PT school: “I found myself in the quote unquote, principal’s office a lot because I challenged a lot of beliefs. For better or worse, being fresh out of a master’s program in exercise physiology, I came in fresh with a lot of exercise physiology knowledge. And a lot of the initial year of your didactic training in physical therapy school is covering a lot of physiology and a lot of exercise science related topics. And, they were taught pretty poorly and I could expose how poorly they were being taught and I don’t think that they enjoy that very much. And I tried to be respectful and ask good questions, but they just didn’t want to be questioned.”
Tendon rehab: “If you follow the typical treatment parameters that is often followed by like old school outdated PT, yeah, it does follow that a lot of the first 6 weeks are probably neurological adaptations because all you’re doing is like feel good modalities and you’re not challenging the tendon at all and you’re resting. So yeah, things probably are just a little bit more of like nervous system, calm down and you’re just not poking the bear and running behind the tree to hide as often. Like, yeah, probably you’re going to feel better. That does not mean that you’re anywhere close to being prepared to what you need to do, but it’s probably going to feel better. And then what do we do next? Like, well, in typical PT, they do a lot of like BFR, they do a lot of like pretty low load resistance exercises. So yeah, I would expect that you’re probably going to see muscular adaptations in those types of training modalities versus tendon adaptations. And then what do we end up doing? Well, eventually the person gets strong enough or comfortable enough that they can push harder or the PT stops restraining them as much and says, I think you’re acceptable for load now. And now that we’re putting real load on them, now we do get tendon adaptation. So it was all happening all the time, but that very outline that you gave is probably more of how it happens when you follow a poor treatment modality or poor treatment model. And I think that’s funny. That’s like we’re taught that that’s how tendons adapt and it’s like, well, maybe that’s just how they adapt because that’s the really crappy way of treating them.”
“I think it’s unfair to criticize all of PT school for being so lackluster and poor in its ability to help with athletes when PT school is also trying to paint in broad strokes. And I think where we dropped the ball in education is that we’ve created a curriculum that’s supposed to like crank PTs through in two and a half to three years painting in broad strokes and then expect that that education is going to prepare you to work with very niche specific people.”
Sports physical therapy: “Instead of becoming too much of a generalist, which is required to pass your board exams. I think that they probably do need to go actually be in a strength and conditioning environment for a while. Like they need to coach on the floor with real athletes. They need to see the performance metrics. They need to be mentored by people who are in a strength and conditioning space, or at least PTs that really know about it, if that’s what they’re going to do.”
On college Lacrosse: “We used to joke that we called, we don’t play lacrosse, we play lacrosse country, because we just ran so much.”
“A lot of the conversations I would have with physicians, a lot of the narratives that were being passed by the athletic trainers, even sometimes the strength coaches, I felt was just totally bullshit.”
College Lacrosse: “When I dealt with injuries, it was just scraping or cupping or dry needling or massage. I didn’t feel like any of that stuff did anything. I’m having this problem. You’re telling me that this thing will feel good. But I was like, but what do do tomorrow? Like, do I just play? Cause like you did this thing. It’s the same. like nothing changed. Like it hasn’t adapted. Like I need to plan. And nobody could give me any kind of direction.”
College Lacrosse: “What is it that I’m actually supposed to do other than just come to you when I have pain and you’re just supposed to like put a bandaid on my boo boo and like pat me on the ass and keep going.”
Midportion Achilles tendinopathy in college: “Even at that time I knew, if I loaded my calf, if I just did like really heavy calf raises, it automatically felt better. And if I didn’t do that, or if I did too much running, it was worse. And no one told me that I just kind of figured it out because I enjoyed training.”
