What are the key principles of sports rehab and how can you best apply these principles in ACL rehab and overhead sports injury? How do we most effectively utilize load management in rehab and during return to play? Well in today's episode of Physio Discussed we discuss these things and much more with our two amazing guests Dr Ted Wilsey and Dr Travis Pollum. Teddy is a sports medicine focused physical therapist and private practice owner in Rockville, Maryland and Teddy has an interest in working with high level athletes and return to sport rehab. Travis completed his PhD in rehabilitation sciences and holds a master's degree in biomechanics and movement science. His research interests focus on movement screening, injury risk appraisal and return to play testing in athletes. You will learn so much about the application of key principles of sports rehab that you'll end this podcast feeling so much more confident the next time you see a patient in the clinic with any sporting injuries but particularly ACL and overhead injuries. So let's get into this. This is Physio Discussed and I'm James Armstrong. Travis, Teddy, thank you so much for coming on too. Physio Disgust, welcome to the long form of this podcast. Thanks for having us.
SPEAKER_02:Yeah, thanks for having us, James. I'll look forward to being able to be verbose here.
SPEAKER_01:Absolutely, yeah. We've got time to really delve into some of the topics in more detail than we do in our brilliant but shorter form version of Physio Explained. So today we're going to be talking all about sports rehab, which could take us down so many avenues, but the beauty is we've got 45 minutes or an hour to go down those avenues wherever we see fit. And, you know, what better two guests to have on with a real special interest in research and practice in sports rehab, load management and all the things that we're going to talk about today. So we're going to get started straight away because we need to make the most of this time that we've got and we're going to be talking first of all about some of the principles around sports rehab and Travis I'm going to kind of throw this straight at you if that's okay. Just talk us through what do we mean by the principles of sports rehab?
SPEAKER_03:Well, I think that it's really about what is the foundation of our practice, right? And what are our guiding principles? And so my area is really the research side of this. And so a lot of my focus is on testing, like return to sport testing, but also I come at it from a pre-participation standpoint as well. And so when I think about, okay, athlete is needing to get back to whatever sport, What are the demands of that sport? Where do we need to get them by the end of this? And where are they starting? And then how do we get them from A to B? So for me, that's kind of like principle number one. And then tied into that would be a lot of foundational strength and conditioning principles. I mean, we can, I'm sure, dive more deeply into this, but coming from an academic perspective, I'm very involved in undergraduate education, but I also kind of work with students who are going into And just my understanding is that the education on that side of things, the strength and conditioning side of things is relatively underwhelming. So basically, how do we marry strength and conditioning with rehabilitation to get athletes prepared to go back to their sport? That's kind of how I think about it.
SPEAKER_01:Brilliant. I think you've touched on a really important, and it's really interesting to hear you say that because I think in the UK, there's a similar thoughts around undergraduate physiotherapy degrees, not necessarily covering as much strength and conditioning and exercise prescription as some clinicians think they should. I think it's difficult. It's a three-year degree over here, so it's hard to cram everything in. But I think actually for the listeners, which many of them will be students and new grads, let's delve in a little bit more about the strength and conditioning. Teddy, you pumped the air straight away as soon as Travis mentioned strength and conditioning. Tell us a bit more about that principle and how that fits into what Travis is talking about there.
SPEAKER_02:Well, you know, I come at things from the lens of a strength and conditioning coach turned physio. And a lot of what I do is finding ways, looking through that physio lens to apply these strength and conditioning principles, whether it is considering how fast they're moving, That could be VBT, velocity-based training. Considering how much work they're doing and how that's influencing the recovery, that comes down to workload management. More of that is on the strength and conditioning side of things if we want to dichotomize. Thinking about return to performance, not just return to our activities of daily living. Again, that is more the research on it, the knowledge on it is much more robust on the strength and conditioning side than it is on the rehabilitation side if we are to dichotomize these. When I think of principles of sports rehabilitation and some of the work that I've done on it, really, I kind of break it down to the strength and the adaptation piece of it, which is very much conditioning driven. The goal driven plan of care and needs analysis that comes with an athlete's demands. You know, do they need to run on the pitch for five or six miles a game, 10 kilometers? Or are they playing American football where they're just doing quick bursts? Very different approach at the end stage of rehab. The careful balance of stressors and workload management. And then finally, what Travis mentioned, that testing and return to sport. Are they from a local tissue status and the zoomed in status, like looking at the knee, the quad strength after a quad or patellar tendon graft? Are they able to produce enough force compared to the other side? And that's why I kind of pumped my fist with strength and conditioning because... I had an undergrad degree in exercise science. Even in that world, most of the education is based on the general population because that's the majority of the people out there. It's on health promotion. It's trying to make our population of the country or the world healthier, which is really important work. Strength and conditioning is niche. And so if you want to get a high level education in that, you have to do it through self-education, internships, that sort of thing. You're not going to have any university that spits out a high level strength and conditioning coach. You're just going to have time to learn the basics, the physiology, a few early ideas, and that's it. So yeah, I view the principles of sports rehabilitation very much governed or through a lens of strength and conditioning.
SPEAKER_01:You've touched on there as well. I think we always undervalue strength and conditioning as a topic and a subject by saying it should be just sandwiched into a physiotherapy degree. It's massive. And when we take the true strength and conditioning subject, As you say, people specialize in that. That's why we've got strength and conditioning coaches. That's why physiotherapists really should be using their strength and conditioning coaches for the skills, not necessarily just trying to become watered down versions of that. But I think there are some key principles in that strength and conditioning which apply to sports rehab. Looking at Claire Mintshaw's work and the masterclass that she's done and really focusing on those principles, those core elements of strength and conditioning, which actually can be applied to some of our other general population, which I think is really interesting, actually, and how we can pull those elements through. You picked up on there, Teddy, you talked about this dichotomy of strength and conditioning and physiotherapy and rehab. The term that I quite like and be interested to see what you guys think as well is, is rehab is training in the presence of injury. What are your thoughts on that? I can't credit, I know that has come from somewhere, someone, so apologies to the person who first said that. But what are we thinking on that one, Travis? Do you agree with that sentence?
