E11: Reconciling Biomechanics & Pain Science

Jimmy (00:01.258)
Good morning, Greg. Welcome to the podcast. How’s your day going?

Greg (00:04.718)
It’s good. Thanks for having me.

Jimmy (00:06.88)
So I have been following you for basically my entire PT career. been heavily influenced by you in your work. But for the listeners who don’t know you, do you mind giving a short introduction about yourself?

Greg (00:22.606)
sure. So I’m a, a physio or a physical therapist at a Toronto. I used to be a chiropractor. when I was a chiropractor, I was a researcher at the chiro college. Before that, I did a master’s in spine biomechanics, primarily exercise biomechanics, undergrad and kinesiology. I still fancy myself, myself like a strength and conditioning coach, but I don’t work with teams anymore. Although I did a long time ago. but I work with individuals.

I still see patients in Toronto and I would probably call myself like a clinical educator with two courses and then mentoring and all that stuff. Same things that everyone else does, nothing special.

Jimmy (01:06.068)
Got it. Yeah. So, but you’re still practicing and you’re teaching regularly. You have two online courses. and yeah, off air, we were talking, but your course of Reckland styling pain science with biomechanics was one of the first courses I took probably 10, 10 years ago. And I think that course is 10 years old right now. that what I, yeah. yeah. So pretty incredible. And I remember back then I was a new grad. I had quickly become

Greg (01:24.674)
Yeah. It’s awesome.

Jimmy (01:35.902)
disillusioned with some of the PT world stuff with some of the mentor early mentors I had trying to help me isolate segments for manipulation and things like this and just kind of quickly feeling like either I just completely sucked or there was something like wrong with this this model. And so I dove kind of headfirst into the pain science world. And I think that’s where I first heard like found you.

through, yeah, maybe it was SomaSimple or something like that. But yeah, so when I saw your course 10 years ago, Reconciling Pain Science with Biomechanics, I was really intrigued. Can you tell me a little bit about what prompted you to start that course?

Greg (02:23.534)
So I had been teaching for forever, like since I was in my masters and I was teaching at the chiropractic college when I was, you know, 24 or whatever after my masters. so I always liked to teach. And then I always thought that I, I think I had a pretty fresh take. you mentioned about motion palpation and finding little things that aren’t moving in the spine. My masters was in chiropractic manipulation.

Right. And we were writing about that stuff back in the nineties and saying motion palpation is invalid. You can’t do it. There’s no such joints. Don’t go to the alignment. So we knew that stuff then. And I just took it for granted. And then I would get into discussions online and I was always surprised that the ideas that people had about the body. And I’m like, this is completely not. I don’t even want to say outdated because outdated always implies like once it was accepted and like had proof.

I always say like these things were accepted way too readily and never should have been. And so I was pretty outspoken. And then people would say, well, what do we do then, Greg? And I was like, okay, fine. Like instead of just complaining about all these things and critiquing, I’ll show another model of care. And to be honest, I think I’m in the past 10 years, when I look on Instagram, I see that model is…

being accepted and it almost seems the standard now. Not the standard, sorry, but like it’s popular.

Jimmy (03:57.108)
Yeah, it makes me wonder. Well, so it’s back, let’s say like 10, 15 years ago when I was a new grad or in school, it did seem like it was like very polarized. It was either like very biomechanical or you’re diving deep into like the pain science world and educating patients that way.

Greg (04:14.434)
Yeah. Yeah. And I never liked that. And that was the whole point. Like, and, and I, again, this is the thing you see it in the pain science world of people who were being in the pain science, realize you couldn’t just throw a whole book at people. need simple messages that resonate biomechanics and physiology is still important or biology is important. And that’s what we always taught that like there’s they interact together.

Jimmy (04:26.356)
Yeah.

Greg (04:39.52)
and simple interventions go a long way and you can treat the whole person with this type of approach.

Jimmy (04:49.94)
Yeah, so the title of your course being Reconciling Pain Science and Biomechanics.

Greg (04:54.03)
Sorry, it’s reconciling biomechanics with pain science. Not that it matters, but sorry. I was gonna let it go.

Jimmy (04:57.084)
Yes, there we go. Yes. No, you’re fine. So yeah, with the title though, like, you trying to bridge the gap there or like what?