“A lot of the time it’s a DB or a wide receiver and maybe they’re dealing with patellar pain from a lot of really hard decels as they were preparing for training camp or just immediately after training camp. And instead of doing things that may help them like heavier, slow resistance, or even isometrics for God’s sake… It’s like, well, we’re just going to cup it and we’re going to dry needle it and hopefully you’ll be good for practice tomorrow. And it’s like, well, you know, you, you can feel kind of good. Like you can relieve some pain through neuromodulation in the temporary space. But like, if you just go back to practice tomorrow and there’s really no game plan of how we’re going to like count your decels or moderate your speed or your reps. And then we’re also not going to do anything that is known to be a little bit more tendon helpful in terms of loading in the weight room. We’re just going to avoid any kind of like heavy knee loading. Yeah, two, two weeks goes by and sometimes like they’ll feel better. Like they sat out of practice, but we literally got like on a piece of paper that they’re not allowed to do X, Y, and Z. ⁓ meaning like any kind of patellar loading for those two weeks and that it would be handled by the athletic trainers. And then you go in and look at what they’re doing. And it’s like all passive modality or blood flow restriction is like what they just love for some reason. which you’re again, not going to get good tendon load.”
“If high load is what we need for the tendon, you’re not going to be achieving that with like 20 to 30 % of a rep max doing BFR.”
“Athletes will just be in this rehab purgatory and then they’re [athletic trainers] all scratching their heads like, my gosh, we just don’t know what to do about like so-and-so’s knee pain. It’s so challenging. And it’s like, no, it’s, it’s really not that complicated. You’re making it really complicated by doing really poor treatment again and again.”
Using manual therapy too frequently: “When you make every practice and every game important, none of them are.”
“If you have pain then we’re a bad medical team and we’re not doing our job. And it’s like, no pain’s a part of human experience and probably even more so a part of an athlete experience, trying to like edge on the pursuit of really, really high level performance and pushing their body to a level that like very few humans ever will in their lifetime. ⁓ Yeah, pain is probably going to be a part of that equation at some point in the athletes life and how we deal with that is not all that complicated.”
“People are complicated, not the treatment process.”
“You can test a quad, it could be very strong. That doesn’t mean they have the ability to decel and jump really well repeatedly. There’s a coordination factor, there’s just sheer amount of tolerance to that thing that we don’t know how they’re going to respond. Everybody responds a little bit differently.”
“We do chase pain a lot. And even a lot of the research when people want to argue about certain treatments being effective, a lot of it is effective for what? And it’s effective for pain reduction. And we already know from tendon research that you can have a pain reduction long before the tendon has actually changed and that we see changes in the tendon still exist when pain and function have returned. So that doesn’t mean that you’re out of the woods yet. You still have a potential risk factor in place and that maybe some of these training modalities and the methods by which we arrive at a level of function need to be continued.”
“If the way that we are constantly teaching people to arrive at a better level of function or reduction of pain is through very passive modality care and palliative care, that’s not really a good long-term solution in any case for a tendon health related thing where we know this is a long-term thing, both from a pain ebbs and flows standpoint, as well as from a histological or morphological change that needs to happen.”
“If you’ve been treating in this space for long enough, you’ll have experiences where patients had a very negative outcome with things like dry needling and passive modalities where it made it so much worse, where it blew up their knee. And you may even have an experience where we were able to, to really increase the load. This person was able to tolerate in session and the next day their knee was blown up. But I think beyond that, ⁓ you, may also have instances where it’s not negative, where they were able to do a little bit more. They felt like a champion. both high-fived and it was great. We just carried on. ⁓ where I think the problem comes is more of like the psychological nature and the, ⁓ passivity and what actually is causing the change.
“You cannot take away the very lived experience that I had X amount of pain. You performed this thing with high base validity. I watched a needle go into an area that was hurting, you pulled that needle out and now it hurts less. No matter what I say about it, the person’s going to believe like, God damn, that needle was awesome and every time that my knee blows up, I need that. And I don’t want to create that narrative.”