SPEAKER_03:Yeah, I like that. I think it streamlines and simplifies the process, right? Because without that, it's like, well, it feels like I have to reinvent the wheel. And that's really not the case. It's like, okay, I understand strength and conditioning. I have a background in strength and conditioning. Now, maybe I layer on my physiotherapy education and I can put those two things together. All right, now I can rehabilitate an athlete. But the trouble is that oftentimes people are forced to work with that population without that training. And then, like Teddy said, it's really about picking up those skills on your own because there aren't so many places where you can really acquire those skills all at once, especially in the context of physical therapy education. It sounds like in the UK, it's very similar to what it is in the US. It's like, maybe you get a lecture or lucky if you get a whole course. but you certainly aren't getting the two or three year education that you could get fully in strength and conditioning. Well, I have this physical therapy, physiotherapy degree, therefore I can rehabilitate anybody because it's a generalist degree. But then what we learn is that that doesn't really shake out so well when you talk about, well, here's what we should be doing with athletes and here's the current status quo. So yeah, I think rehabilitation in the presence of pain, if you can understand rehabilitation, is when you're working with athletes, strength and conditioning and the presence of pain, then if you have those two expertises, then you're really well equipped to do the work. Teddy, anything to add to that?
SPEAKER_02:Yeah, absolutely. Among other people, I've definitely used that line about rehabilitation really just being training in the presence of pain or injury, because it's hard to dichotomize or know where to draw the line. Most higher level athletes, people that have been doing this for a while, they have pain, they have injury, they still have to train around it and through it, but they're not always rehabilitating. And so it's hard to really draw these lines like the old school coach that said, are you hurt? Are you injured? And these silly kind of usages of words in ways that they aren't necessarily made to be used. At the end of the day, whether you're training or rehabbing, and if we have air quotes there, you're just trying to find what your entry point is and make progress from there. I think that, as Travis mentioned, the entry degree or what you start off with, that can get you pretty far if you're working with general population. But once you start to get to a sports environment or athletes that need to perform at higher levels, There's this whole other litany of types of exercises, ways to apply them and demands that come into play that you don't necessarily have to think about in general population. And it's not to say that the general population is easier. It's absolutely not. If anything, your quote unquote success rate or your outcomes might be even lower than they would be normally, which can be very challenging and emotionally challenging, especially when you're a new grad and you're going through that and you're seeing a lot of patients in a day. But at the same time, there's probably a fewer opportunities number of exercises and different things that you need to do with that population, less that you need to know about in terms of like all these different athletes and different positions and different injury patterns and common issues that you see across sports. Again, it's hard to draw that line. Where do we go from rehab to training? But it is important, as you mentioned, James, to understand that we as physios are not grandfathered in to be in strength and conditioning coaches simply because we have a degree in that might have more letters behind it or might look higher on a totem pole of education. It's very important to respect the individual disciplines. And even myself, as somebody who was a strength and conditioning coach for years, I respect the fact that I haven't gone to a strength and conditioning conference and sought out that information solely in over a decade at this point. And so I don't consider myself to be at the top of my game for strength and conditioning is the same way I would for being a physical therapist. And so I'm fortunate to work in a multidisciplinary environment where I have strength and conditioning coaches that when I'm reading about pathology and differential diagnosis, they're reading about force plate data and load management, and they're really deep into their world. And so I do think it's important no matter where you are in your career progression to respect every individual's expertise.
SPEAKER_01:I love that. I think that's really well said, Teddy. And I think you mentioned there that multidisciplinary approach. We see it in the healthcare system all the time. Physios working on the wards with ill patients, as it were, we couldn't do without. And we wouldn't even think about not working with the nursing staff, the occupational therapists, the doctors, etc. So in a sporting environment, actually, we should be thinking very, very similarly, actually, utilising the skills and the specialist areas effectively. of the team around us for the person that matters the most. And that is the athlete at the end of the day, which brings us really nicely background to the principles. Travis, you spoke about right at the beginning there. Travis, anything you want to add on to principles, the actual principles before we start looking at how we're going to apply these to some populations?
SPEAKER_03:Two things that were mentioned that are really interesting are one, the idea that where does rehab end and training begin? There's a really cool graphic, and I'm totally blanking on the paper now, but it's like the utilization of physical therapy for ACL rehab, which I'm sure we're going to talk about. And it's like the number of visits obviously declines over time. Unfortunately, it declines probably too rapidly relative to the timing of when an athlete is ready to return back to sport. 7, 9, 11, 12 months post-injury or surgery or whatever. But the idea is, okay, well, when... rehabilitation is dropping down, strength and conditioning or training should be picking up. And maybe that's one person who's doing all of that. Maybe it's not. Maybe you work in an interdisciplinary clinic and you have access to both practitioners and you can just do that handoff and still be involved throughout the process. That's kind of like the ideal world. But I think the challenge is that a lot of times you are only one physiotherapist And maybe you don't have access to the person to hand them off to for the training part of it, the strength and conditioning part of it. If you are doing all of it, then you really do need to be comfortable wearing all of those hats. But I think what we often find is that the physical therapist, physiotherapist has the specialty in rehabilitation. They see the knee, they address the deficit at the knee, and either they don't have the resources, the environment to do do the training piece of it or the knowledge or some combination of those things. So, hey, the knee, shoulder, whatever, you're out of pain, you're able to do your activities of daily living. It seems like you're good to go, but then that's a far cry from where that person actually needs to be to return to practice or competition or the same level of performance. Like you said, James, it's when you're in an inpatient acute setting, The nurse is right there. The occupational therapist is right there. Not to say that interdisciplinary practice is easy, but at least you're running into that person every day, right? To network with the strength and conditioning coach or create the system where you have everybody working with that athlete is really hard in an outpatient orthopedic setting. And I think we see the ramifications of that often.