Greg (05:06.67)
Yeah, absolutely. Cause that’s how I always practice. Like I was in the nineties. My influence was biomechanists who were also talking about psychosocial factors in 1997. That’s crazy. That’s so long ago. I wrote a paper in an master’s ergonomics class about central sensitization. I have a paper published in the year 2000 that talks about central sensitization and spine manipulation. So we knew this stuff back then. It was never meant to be siloed.

Jimmy (05:34.388)
Yeah.

Greg (05:36.96)
and

Jimmy (05:37.088)
So why do you think that happened? Why do you think like people like me coming out of school, is it just the nature of like the education system? Why was it everything still being taught the other way? Like I graduated in 2014.

Greg (05:51.023)
So I’m the manual therapy thing has always angered me because now you have people this is now being a curmudge in here You have people who are like calling this new modern manual therapy They call it modern manual therapy and they’re sort of leading the charge about you know manual therapy is still helpful We’re just not realigning joints motion palpation isn’t valid, you know, but has these neurophysiological effects and they say that they’re

they’re leading this. And I’m like, you guys were part of the problem. You were teaching this 12 years ago and you had no right to teach it. You were out of date back then and you shouldn’t have been doing it. And now I get angry because now, now they’re acting like they’re the leaders. Like we knew this 20 years ago, all these things. So, so I think what happens with you is like you get frustrated because you have these, you have well-intentioned teachers teaching this stuff, or not all of them well-intentioned, but many of them.

Jimmy (06:25.258)
Yeah.

Greg (06:46.924)
And then you get disillusioned and pissed off. So you look for something that’s a reaction to it. And people, of course, some people go too far.

Jimmy (06:52.693)
Yeah.

Yeah, so I definitely feel like I swung very far. And so like in my bubble, that’s what it felt like everyone or lots of people did. But do you feel like it was more balanced back like 10 years ago or were people swinging way far to this?

Greg (07:09.67)
So that’s really hard to say. Like I think profession wise, there hadn’t been a massive swing to psychosau, or, you know, explain pain or anything like that, whatever we call it, but individuals certainly did. So they didn’t, they, they had about, they didn’t know what to do with their biomechanical approach. So people just got rid of it. And my whole thing was no, no, no, don’t get rid of it. Just, just reframe it.

Jimmy (07:20.915)
Yeah.

Jimmy (07:31.134)
Yeah. Yep.

Jimmy (07:37.568)
Yeah. And so I know you have a whole course on this, but like, what’s the crux of that course? How do we reframe that and how do we kind of bridge the gap between the two?

Greg (07:46.049)
It’s finding common threads. This is my favorite thing to do. I can’t remember if we did this 10 years ago as an exercise, but like, I think you can look at people like leaders or popular people in the profession who come from different backgrounds, like say Shirley Sarman and the Kinesiopathological model or Mulligan or Stu McGill or Peter O’Sullivan. You can look at these people who seem very different on the surface, right?

or at least in their explanations of why people recover. And then my joke is put them all on mute. Don’t let them speak. Watch what they do mechanically and you’ll see how that many of them are doing the same thing. Right? Which, yeah.

Jimmy (08:26.996)
Yeah, that’s true. I think you did say that 10 years ago because I remember it and it resonated because I did like I went back to the clinic and I felt that it was interesting. I felt judged by my colleagues for the language that I was using, but at the end of the day, we were doing the same thing. maybe that was a little insecurity of my part by feeling judged because I wasn’t, I was young, I lacked the confidence. And I felt like sometimes

Greg (08:46.07)
Yeah, for sure. Yeah.

Jimmy (08:56.702)
with those clinicians who are giving fancy biomechanical explanations for why they’re having pain. It sounds very scientific and it sounds like, yeah.

Greg (09:07.502)
Yeah, you still see it now. It’s like, like, we talked about people having a false precision. And that’s the idea. no, no one, like, people say to me, they’ll get upset to me, because I’ll say a lot of your clinical tests, you’re just doing them. And they’re not really informing your practice, right? You’re going to end up doing a lot of the similar things, same things anyway, or the, you know, the tests on foot strength or calf strength, you’re still going to give a calf raise.

And then people are like, make sure you get the foot intrinsics as well. And I’m like, well, if you do a calf raise, you’re going to get the foot intrinsics, you know?

Jimmy (09:43.828)
Yeah, all right, so can we pause for a second and can you explain like what false precision means?

