you're in gymnastics or you're into just learning more about kind of some stuff that we have going on. The shift show is the podcast. She's movement science.com. We have like Altamash says we have courses. If you want to learn how to treat gymnasts, we have an online membership group called the Hero Lab, which is like, you know, all the medical providers and coaches you could possibly think about around the world. Just, you know, they pay like two bucks, five bucks a month to get access to a form where we can all just chop it up and ask questions and help people out. So yeah, a lot of that stuff, man. Awesome, Dave. Well, I just want to acknowledge you before our last question here, man. Just thank you for taking out a chunk of your time here, man. This has been super awesome. Really got deep into the weeds of gymnastics, which I've learned a lot. Honestly, a lot of the things that I did not know. So I just really want to thank you for that, man. And you know, you're probably that beacon of light for us in terms of the PT and the performance and rehab stuff. So thank you. I appreciate that. I appreciate that. Absolutely. And so the last question here, we always ask our guests is, how do we add the health back in healthcare? That is a great question. Two pieces. One for me, I firmly believe in taking responsibility for your own life before you try to help somebody else. So I think in gymnastics, we saw people who maybe weren't responsible for their own fears, insecurities, vices, they weren't willing to tackle their own demons. And so I can tell you from my personal experience and many of the people, more I was happier with myself and healthier for myself. I delivered better quality of care for healthcare. So I'm a much more empathetic, happier, healthier person to help somebody else. You know, a class example cliche, put your own auction mask on first. So if you have physical or mental or emotional issues, therapists find someone help you out, figured out to tackle your own demons, because that's really tough to give somebody great quality care. And I think that's unfortunately a still problem we see a lot is part, I lead my life with very much what I call virtues over vices. I try my very best to be led by virtue and not my vices. So I wish I couldn't say it, but I've definitely seen a cardiac surgeon do a surgeon and go smoke a cigarette. I've seen that happen. So stuff like that, like take care of your own stuff first. But then past that, man, I think really it comes down to just being more empathetic and being more compassionate in terms of not wanting to be the person who is not delivering care, because you're just constantly trying to hear someone's story. But I think when you take the time to resonate with someone's problem and listen to them, like we talked about earlier, and really try to empathize with them and be in their shoes about maybe you've never had raging back pain before, but for someone who's got a young kid and can't help their young kid, like you should maybe try to be empathetic to their point of view. So yeah, I think putting yourself in someone else's shoes is really important and then trying to make sure that you are, at all times, doing what's best for the patient, even if that means you're not involved. Right, I've referred a lot of people to other people because I'm just not the guy. I'm not the guy for hand therapy. I'm not the guy for, you know, inner stomach kind of GI pelvic floor stuff. I'm not the guy for that. I'm not the guy for concussions. I just know what I'm not the guy for. And so I think I try to refer a lot to people the other way. And I think if all of us could just check that ego and maybe swallow the financial hit acutely, I think I think a lot of people would have a better time. Well said, buddy, thank you so much for your time, and I really appreciate you. Happy to do it, man. Thanks for having me on. Thanks for listening to this two-part series. We really hope you enjoyed both episodes. I'm super glad we brought on Dave Tilly to discuss gymnastics because it is a worldwide phenomenon. But for those of us that are not active participants in the field and just watchers of it on TV, it's almost impossible for us to get a true, deeper understanding and be appreciative of what really goes into the sport, of the culture of the sport, of the emotional and physical tolls that these athletes go through. Now, before we end, here's a quick reminder. If you want to boost efficiency across your practice and make staff scheduling easier, try the DVD app. You can try this smart technology for free by going to DrPodcast.org.com or slash deputy at stodropodcast.org.com or slash deputy. Time for that quick disclaimer. Everything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing medical advice. No physician, patient relationship is formed, and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health-related issues.