SPEAKER_01:Yeah, absolutely. Anything to add before we move on, Teddy? You
SPEAKER_02:hit the nail on the head, Travis, because it also it takes extra time. Just from a practical and logistical standpoint, it takes time outside of what your normal treatment hours are. And unfortunately, we are not reimbursed or compensated for that extra time. And so that's a major barrier, particularly when this case is likely the person that you're trying to communicate with. It also takes extra time for them. And they might not get back to you. You might have to stay on top of them a little bit. So that can be really hard to coordinate. But yeah, I mean, realistically, when you work with athletes, you're typically most athletes are under the age of 25. The majority of them are under the age of 20. You're typically coordinating with parents. You're coordinating with maybe a coach, maybe multiple coaches if they're like in a club and a school league. You're coordinating with athletic trainers, maybe, maybe a flight trainer from school. I mean, it can be quite a few people. And particularly when you talk about ACL, sometimes they might see a few providers throughout that time period. I work in this multidisciplinary sports environment and we're out of networks. So we see a lot of people that come over around three or four months post-op and they stick with us until that eight to nine month time when we start to hopefully get them cleared and get them ready to go. The one other principle I would add in the sports rehab world, and this is Exactly what Travis was saying, but just keeping an athlete prepared to get back out on the field. In my masterclass, I broke this down as I just, it's kind of arbitrary, but I called tier one exercises, ones that are more local and specific to the injury itself. And then tier two are everything that's more global or around the injury. There's no reason why you can't really progress and get somebody very strong at a single leg deadlift when they're still pretty restricted with their knee over toe type of movement or their anterior knee loading. You know, there's no reason why you can't keep a grade two hamstring injury patient in shape so that their cardiovascular conditioning doesn't severely drop over a two-week period, which we know it does, because they might get back out on the pitch in two and a half weeks. We look at the research behind grade two hamstrings. So I think it's extremely important to whatever we call it, tier two, work around. And it might be education. It might be that you're giving somebody these tools to go do on their own, because even if you're a physio and you're only seeing them for one or two hours a week, this is somebody that's coming off of three or four hours of gameplay or two or three hours of practice most days of the week. So they really need to stay in shape and to maybe use it as an opportunity to build up other areas of the body if it's a longer term rehabilitation. So I think that's an extremely important aspect, keeping the big picture goal in mind for sports rehab.
SPEAKER_03:And I see those things as like somewhat huge challenges, right? Depending on what environment you work in. Like you said, if you have that patient for an hour or two a week, All of that other stuff that you mentioned is really work that's not necessarily under your jurisdiction. So from the standpoint of, all right, contacting, being in touch with the other providers, the surgeon, the athletic trainer, the sport coach or coaches, especially maybe if it's a sport that you haven't worked with a ton to just get a better handle on that. But then, yeah, okay, so they're a knee injury, right? But they have the other leg, they have the upper body. You have an hour or two. When are you going to figure out what to tell them to do and when to do it? So that is the best case scenario, right? Is that you're treating the entire athlete, especially from the standpoint of, well, here's where they have to be just because they have this one deficit doesn't mean that they shouldn't be doing all those things. But this is the thing that we're hyper focusing on right now necessarily. But when are we going to find the time to program the rest of the stuff and to execute the rest of the stuff is a huge challenge.
SPEAKER_02:I was just going to mention, it just kind of came to mind, I discussed or mentioned how young a lot of the people are that you're working with when you're working with athletes. I think as a lot of strength coaches go in further into their career, they really focus on communication and thinking about how to really connect with their athletes. I think that a lot of health promotion work in general is just as much focused on how to get people to do it as it is what they're doing, because we know that that's so important. And when you're working with athletes, Some of those first questions need to be like, okay, if I'm giving Travis, if I'm giving you extra work to do outside of here, where are you going to do it? How are you going to do it? What time of day are you going to do it? What fields or things do you have access to? Do I need to text it to you? Are you not going to see it in your email? Do I need to send you a PDF and remind you to save it to your notepad? Like all of these silly little things really come into play when you talk about implementing sports rehab, because you're working with young people and it's just so different. Like working with a 19-year-old competitive athlete who's so immature and has, you know, is a completely different experience than working with like a 30-year-old professional athlete. So there's a lot to consider there in terms of implementation of the actual work.
SPEAKER_01:It's implementation, but you mentioned in there, Teddy, it's that compliance and adherence, which, you know, we can have the most incredible rehab plan, the most incredible periodized strength and conditioning program. But if they don't understand why, they're doing it, and they don't want to, or they're not bought into it, and you haven't communicated that with them, then you've wasted all of your education, all of the specialist skills you've had, and all of that time. So I think it's so, so important.
SPEAKER_02:Right. And not to be pedantic, but I think it starts before we even think about the words compliance or adherence, I think it starts with alliance.
SPEAKER_01:Yeah.
SPEAKER_02:Being on the same page.
SPEAKER_01:Yeah. Yeah.
SPEAKER_02:Absolutely. I
SPEAKER_01:love that.
SPEAKER_02:Once I'm upset about somebody not complying or adhering to what i give them it's like it's i already lost them at that point
SPEAKER_01:it just if you're not on the same page yeah right yeah absolutely yeah
SPEAKER_03:definitely that perfect program is only perfect in a vacuum right it's the perfect program for the person in front of you based on what they told you their willingness to do was
SPEAKER_01:yeah exactly exactly definitely Let's dive into some specifics now, as best we possibly can. And thinking about the principles that we've talked about, we've really dived into this really nicely, actually. And we're going to take this now into a really very hot topic of research. It's an area that I know the three of us have all got an interest in. Yourselves, an incredible amount of knowledge and specialist skills in research and practice. And that is ACL rehab. And it's something that we see an awful lot talked about on social media. It's a really hot topic. Not just me that's seeing that at the moment. Let's think about our principles and how we can apply these in ACL rehab. So who wants to kick us off on that one?