Greg (09:49.455)
So what people really hate in our profession is this idea of giving recipes. I don’t just give recipes. I’m science-based or evidence-based. You can’t just give a recipe to everyone. And then I swear, if you went and looked at their clinic notes, you’re going to see a lot of the same exercises. And the irony with giving recipes is most all of the research we have, they test recipes. They have to.

Jimmy (10:05.267)
Yeah.

Jimmy (10:15.38)
Yeah, yeah, it’s funny. was just, when you said that, was just thinking, I was thinking about a strength, a recent paper on strength training and improving running economy. And it basically provided a recipe for the program to follow.

Greg (10:23.555)
Yeah, of course. Look at all the Achilles tendinopathy research. It’s a recipe, right? And there’s, there’s, tailoring in there, but people hate that. People want to think, no, I’m going to find the one dysfunction. I’m going to find some weakness. I’m going to find some muscle that’s overactive or underactive. Right. And then I’m going to tune it to, the person. Right. Which is very biomechanical. And I, my whole thing, if you remember the course is like,

Jimmy (10:30.656)
So why did… Yeah.

Greg (10:53.207)
If you just treat comprehensively, which is a common theme amongst even the kinesiopathological model, when they’re trying to correct movement patterns, if you look at it, they’re just treating comprehensively. And that means if the knee hurts, what do you do? You do some sort of strength training at the knee or you back off and then you end up loading it in the future. And then you train at the foot and the ankle and the foot, sorry, and the hip. That’s, that’s what they all do. And so, but some people like, make sure.

Jimmy (11:17.876)
Yeah.

Greg (11:21.315)
You find a weakness in the glute med. I’m like, no, you could just train the hips as well because the sport demands it. You don’t need to find these things. So we have this false precision or, or we think we’re choosing an exercise that’s like targeting the flexor, Holocaust longest, or some little muscle in the foot. And, we’re shifting the stress to the soleus. But if you know the biomechanics, you know that you’re really not doing that either.

Jimmy (11:46.177)
All right, so, so quick. right. So false precision is you’re, you’re just finding it more as like that we think we can uncover some meaningful tiny little flaw that we need to address with. And if we don’t address them, they’re not going to get better. And instead the alternative would be to, think you call it like the belt and suspenders model. It’s like, just cover all our basis, do everything.

Greg (12:01.849)
Yeah. Yeah.

Greg (12:07.801)
That’s right. Yeah, and people, that’s right. And then people say to me, well, Greg, you’re not tailoring it. I’m like, are you kidding me? I’m just not, there’s so many other ways to tailor it when you have that approach, right? Cause now you can tailor to the person of what they’re interested in, what they’re willing to do, what their secondary goals are, if it’s performance, is it weight loss, what equipment they have access to, exercises they like to do.

Jimmy (12:27.262)
what equipment they have access to. Yeah.

Yeah.

Greg (12:33.877)
There’s so many different ways. And that’s what all of the research in strength and conditioning has told us. There’s so many different ways to get strong and so many different ways to get hypertrophy.

Jimmy (12:39.526)
So.

Jimmy (12:43.754)
Do you think this is a problem that’s the way you just laid it out, that’s unique to our profession? that, okay. Do you see it in like the strength and conditioning world as well?

Greg (12:49.771)
No.

Greg (12:55.253)
yeah, but they’re getting better too. They’re going through the same revolution, right? Where people are like the whole set rep continuum, right?

Jimmy (13:04.308)
Yeah, I think I just saw a post recently, which is like a picture of a muscle and it was like three by 10 grows muscle three by 20 grows muscle, whatever. Yeah, three by three grows muscle.

Greg (13:13.273)
This is it.

Greg (13:17.005)
So I did a post literally eight years ago, or I was at a conference and someone was saying, moving beyond three by 10. And I’m like, if you can’t prescribe three by 10 and get the, the attributes you want, then you’re just shit. If you think three by 10 is horrible, then you don’t know what you’re doing. Right. I mean, you can also do three by seven, you know, people would be like, like this, this is what I don’t like it. You’ll see strength coaches a lot in the UK for some reason who really are like,

Jimmy (13:29.908)
Yeah.

Jimmy (13:34.772)
Yeah.

Yeah.

Greg (13:46.105)
Physios don’t understand strength and conditioning principles. And I’m like, prove that. Because what I’m guessing is your principles are wrong, right?