“I don’t think that it’s all that helpful if I can get a increase in load in a particular tendon in that instant, and that it necessarily means that I’m categorically doing better by the person and by their rehab process. When we already know this is a very long standing thing that will ebb and flow over time. I want them to have self-efficacy and have strategies and understand the principles behind what needs to happen in the tendon and how to pivot and how to think about their tendon the way I think about their tendons so that they have the strategies to manage it on their own versus watch me in this white coat and I’m Dr. Q and you’re responsible to rely on me now to fix you. And I look super smart and it makes me look like a really good clinician because I have all these answers and I can make you feel good when you leave. But I don’t think that that’s a good healthcare model. I don’t think that that’s actually helping people in the longterm because inevitably we know that when people have pain in a tendon, there’s a pretty good chance that at some point in their life, again, if they want to do those activities, they may have pain again, right? And I don’t want them to have to come to me every single time like, yo Q, give me that fix dog. It’s like, no, if you already understand the tendon principles, you have a lasting methodology that you can go to and a well of information that you can pull from again and again and again, every time this comes up, not only in your knee, but probably somewhere else.”
“We may think that people are a lot more anxious about their pain. And then you listen to someone like, yeah, this is, mean, it’s lasted five months. It is probably going to take at least three months. And you’re like, ⁓ gosh, that was not at all what I was reading from the way that you were talking about it a second ago. I’m really glad I asked.”
Being a strength coach vs. a physical therapist: “I think that the healthcare model has just made us culturally so indebted to it that like we need it to fix our pain all the time. And so it almost becomes a little bit more of a barrier when you have a healthcare degree because there is a little bit more of that expectation.”
“I think what’s frustrating in the in-person field in the elite sport realm is that people and even gyms and private practice, they use this word all the time. They say, well, we’ve got to get buy-in from the patient… But the more that you perpetuate that game of getting buy-in via the things that we talked about just prior of pandering and palliative nature of care and passive modality type stuff, it only exists because that’s our cultural norm. And you just feed that dragon by continuing to pander that need.”
“They’re really good at like sticking a red light on you and making you feel good in the moment and warming up your muscle. But they didn’t talk to you about basic physiology or basic training parameters that you should adhere to in the gym and give you a program. Like that is not a physical therapist that I would trust.”
“If you make them think that this little shiny gizmo or gadget that I’m sticking in you is going to be the thing that’s the cure all and that you need me to do it every time you have this pain, I don’t think that’s a long lasting healthcare model that we should be promoting.”
“Yes, the person has a knee pain, but we don’t just armor the knee and forget about everything else that has to be in high function and high system in order for them to, you know, go onto the quote unquote, like battlefield, so to speak. Right. That if they’re to go back to playing, we want that knee or we want that Achilles or this tendon issue to be the absolute very, very last thing lagging.”
When dealing with tendon pain, “I think a lot of participation in the sport can be restorative in nature if done correctly.”
“When you work in an environment where the time loss to injury that’s marked on paper is directly related to whether you get to keep your job at the end of the season or not. Like you’re probably going to be a little bit averse to taking risks or to like exposing people. So you’re just afraid of everything.”
“The way that the model is set up where now, you’ve placed a lot of power in the hands of the patient, essentially the player, who does not have the knowledge or ability to fully understand the nuance of how these things work. And they are just seeking out a lot of pain stuff and if you don’t give that they’re going to find someone in the sport world who will. I think it’s going to take people to stand up and say like, no, that’s not how our culture and operation works here and we’re not going to do that. This is what we’re going to do. And once they start doing that and then also following that up with like we get the same results, if not better over the long term.”
“I’ve been doing this online for four and a half years almost now and have just as many success stories by not touching a patient at all.”
“I warn people on the front end of working with me that flare ups are normal. During this process, this is not going to be a linear thing.”
“Have you ever just thought about caring less? Cause if you did care a little bit less and stopped poking it all the time, trying to make it better. It may just happen on its own.”
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Website: https://www.findphysiotherapy.com/