SPEAKER_02:Yeah, I will start off and forgive me for staying very broad and generalized here. But, you know, I think from a principle standpoint with ACL rehab, strength and adaptation, like the four principles that I kind of laid out are strength and adaptation, a goal-driven plan of care, careful balance of stressors, workload management, and then the testing return to sport. Starting with the strength and adaptation principle, ACL rehab is, I mean, there's no other rehab that you see such profound weakness and loss of force output in arthrogenic muscle inhibition from a neurological level. There's no other injury that I'm aware of that causes the same degree as ACL does. Yes, I've seen some people that really struggle to regain active shoulder flexion after a labrum repair or a traumatic dislocation. Like I've seen other really bad stuff. And I'm just speaking anecdotally here, but man, ACLs, they just come out of that surgery sometimes so profoundly weak and deconditioned and loss of ability to create force. So the strength and adaptation is so challenging for them because you're working through injury and you're trying to decide how much tendon pain, how much anterior knee pain is okay. You know, at the end of the day, though, they have to regain that force output or else they're going to be at a severely increased risk of re-injury and they're not going to be able to perform. If they can't do it, even if an athlete says, I can't do this or that on the field, it might come back to that. What's your quad doing? Is it sufficiently decelerating you? Because if it's not, nothing else is going to work well. And then from ACL, like the goal-driven plan of care, that's where you get into recovery. specific positions on the field, specific sports, where are they in their season? You have to start to think about this stuff too. Like with every ACL rehab evaluation, I'm already looking forward to where are they going to be in their competitive season at nine months? What are we going to be up against during that return to play time period? And I'm already talking to them about what I'm going to need from them, meaning percentage testing numbers, that sort of thing, to try to lay that out at the beginning. And then the careful balance of stressors is particularly challenging when they get into that late stage. So that Travis, like that paper you're talking about with the graphic, and I'm not sure which paper that is, but one thing that you see a lot is When athletes start to get into their return to play activities, their testing numbers actually get worse because they're less focused on strength and force output at that time. And they're more focused on getting back into sport. And they have other factors that might increase swelling in the knee, decrease force output. And sometimes we even see that on the unaffected leg as well, which tells us that there's a really suboptimal balance of stress at this point in time if they're losing strength on both sides. So it's really important to have raw numbers, not just percentages that you're looking at over time. And then finally, as we've alluded to throughout this, the testing and return to sport decision making. Whether you're using an inline dynamometer, you have access to an isokinetic dynamometer. Those are both really good tools. One costs$100, the other costs$40,000 U.S., So you can imagine a lot more people have the inline dynamometer. But at this point in time, where we are with the research, it's implausible to me as to how somebody would have a explanation for not testing an ACL return to sport athlete. So that's an extremely important part of the process. And please understand that a jump test or a triple hop test, rather, I should say, to be specific, is not synonymous or exchangeable with a forced output test. Yeah, those are the main principles and kind of how we look at it through the ACL side of things. And it's a long journey. And you got to prepare people for that beginning. And one last thing I would add is the mental part of it, right? And so I mentioned a few things about like therapeutic alliance, but that is so important. You got to keep these teenagers engaged for the long run, got to get to know them and really their confidence and their trust in you and their relationship with you will make a difference for their long-term outcomes and whether you're able to keep them on the same page with you when they're itching to go back, but their numbers are stagnant and they're just not ready yet. A lot of hard conversations and tears can happen throughout the ACL rehabilitation process.
SPEAKER_01:Definitely. Travis, over to you. I
SPEAKER_03:echo everything that Teddy said. One of the interesting things, and I can't even remember who I heard this from, but he was talking about the equipment that you have in your clinic, right? And Teddy mentioned, do you have a dynamometer? Nobody has an IsoConnect dynamometer, but at the very least, do you have a handheld? Or they make these Tindec force monitoring devices for rock climbers that you can hook up to your iPhone and you can do the leg extension, hamstring curl, pretty accurately for$100 and there's no excuse. But the conversation that I was having was like, if you don't have a leg extension, leg curl machine or access to one, or the athlete doesn't have access to one during their ACL rehab, or if you don't have these force monitoring devices, you shouldn't even be advertising yourself as a physical therapist or a clinic that does ACL rehab because it's essentially malpractice. That's a harsh reality or a hard line to draw, but I think it's the honest truth. And yet we see, I was just talking to a friend the other day, new grad, relatively new grad, her clinic doesn't have any of these force measuring devices and they often work with these athletes. And so she's aware of this and wants to make the case for why they need these things. I'm sure that that is not atypical, but it's so frustrating to hear that because step one is having the devices and Step two is doing the measurements serially. So not just at nine months, but as early as you can. And as often as is makes sense so that you're not just looking at a snapshot of a skier going down a hill, but rather how fast are they going? Because we have multiple snapshots so that we can kind of forecast. Here's where you were. Here's where you are now. Here's the speed that you got there. What can we expect? Oh, you just started going back to practice. Like Teddy said, maybe there's some swelling, maybe there's some deficits that are occurring as a result of ramping up. You're actually a little bit lower. How do we now balance what we still need to be continuing to strengthen alongside the sports participation that you're doing to make sure that we're keeping that number high. So if you don't have the device, step one, but step two, like figuring out the best practices for these things, something that Teddy mentioned too, that I thought was really, is really profound is not just an LSI, We all hear that's the gold standard, 90%. But is that unaffected side really the best benchmark? Or do we want to look at these raw numbers? But even that, I don't necessarily know of good normative data on that. I'm sure, Teddy, based on your clinical practice, you understand a body weight ratio of what a good number is for a male athlete, a female athlete at this age for this sport. But I haven't seen a paper that came out with all of that, right? So that's where the rubber meets the road of, okay, I understand that this is what the gold standard in research says is the testing. Probably not just hop testing if you're just doing that. If you're not testing at all, okay, at the very least start hop testing, but you should also be doing strength. But then the best ways to do the strength and where to find the information about how to interpret those tests and then how to use that information To guide that return to sport decision-making and how to have those conversations is like a very big challenge in this.