Jimmy (13:55.359)
Well, are they over-complicating it or what’s happening? Why do

Greg (13:58.211)
Yeah, they’re over-complicating. They’ll be like, you did three sets of 10. You know, that’s not the best way to get strong. And often they quote this Mangione research. And I’m like, actually the systematic, cause they would say you should be doing four sets of four or four sets of five. And that, you listen to Stu Phillips or all the systematic reviews there, that’s true. If you want to get, say it’s your bench press, you know, I get stronger on the bench press, then you should be training.

Jimmy (14:03.924)
Yeah.

Jimmy (14:15.252)
Yeah.

Greg (14:27.993)
three by three, very, very heavy. And of course, three by 10, you’re gonna get stronger, but your peak strength won’t be the same for that task because the bench press is a learned skill. So you will get stronger in the bench press, but if you wanna get generally strong and have it carry over to some non-specific chest movement, both of those set rep approaches will get you equally strong. You just get stronger at the, excuse me, at the specific task.

So you can do both is what I’m saying.

Jimmy (14:58.72)
So and is there a, yeah, and then is there more of a, would you almost break it up into like, kind of like a health buckle bucket over here? We can be more general, less specific and then more of a specific performance bucket over here. And maybe we do need to be more specific or is that not true?

Greg (15:18.201)
think for performance you need to be more specific, even that has a lot of leeway. That’s what I’m saying. You can go ahead and do three by nine and you can go ahead and do three by three if it’s general carryover. This is what’s…

Jimmy (15:32.34)
And you’ll get strong. if, if, but what if, the, if the tasks or the event you’re training for is one rep max.

Greg (15:39.297)
Of course, yeah. Then if you’re a power lifter, you need to deadlift. Yeah. Of course, yeah.

Jimmy (15:43.713)
And low reps is what you’re more specific to the task. Yeah. So are there other areas within our profession that you see this false precision being prevalent and problematic?

Greg (16:00.557)
mean, well, it’s a lot of would be there’s a push now, which is funny. There’s a lot of strength testing out there with quantifying, quantifying it, which I, which is weird. Cause again, I, my masters was in like the nineties and we, that’s, we did a ton of that then I had all that equipment in my first clinic. And now people are like, this is the way of the future. I’m like, this is the way of the eighties.

Jimmy (16:08.957)
Mm-hmm. Like quantify. Quantify, Mm-hmm.

Jimmy (16:21.217)
Yeah.

Jimmy (16:26.785)
Well, now it’s more accessible because it’s like a small clinic like me, I can buy a dynamometer for a couple hundred bucks, right?

Greg (16:31.396)
Yeah.

Greg (16:36.239)
Yeah, I had a BTE system like that. They, don’t know you know BTE, it doesn’t matter. in the States. It’s like functional capacity testing and all that stuff.

Jimmy (16:39.647)
Yeah, I have no idea what that even is. yeah. OK, yeah. So and do you see, what do you see the problem is there? is it, go ahead. Yeah.

Greg (16:53.775)
The problem would be that it’s not inherently a problem. I don’t want to say it’s bad. It’s just, I don’t like it sometimes when just like you had with your clinicians saying, if you can’t motion palpate this, you know, don’t worry. You’ll get it five years through now. You just got to keep practicing. And then it’s really important. It’s the elevating it as being superior. When it’s not, you can absolutely do strength testing.

And for forced testing. I kind of, I, I like it for, just gamifying it and it’s fun and people can see that stuff. But you can also see people be like, well, how do know they’re getting stronger? I’m like, are you serious? Cause you just bench pressed more weight. Like what the fuck? So it is a bit weird, but it doesn’t, it doesn’t tell you what to address. That’s the thing. I had this debate online where someone’s like, the, they have a foot issue and they’re like, Hey, the hip is involved with.

Jimmy (17:43.297)
Sure.

Greg (17:52.558)
with the foot. like, yeah, no shit. That’s a truism. He didn’t say anything. So I always make sure that I check the hip and I’m like, what are you checking the hip for range of motion or strength? I’m like, so the assumption there is that if you have a foot issue in order to benefit from doing hip training or hip mobility training, you have to be weak in the hip or have a tightness or restriction in the hip. And I would say that’s a false sense of precision. You’re making an assumption of

what mediates recovery and you can’t, right? Just because like you could still benefit from a hip exercise even if your hips were symmetrically strong or had symmetrical motion or relative to some absolute value of strength or mobility, they were at the norm. That’s the false sense of precision.