SPEAKER_02:Just one thing real quick on the normative values. A number that's thrown out there, Travis, sometimes is, I'm sure you're familiar, is like the three newton meters per kilogram. And that is an idea. And so you're looking at relative force or torque production newton meters per body weight. And if you do the equations and you put that math in, then you can kind of start to have an idea. Like if somebody is looking at 90%, but they're a 13-year-old athlete and they're only at 1.2 newton meters per kilogram on both sides, and they're at 90% at four months, you're not going to clear them at four months because we know that's kind of negligent practice. And then let's get both of those numbers. 90% is fine, but let's get both of those numbers up to 1.8 or two newton meters, whatever it is. So you got to understand that if you're comparing crap with crap, you're not going to get the best idea. And we know the rate of re-tear quite high and half of those re-tears are on the contralateral side. We've had this dozens of times in our clinic over the years where we're comparing a two and a half year post-op ACL as our one value against eight month ACL as the other one. That's not going to be a great number. So the Newton meters per kilogram can at least start to give us an idea of strength relative to body weight.
SPEAKER_01:Brilliant. Okay. We've had some sort of real key things there and Travis you can see there that you're really passionate about this and actually from the both of you seeing this in practice and as you say people out there who are doing this I'm going to be you know throw this out there there's going to be some people listening to this episode right now who will be treating and rehabbing ACL patients and they might be in in the UK in an NHS setting or they might be sort of privately working who aren't doing this And they'll probably have some opinions about what we're saying here. Let's talk to that. I just want to have just five minutes to talk to those people now who are listening to this who are thinking, well, I'm not using a dynamometer. I don't think I'm testing enough as Travis and Teddy are telling me here. So what would you say to them in their first steps to move forward with their ACL principles of sports rehab? If we're not testing,
SPEAKER_02:if we don't have those resources, I think the obvious first thing is to implore the decision makers in your place of work to potentially consider this. The Easy Force made by Moloch is 350 USD. I just looked these up. The Tyndek, these are both inline dynamometers. You're going to get a much more reliable reading than you would with a handheld. The Tyndek is$212 US. So these are not extremely expensive pieces of equipment. That's kind of the obvious. If you are not able to implore or convince the decision maker in your clinic And it's not something that makes sense for you to potentially fund yourself or bring in or put your license on, et cetera. There are some other clever ways that we could at least look at some power production. So vertical jump with an app using our phone camera. I think that that's probably going to be your most helpful way to look at in-stage return to sport numbers. So I kind of worked backwards here and I'm still trying to find a way to test in some way. Because at the end of the day, if we're not testing in any way, I don't know what numbers we're using to clear people. We're just guessing. If we don't have access to that, at least quad girth measurements in multiple places and some sort of maximal repetition single leg test, which is like what they taught me in physio school over a decade ago at this point. But at the end of the day, you got to test. You got to test. maximal output, not endurance, not 10 plus repetitions.
SPEAKER_03:I've had some pretty extensive conversations with Tim Roland from PhysioNetwork about this. This is bread and butter. And we talked about testing from the context of I have a return to sport app for ACL rehab, late stage rehab, and how to empower athletes to do this on their own in the likely event that they don't have access to this equipment. best case scenario, they have access to a leg extension and like a curl machine at a gym. And the key point is it's not how many, what weight can you do for 12 reps on each side? That's not strength, right? It's like, what weight can you do for five reps on each side? Maybe four, six, somewhere in that ballpark. And then if you don't even have that, what movements are you going to do in the gym and making sure that you're loading them up heavy enough to or at home if you can have access to at least some sort of weight. So like a single leg squat, single leg hamstring bridge, not perfect, right? Because it's not isolating those muscles in the same way that the single joint movements are. But how can we, in the worst case scenario that we don't have force measuring equipment or machines, how can we get at some understanding of what the strength is relative from side to side?
SPEAKER_01:Again, you could argue if you've got a handheld dynamometer, an inline dynamometer, that's great. But if you're not being robust in your testing, then also you're going to get extraneous circumstances in terms of slack in the cord or something like that. So I think in terms of it's all very well just having one, but actually investing in knowing how to use it's pretty important as well.
SPEAKER_03:Yeah. And it's not trivial. It does require practice with the setup and the right equipment. So find YouTube videos, seek out mentors and practice, practice, practice, because the reliability, making sure that you are consistently and accurately measuring those is huge.
SPEAKER_01:Just a quick one on this one, Teddy. We've just recorded an episode with Claire Minshaw on exactly that, on how to use a handheld dynamometer for clinicians. And it's one of our short form ones. And it just goes through the things not to do and the things just to do that are really simple that can make a massive difference. Sorry, Teddy, carry on.
UNKNOWN:Yeah.
SPEAKER_02:I was just going to say in terms of quality control and reliability from one testing environment to the next, we've built in both of our clinics, we've built testing stations that are essentially wall mounted miniature squat racks that are about 36 inches wide. And then we put the box in the center of it. We've got pin pipes that span across and then we hook the dynamometer up to it. So I've built a whole station for this quality control. And it just also speaks to how often we're testing people. So I think it's extremely important to have a repeatable environment. And that also speaks to the tester themselves. They need some familiarization with the testing protocol. Otherwise, you're not going to have a reliable number. And so sending somebody out to do a test once is not going to give you nearly as good data as if they are doing this test regularly. And please remember, too, that testing is not just for us. It's also for them. Our athletes, I speak to how young they are. They're used to testing. Our education systems in the Western part of this world are all based on testing, test, test, test. Athletes and young people, they want to know their numbers. They want to know where they are. They want to know where they stand. It motivates them. It keeps them coming back. After a good testing, let's say we're doing some sort of athlete monitoring, which is in strength and distance. After a good test day, they're going to be really fired up for the next few weeks to come back. And it's a long, arduous grind, the ACL rehab is. And so this can kind of keep them going. And if, unfortunately, they don't have a great testing day, nothing's going to sneak up on us. I always tell my patients that in early stages of any rehab, nothing's going to surprise us or sneak up on us. We're going to know where you are leading up to this. I'm not going to just say, oh, you thought you were going to be back today? Nope, surprise, you're not. They're going to know. And so If the testing's not there, or sorry, if the good numbers that we want and the number of progressions not there, we have an opportunity to intervene and change whatever we need to change and tweak and the whole iterative process of rehab. So testing is extremely important, not just for us, but for them too.