Jimmy (18:43.553)
So in that case, would say, if they didn’t present with the deficit, we’re not going to do anything about it. But they may still benefit from doing something with

Greg (18:52.173)
Yeah, because remember we don’t, we’re not at the stage yet where we know what mediates recovery. So with strengthening with kneecap pain, there is actually no research that shows you need to be weak to, to benefit from knee exercises. Because who cares if like, look, go this way. If you start strength training, your strength is going to increase 20 to 30 % in three weeks. Does that mean the joint is actually stronger quote unquote that it’s more resilient?

Jimmy (19:08.513)
Mm-hmm.

Greg (19:21.871)
and can handle more stress. No, you’ve just learned how to like rate code and recruit your muscles better. Right. It’s, it’s, it’s a totally different thing. You’re, you’re assuming that the ability to produce force is what is important and it may not be right. So you can still benefit from the strength training. So I wouldn’t toss it out so quickly.

Jimmy (19:27.777)
Sure.

Jimmy (19:36.949)
Yeah.

Jimmy (19:41.921)
So this goes back to treating comprehensively. yeah, what if the patient tells you like, can only do, I’m only gonna do five minutes of exercise. Are you gonna then be more specific or do you think it matters to not?

Greg (19:45.913)
Hmm.

Greg (19:58.191)
So this is my favorite question because anytime someone like me says we can be kind of general, you always want to say, well, okay, let’s check that bias. And when, when do we actually need to be specific? And I think I started my course with, with, with, with that. Right. And, and that’s where research is hopefully guiding us. So the best example would be ACL tears, right. And quad weakness. If you’re returning to saw.

Jimmy (20:10.943)
Yeah, I think you start most of your courses with that question. Yeah. Yeah.

Greg (20:27.843)
That seems to be some, and that’s like a specific deficit that seems to be associated with future injury. It’s logical and plausible. And you can’t just do squats because the body has the ability to protect and offload or shift the stress away from the knee. So you have to do a leg extension, you know? And then the other things, sorry, go ahead. Yeah.

Jimmy (20:47.243)
Yeah.

Yep. Do.

No, keep going along that thread.

Greg (20:56.399)
Another one would be fear. If someone is specifically afraid of bending their spine, tying their shoes, you, and you think that fear is something that needs to change for someone to recover. You have to do that task eventually. You can’t just do squats, right? Even though there’s spine flexion during a squat.

Jimmy (21:13.633)
Yeah.

Yes.

Great, all right, so there’s a time and a place for being specific. And maybe another example in the running world, like a bone stress injury.

Greg (21:24.782)
Yeah.

Greg (21:28.813)
Yeah. So that is actually my favorite topic because that that’s the debate of like, if we want people to run, like that’s the, we assume that people have to be prepared to run, right? They have to build themselves up to run 30 K 20 miles. And so the debate in our profession now is what’s the best way to do that. Do you need like calf raises and squats and hopping, or can you just progressively

create a running program. I’ll create a progressive running program. That’s what like if I’m Chris Johnson, I’m doing my slow motion calf raise where I stare off into the wall. I’m friends with Chris, so I am allowed to make fun of them.

Jimmy (22:02.688)
Mm-hmm.

Jimmy (22:09.953)
Nice, yes. Well, Chris was on the podcast as well. Hasn’t been released yet, but his episode’s coming out. But yeah, so it’s debatable. I’ve also heard you, like on one of your previous podcasts with maybe Steph Munt talking about, is there, can we treat low risk stress fractures almost like a tendinopathy? Did you, can you talk about that a little bit? Cause I think it’s interesting, cause

Greg (22:17.623)
Greg (22:35.437)
Yeah, yeah, So my, my, my.

Jimmy (22:39.881)
We’ve jumped into like maybe a prescription there in a sense where it’s like with the Stu warden papers and things like that, where it’s like zero pain. We’re very strict on that. Yeah. So I’ll let you run with it.

Greg (22:44.76)
Yeah.

Greg (22:48.589)
Yeah, it’s weird. This is like old school. you know, in the mid 2000s, the Silvernego research said with tendinopathy, you can keep doing the tasks that you love your sport, even if it hurts, provided it doesn’t flare up. The assumption there was that, and this is all in the pain world, that pain is not a good arbiter of tissue safety.

That’s what we learned in the pain science world. you know, the pain gets a seat at the table, but it’s not the CEO. It’s in the car. It’s not driving the car. That sort of.

Jimmy (23:25.057)
But I feel like, but in the bone stress injury world, that goes out the window.

Greg (23:29.401)
So that’s what happened. For some reason, the bone stress world went out the window, even though a lot of the same research would argue not to listen to pain, because how often do people have bone marrow oedema in their feet without pain? How often do we see some sort of a bone stress injury reaction in there and no pain? So we do know that the correlation isn’t that great. And so what we’ve kind of done is said, no.

Jimmy (23:31.766)
Yeah.

Jimmy (23:44.457)
Yeah.

Greg (23:59.001)
Pain is the best guide here. And I would say it’s probably because the risk is so much greater.

Jimmy (24:08.826)
Okay but yeah if we separate it though we got high risk low risk and we just look at the low risk.

Greg (24:13.401)
So then you have people like me who are questioning this, and then you have colleagues of mine at the running clinic like J.F. Esculier and Blaise Dubois who’ve been teaching for 10 years. Like if it’s a low-risk stress fracture, you can load it and treat it like a tendinopathy.

Jimmy (24:30.241)
Yeah. And load it with some running. Yeah.

Greg (24:34.115)
Some running, even when it hurts. And so what Steph talked about was a military paper where that’s what they did in lower stress structures. They had them still run even if it hurt. And they just followed your classic rules of it’s stable the next day and doesn’t get progressively worse.

Jimmy (24:48.225)
Okay, like do you think there’s a potential if we go the other way for a low risk site and we tell the patient you cannot have any pain, like we’re very strict with this, what are the potential downsides you see of that approach?

Greg (25:02.975)
So with a small subset of people, it’s just like with people with persistent pain, they tend to ruminate. You could magnify what you’re feeling. So the big assumption with pain is like, yeah, you might have some signal from the tissue. And if you have a really healthy system, if it’s nociception, you’ll be anti-nociceptive and you’ll modulate the spinal cord in the brain and not feel pain. But let’s say you’re ruminating and you’re worried and you’re fearful and you’re anxious. Now you can have this signal from the tissue that

Maybe a healthy person would ignore or modulate and you amplify it. I’ve had a few people through the years who have sort of this bony type pain and they’re runners and had stress fractures. This is a long time ago, but they had MRIs, which in Canada we don’t see lots of, and said it’s healed. And I was like, okay, we’re running even if it hurts. And they got better. And so it’s just, it’s hard, it’s hard. I’m not saying this is easy.

Jimmy (25:49.408)
Yeah. Yeah. Yeah. I’m thinking of a patient. I’m thinking of a patient I have currently with just a tibial stress fracture, yeah, stress reaction. And we, I followed the approach of zero pain and talked to her about that. And

She’s definitely developed some hypervigilance around this, some fear, worry. She was in a boot for, like was afraid to get herself out of the boot. When we finally got her out of the boot and we tried to run, she’s experiencing symptoms that are freaking her out. she’s, just very, it’s been a very slow return to run. And I wonder, like, she might be in this subset where she definitely is like a catastrophizer. didn’t…

Greg (26:23.545)
Yeah.

Jimmy (26:40.393)
I probably did that Tampa Catastrophizing Scale. I can’t remember what her score was. Yeah. But yeah, that’s, that’s, she’s one that immediately pops in my head where I’m wondering, yeah, did I, by tell, by stressing zero out of 10 pain, have I like set her up for this path of just being like hypervigilant?

Greg (26:44.057)
Yeah, Kinesiophobia, yeah.

Greg (27:02.733)
Yeah, it is possible. just, it’s just weird that we treat bones and I do too differently, but where’s so here, even go back a step, say someone has kneecap pain. Where, where do we think the source of nauseaception is? I’m pretty sure if you look at like, well, seno-vitis, but there’s also like some bony edema perhaps that’s a, that’s a what’s his name? The dyes research, right? There’s actually the bone that gets sensitized.

Jimmy (27:11.935)
Mm-hmm.

Jimmy (27:17.771)
Trish, you?

Jimmy (27:31.039)
Interesting. Yeah.

Greg (27:31.779)
And so we nudge into kneecap pain. Although I feel like there is a sort of, you’ll hear a lot of clinicians sort of backing off more than ever now with kneecap pain.

Jimmy (27:41.311)
With knee pain, where they load the hip first and void. Yeah, avoid.