SPEAKER_01:That's really, yeah, you kind of give a nice full circle back to that relationship you have with the athlete to have that regular communication, that regular check-in and that buy-in. But also, as you both said there, in terms of not just waiting till, oh, we think you might be ready to return to play, let's do some testing. It's a case of having that a bit more regular, which, you know, is great. As much as we've got ages, I'm aware the time is flying by. There is one thing I just wanted to very quickly touch on here, which is an obvious answer to this, but for listeners, I just wanted to touch on it. With ACL rehab and sports rehab, is this moving away from time to criteria-based? Is there anything you just want to give me a 30-second snapshot on that one there? It's something I think we should be knowing that we're moving towards, but any thoughts on that?
SPEAKER_03:If you're only basing the decision on time, I think... from the last 10 minutes of conversation that it should be quite clear that that is not enough. But it's not to say that time has nothing to do with it, right? There's research that shows that the longer you wait up to a certain point in some studies, but in other studies, just like the longer you wait up to like two years, the lower your risk of a re-injury or contralateral injury. So it's both of these things. It's the, hey, let's make sure that nobody's going back at six months anymore. Like we're, we're way beyond that understanding. And I, and I recognize the challenge working with young athletes. They've seen the, who was it? Adrian Peterson led the league and rushing six months after his injury. Like most of our athletes. Luckily we're, we're dating ourselves. Yeah. Our athletes hopefully now don't even know who that is, which is helpful because we should only be saying, Hey, this is a nine to 12 month process, but also like if we're doing all of that testing once a month, let's say nothing should be surprising us about where we're going to be at that time point. You know, we know where we're heading so that when we say, all right, we're targeting this point of the season to return, which would be nine months, which we feel pretty comfortable with or 11 months or whatever it is. And the numbers are trending in the right direction. And we have maybe two months in a row of, numbers that are above our benchmarks coupled with the subjective experience, then that's how we use time together with the subjective criteria and the objective criteria from our testing.
SPEAKER_02:The challenge that I run into in this sometimes or we run into in our practice is that the person that actually operated on their knee, that's wearing the white coat, that generally carries more influence maybe just because they don't know, the patients don't know them as well. The orthopedic surgeons who I'm referring to here, when that person inevitably clears the athlete somewhere around six, seven, eight months, we oftentimes have to have this conversation. Hopefully we've built up enough of a rapport by then that the athlete just kind of knows exactly what the deal is. And there are some surgeons that we work very closely with that don't actively work against us, work against us, but there are a few that do. we just kind of remind people like, look, that's great that you're medically cleared and that everything is healed inside. Now we just want to make sure that physically you're ready to go and you're not quite there yet if they aren't. And so we sometimes try to draw that distinction as independent practitioners that should be autonomous to a certain respect and just remind our athletes if we need to. And if we need to have those hard conversations, remind them that their risk is significantly heightened if they do decide to go back at X or Y time period that they're not ready for.
SPEAKER_01:Perfect.
SPEAKER_03:That's not an easy conversation to have, like you said, because this is the surgeon, right? This is the person who operated on them. There's a certain understanding of what the surgeon seems to be at the top of the totem pole for various reasons. And they hear from the surgeon, oh, the surgeon cleared me. Yeah, the surgeon cleared looked at your integrity of the graft. They did a Lachman test or whatever. They had to kick into their hand. And from their perspective, they either don't need to see you anymore or don't need to see you again for a while. But what might get lost in translation is to be cleared from that context to then be cleared from a physical performance standpoint to return to sport are not the same. And it's hard to be the bearer of bad news when having that conversation, right? If that wasn't totally crystal clear communicated.
SPEAKER_01:Yeah. But then again, it comes back to if you've said already, if you've had that communication, you've been doing that regular testing, none of this is a surprise. It'll almost be a case of you'd love it if they came back and said, I don't know what the surgeon was on about, but they reckon I'm ready to go back again. Definitely not, am I? And that's where you want to be with the patient. So that athlete has a bit more self-efficacy and control over their own rehab in an ideal world. But I can imagine you get some scenarios where they come back and almost it's just there's been an explosion in everything you've worked towards. You've then got to kind of pull it back a little bit. So, yeah, very, very difficult. And we're dealing with people's livelihoods and lives. The other thing,
SPEAKER_03:too, is like Teddy mentioned this from the beginning. What point of the season are you going to be at nine months? Are you a junior in high school being recruited to play in college and playoffs are coming up? As much as that shouldn't be the primary factor in the decision, it is part of the decision, right? We're acknowledging your risk of retail is higher if you go back a month earlier. At the same time, your numbers are looking good. We understand the importance of this point in the season and your career. And so everything is going to be on the table in that decision. Brilliant.
SPEAKER_01:So on our list of things to do, as I was thinking we'd have so much time, but we maybe haven't. So we've talked about the principles and we've really nicely delved into ACLs. Do we want to have a think about now how the differences may be, if there are any, in how we're applying these principles now? to overhead athletes?
SPEAKER_02:I'll try to keep it brief here, but Travis mentioned swimming and a background that he has an interest in working with swimmers. One of the principles that's key here for swimmers is load management. And that's also something that's very hard to intervene from a physio standpoint. The culture of swimming is such that you get in the water and you do your four or 5,000 yards every morning. you know, no matter what. And you look at swimming has the highest prevalence of overhead of shoulder injuries of any sport, you know, and it's just extremely challenging at times, I find, to work with swimmers and to work through and around these issues. And sometimes they don't even really need to take that much time off, but they just need to modify what they're doing a little bit. But The communication between swimmers and their coaches sometimes isn't the greatest. They're in the water. The coaches are out of the water. I didn't swim as a kid. I did the swim team with my community pool for a year, but All of the things I've learned about swimming, like the yardage and everything, is post-graduate, self-taught. And so I find that the load management for me with swimmers, and we work with quite a few, is very challenging and something that you have to really kind of educate them on early on the value of it and get them to kind of buy in if they're able to. And try to understand their sport. Ask a lot of questions before you tell them what to do.