Greg (27:44.151)
I’d stole that study, but that was like 11 years ago, yeah.

Jimmy (27:48.427)
Time flies, yeah, okay.

Greg (27:50.255)
But you know what, remember with her paper, I don’t know if that doesn’t matter. That was only where there was a decrease in pain at four weeks at eight and 12, there’s no difference. So just so people know this paper, both groups end up doing hip and knee exercises after four weeks, but one group only did hip exercises for the first four weeks and the other group did knee exercises for the first four weeks.

And the group who backed off of the knee exercises did better in the first four weeks, but then at eight and 12 weeks in the long term, it didn’t matter. Is that where you recall from it? Is that seem fair? Yeah.

Jimmy (28:24.011)
Hmm. Yeah, that’s one. Yeah. But then like, I guess clinically, you’ll see like, it just makes sense a lot of times somebody’s just super reactive and you don’t want to load the knee if it’s right there. The symptoms are so high.

Greg (28:37.903)
So look at this, this is like another way to tailor. So we often think I need a diagnosis to tailor, meaning a tissue based, we’re basing on a tissue. Perhaps the other way to let something guide your treatment is, well, are they an endurance co-worker? Right? That’s why things are so jacked up. So they’ve already tried to push, to push, to push, and they haven’t taken any time off. So it’s your coping strategy that then helps guide what you’re gonna do.

Jimmy (28:55.723)
Yeah.

Jimmy (29:02.237)
Yeah, no. Yeah.

Jimmy (29:07.777)
Yeah, it’s funny. I was just going to say it’s funny you bring that up because that the patient I had in mind that I was thinking about was this endurance coper and any like if we tried to load her knee, it was just blowing up because she had already been doing that.

Greg (29:08.045)
And I’ll often say, sorry, go ahead.

Greg (29:21.401)
Yeah, and then your other patient is an avoidance coper, right? And you say, no, the more you’re avoiding, the more sensitizing you get. So we got it, we have to start loading it here. We can’t fully trust what you’re feeling here. So there’s it. And again, the tissues, like it’s gonna give you a little bit. I don’t wanna say it’s totally irrelevant. This is another idea of people getting mad at me, because they’ll misrepresent what I say when diagnosed. I’ll say diagnosis doesn’t matter that much. And I’d say for the vast majority of things, it doesn’t.

Jimmy (29:33.545)
Yes, okay.

Greg (29:51.311)
provided they’re safe.

Jimmy (29:51.713)
When you say that, you mean like a specific tissue to blame or just like what do mean by that?

Greg (29:56.813)
Yeah, that’s what a diagnosis I believe that a proper diagnosis is the tissue. Like saying telling someone their spinal flexion intolerant is not a diagnosis. That’s bullshit. No, no shit. It’s like you could have knee pain be like, I’m knee flexion intolerant. Yeah, it’s not a diagnosis. I mean, like, yeah, so like, but I still want to know you want to know the serious stuff. like, with with knee pain.

Jimmy (30:14.827)
Sure.

Greg (30:24.963)
I don’t know if I did this in the course, but I don’t do this anymore. would say like, say you’re in the multiverse and you have a 40 year old who plays volleyball or whatever, and she has different doppelgangers. If she has kneecap pain, if she has IT band pain, if she has early knee OA or something, even patellar tendinopathy, you’re not going to treat her much differently in terms of her rehab and playing her sport and all that stuff.

Jimmy (30:50.517)
Where are, so in those cases, I guess this is another back to the other, the question we already talked about, but like specificity in those, you feel like, do we need to load the IT band differently than we do the patellar tendon? Like does the exercise prescription look a little different?

Greg (31:06.063)
So I, how I like to practice is, I like local load and distal load around it. So I still, I believe in treating IT band pain, like a tendon. So I like to load it up very heavy with hip abduction exercises. And, but, but, so maybe there’d be like a slight bias toward that, that local loading. That’s my bias is to try to be tissue specific, even though I know the research isn’t strongly supportive of it.

Jimmy (31:11.521)
Mm-hmm.

Jimmy (31:22.037)
Yeah.

Jimmy (31:31.937)
Sure.

Jimmy (31:35.701)
Yeah.

Greg (31:35.951)
I still can’t say it isn’t, so I do it.