SPEAKER_03:Like Teddy said, the culture in swimming is so unique and maybe true of many endurance sports, but with the shoulder particularly in swimming it's kind of like aim is a to the athlete is like a normal and expected part of the process and so where you draw the line of this is hurting more than it should to this is like a normal amount of achiness is tough just in light of hey most of us are going to experience pain at some point throughout the season and then the piece about well I can't take a break from training there's like a This is anecdotal, but they say for every three days out of the pool, or for every one day out of the pool, it takes three days to get back to where you were. And there's probably more rigorous research that could confirm or deny that. But the idea is, okay, we have a really straightforward way of monitoring load in swimming, which is the yardage. And so keeping track of that, but really working with the coaches and the athlete to have that entire conversation of hey here's here's what we need to supplement the pool training with here's the amount of training that we feel comfortable with them doing in the water here's the nature of the training that they should be doing in the water whether we're pulling back on total yardage or intensity or frequency or equipment use because we sometimes wear hand paddles which maybe put even more load through the shoulder like teddy said you If you don't have the background in the sport, well, you're going to learn today, right? Because you really do need to understand everything that goes into it. And it's kind of a unique beast. And so, yeah, getting that education, getting that communication going with the coach and with the athlete, helping the athlete feel comfortable having that conversation with the coach, because there's kind of like that warrior narrative that goes into it of, I don't want to tell the coach that I'm hurting. That might mean that they're going to have me stay out of practice. I don't want to do that. They might ask me to miss a meet. I don't want to do that. So that's why the swimmers are so tight-lipped about it. And they finally come to you and you're like, oh my God, your shoulder's practically falling off at this point. How have you been swimming like this for so long? And that's probably a big part of it. Definitely.
SPEAKER_01:So you're sort of understanding the sport, but also the communication there is important. big deal isn't it in terms of i know from anecdotally as well as things like scholarships things like that where there's a lot riding on them being in the pool but you're looking at a sport where they're not just in the pool three four five times a week they're in the pool multiple times a day ten times a week
SPEAKER_03:yeah
SPEAKER_01:yeah and that throws a whole different issue in terms of load management, which is a key topic we wanted to talk about, actually. And it fits really quite nicely into this subgroup of athletes. And it is
SPEAKER_03:admittedly hard. In other sports, I think you can kind of get some training stimulus without doing the sport itself. And with swimming, it's like as much as you throw somebody on an exercise bike or tell them to go for a run, you can be cardiovascularly fit, but it's really not the same. It's a very different beast. So yeah, how to balance that, like Teddy talked about the stressors versus your adaptation, like it's tricky. Yeah.
SPEAKER_02:Something I've had success with is helping them to kind of break down like different strokes and that sort of thing. And this idea of, you know, fly is the hardest stroke. It's the hardest on the body, hardest on the back, hardest on the shoulders. This idea of like, hey, can we kind of like load wave fly, like do it every, maybe every other day. If they're not competing in fly, if they, maybe they want to do IM, but they're not regularly doing fly. Like how much fly do we really need to do? You know? Or even if you're working with somebody like I had an athlete a few years ago, this guy was like a 40 inch vertical. He's an absolute fast Twitch freak. He does 50 meter fly. That's what he competes in. It's like this guy is a 20 second powerhouse and his coach is trying to get him to do 5,000 yards in a practice. He has no business doing that. He's way beyond his lactate threshold for half that practice. He's just destroying himself. It's like, hey, can I get you to just slow down? Slow down on that stuff. Stay in a little bit closer to an aerobic state. Now we get back into strength and conditioning principles, but that's going to help you to recover a lot better, and then you can push yourself more on those brief bouts of fly and that sort of thing.
SPEAKER_03:And that's a really strange tradition that still to this day is very slow to change. There are inroads. So the idea that yardage is king for any swimmer of any distance specialization from somebody who's doing the mile, which takes... 15, 20 minutes to somebody who's doing the 50 freestyle, which takes 20 seconds. Everybody's just going to swim in 10 times a week for two hours ago. And the thinking is that the more is the better. That's obviously not true, but there have been relatively few examples of people who are doing a lot less, making it to the most elite level. And so it's becoming more of a thing in the last 10, 15 years. But still a ways to go but for an injured athlete like that makes even more sense like you're only racing for 22 seconds at a time right do you really need to be doing all of that what's the the minimum effective dose at least while you're actively injured that we can keep you fit but find ways to do it where you're not just hounding yourself
SPEAKER_02:yeah There's just this bizarre survivorship bias in swimming. And it exists across a lot of sports and a lot of disciplines where people are like, well, it worked for so-and-so. So, you know, it's worked up to this point. And that's the thing that's going to get you in the biggest trouble in almost any walk of life. If it worked up to this point, I mean, maybe it didn't work up to this point. What opportunities are we unaware of that we've left on the table? In track and field, you can't even imagine training your endurance or your cross-country athletes the same way as your 100-meter sprinters. So why are we doing that in swimming?
SPEAKER_03:So it's funny because I grew up a swimmer and I didn't get really exposed to track and field until much later. And I was like, what do you mean the sprinters only do so little? Like, that's not possible. And then, of course, I found out that it was true. And my mind was blown. I was like, I just thought everybody just did as much as they possibly could. That was only from my warped perspective from having been a swimmer.
SPEAKER_02:Yeah. You had this naive idea that everything made sense, Travis. And unfortunately, ignorance is bliss.
SPEAKER_01:the sort of the the topics you picked up there is it's just a basic exercise physiology as well and it comes back to this understanding of what are we looking at and when we're talking about load management having a really good grasp of exercise physiology you know teddy you just mentioned the words a you know lactate threshold and i'd be really interested to put a poll out there of listeners of how many of us truly understand what a lactic threshold or lactic turn point and things like that is. What measures that? What is it? And why is it important? I don't think we're arguing that people need to know the absolute ins and outs of that. But I think having some understanding from a point of being able to manage load for our athletes is actually really important.
SPEAKER_02:Yeah, absolutely. Just appreciating the basics of exercise physiology and the zones are kind of an arbitrary label to heart rates or whatnot. But just understanding what an inflection point in your heart rate response represents and how that might impede your ability to recover. And the fact that a lot of different people, there's a huge variation to the tune of like 30 to 40 beats per minute across the board of where people stand in terms of their heart rate response and understanding that a highly fast twitch gifted athlete might not be able to tolerate the same amount of endurance training as somebody who is much more type one fiber dominant. And just, you know, I think a base appreciation of that. I mentioned earlier at the beginning with ACL rehab, like an American football player versus a soccer player or European football
SPEAKER_00:player,
SPEAKER_02:their conditioning and their tier two work, if you will, for their ACL rehab should be very different from one another. So I think these principles are extremely important in a base way. But yeah, it's extremely complex. I don't even understand the depth of it.
SPEAKER_01:That's why we have exercise
SPEAKER_02:physiologists. Exactly. Right. And they spend their lives doing that, whereas I'm more focused on injury. But I appreciate the complexity of it.
SPEAKER_03:That point you mentioned, it seems simple. It's like, oh, we're going to train our wide receiver different from our linemen. Then it's not simple, right? And so... Oh, sports rehabilitation. Okay, well, what sport? Okay, football. Well, okay, what position? Getting that level of detail is necessary and is not so easy to do, right? Especially if you're working very broadly with many different sports. Oh, first I have to understand swimming. Then I have to understand the mechanics of butterfly and the practice habits of the athletes within the sport, within this team, right? They don't teach you that in school, right? So they can't, of course. And we already said, well, they barely teach you any of this, but it's really up to the practitioner to do the homework of getting that understanding so that, okay, athlete needs to be here by the end of this. How can we get them there most specifically? And that's not just, oh, they have an ACL injury. It goes way deeper than that. Yeah.
SPEAKER_02:But what about my 14 other patients that I'm seeing today? That's when it just, yeah. It's really hard to go super deep on any one person when you have such a wide array of types of patients that you're working with. And that's where you're not expected as a physio to be an expert in these principles, but just to understand them enough so that you can Give people some tools. It could be simple for a running program. You could have two different types of running programs that you give people after an ACL. Dan Lorenz has a great paper where he has a return to sprint program with just some basic progressions. We have it printed out in both our clinics, and we give it to kids and say, hey, take a picture of this. We don't always need to be So N equals one prescriptive base, but just to understand and just to get close, like horseshoes and hand grenades, just get close and it will still be way better than average.
SPEAKER_01:Brilliant. Well, Teddy, Travis, we have hit just over an hour, if you wouldn't believe it, but it's been brilliant. Really, really enjoyed this. Can I nudge you both for a takeaway point for the listeners before we head off? I'll leave it up to whoever's ready for it. One takeaway point at least. You can go with two if you need to.
SPEAKER_02:I'll hop in first. Travis and I have been like pointing at each other, but we both kept our fingers down for that one. I'll hop in. You know, my biggest takeaway is that idea of tier one and tier two. don't forget about the other part of the body. You know, in physical therapy, we can become myopic or very nearsighted on the one injured area. Don't forget about the whole person and work around the injury. Sometimes that can be working around the injury while they regain function can sometimes be just as important or more important than the injury itself. So that's kind of my important takeaway. And remember, just because they're rehabbing their knee doesn't mean you're not allowed to do a hamstring exercise doesn't mean you're not a You're not rehabbing a different body part. Insurance will still reimburse. You're still working towards a goal.
SPEAKER_03:That takeaway is so awesome and so important. And then the other thing that I would add is just the reinforcing the testing piece. We talked a lot about you need to do it early and you need to do it often so there are no surprises. You need to do it rigorously and reliably and you need to practice. The other thing is like, well, we have to figure out what tests we're going to do. And we, we talked a little bit about that for the knee and that's just one part of the body, right? Like we talked about shoulders and swimming and the upper extremity is a whole different litany of tests out there. And as little agreement as there is about the knee, there's even less agreement, I think about what tests are important for the shoulder. So I would just say to like, really do your homework, come up with a battery of tests that makes sense to you and to your athletes and then again practice them practice them practice them don't be afraid to throw one test out even if the literature says it's good because it doesn't seem to provide information that is helpful for you and try something different um but try to come up with a battery of tests that makes sense and is comprehensive and is giving you the information that you need to like teddy said earlier like call an audible if things aren't heading in the direction that you were anticipating from the rehabilitation standpoint to help get them to where you want to get them at the end. But make sure you're not just doing the testing for the sake of it, but actually that it's meaningful to you during the course of rehabilitation and then at the end to make the decision to go back to sport.
SPEAKER_01:Travis, thank you so much for your time. This has been absolutely fantastic. I've really enjoyed the last hour or so. I think, again, I always said about the physics plane being sometimes I wanted to carry on the conversation. I never thought, well, at an hour, I still want to carry on the conversation. I know the listeners would have found this really useful and it's probably just kick-started a lot of ideas, some things that people could probably go away and think, actually, do you know what? I need to do more of that. I've never thought about doing that. So I think it's going to be really, really useful for listeners. And I would advise and to check you guys out on social media. And I'm sure you'd be happy for people to connect with you across different networks as well. It's been great. I shall leave you to the rest of your day. Thank you so much, both of you. And I'm sure our listeners will be hearing from you again on one of our other platforms. So once again, thank you very much from the Physio Network. Thanks, James. Thanks, James. Cheers. Have a good one.