Jimmy (31:40.096)
Yeah. So in that case, like my biased and, I’ve been heavily influenced by people like you, but is to, to basically start with something more local so that they feel like we’re doing something to address the problem, but try to transition their PT to what looks like a strength training program with double leg movement, single leg movement, and then a little bit of specificity to whatever the injury is.

Greg (31:57.229)
Yeah. huh.

Uh-huh. That’s belt and suspenders. That’s comprehensive capacity. That’s treating above and below and at at the local, local and regional and then global, which is running or whatever it happens to be your volleyball.

Jimmy (32:13.889)
Sure, yeah. there’s the way that you’re describing practicing and that I just did, there’s like lot of acceptance to lot of uncertainty. How do you feel like we as a profession handle uncertainty?

Greg (32:29.583)
not well, like, like consciously, but I think subconsciously we do it. Okay. We end up because the way I, so here’s the idea, like Kelly’s tendinopathy. I would argue, I think.

Jimmy (32:39.924)
Elaborate.

Greg (32:50.337)
I give exercises that try to increase the stiffness of the Achilles tendon. That’s what I do. It’s the assumption that you build up the Achilles tendon that somehow helps with the tendinosis. It helps someone return to their sport, whatever it happens to be. It’s, it’s good to do. If I’m really honest and I look at the literature, I have no standing to do that. There’s so much research that will show a medium load program that has no chance of increasing Achilles tendon stiffness.

is just as effective as these other programs that I prefer. But I kind of think there’s probably a subset of people who need that local specific load. So I want to make sure I cover them because there’s no risk in doing it. Right. And then I believe the hip and the knee should also be trained around it. So I do that as well. Totally acknowledging

The vast majority of people probably don’t need that either. They just need to get back to their sport and things will sort it out. But there might be a small subset who need it. So that’s how we handle it. We just, if it’s not harmful and it has secondary benefits, we treat comprehensively.

Jimmy (33:55.169)
Sure, okay.

Jimmy (34:02.537)
And that’s how we deal with uncertainty. And that includes like uncertainty with diagnosis and uncertainty. Cause like we really don’t know, yeah, with the diagnosis per se, like we’re kind of guessing, but it’s our best guess. People don’t like to that word guess, but like this is our hypothesis. And then we’re also unsure with like how this individual is going to respond to what we give them.

Greg (34:04.493)
Yeah.

Greg (34:27.373)
Yeah. And I’ll say to people like, I don’t know if this is this tissue or if it’s this tissue, but the way we’re creating your program, doesn’t matter. We take care of all of that.

Jimmy (34:40.381)
Okay, so that’s how you explain it. Because I feel like sometimes when I’m working with a patient, there’s a little bit of insecurity on my part that that presents like a lack of confidence to the patient.

Greg (34:42.541)
Yeah.

Greg (34:52.825)
So you need to develop arrogant ignorance. I’ll say that to people and I’ll say, you know what, you might go somewhere else and they’re going to tell you they know and they don’t. They’re just lying and they don’t know better. So that’s how I do it. A dick.

Jimmy (35:03.359)
Yeah.

how, no, yeah, I, I understand. Yeah. That makes a lot of sense, but it’s frustrating because then, yeah, you get certain, subsets of clinicians who, yeah, very specific. I’m thinking of even like dry needling and things like this, where we’re going to like, have this fancy explanation. And at times I, especially in the running world where they want, runners want to fix, they want a quick fix and.

Greg (35:13.432)
Yeah.

Greg (35:23.331)
Yep.

False precision.

Jimmy (35:34.859)
They often put up a little fight about, I don’t have time to do exercise. I just want you to do something. I think this has been like my battle as a PT is like navigating that.

Greg (35:47.727)
I would, this is sort of the reaction that people had against manual therapy and that our profession had in promoting active interventions as being superior to passive, which I completely disagree with. I don’t do a lot of passive therapy. My bias is active and letting people manage it on their own. But when you look at the research, passive interventions are not subpar to these. so I would not be, I would.

It’s okay to do manual therapy for these patients.

Jimmy (36:19.307)
Sure, if I had to nail you down for like, is there a component to it or could there be potential net?

Greg (36:27.791)
Of course, but it’s all in your narrative. So I always worked in manual therapy clinics, which was a ton of active release technique. They’re all Kairos and physios that did that long sessions. And, and, what was great, I’m just thinking of the good people there is they’re always like, Oh, we’re to do this manual therapy and you have to do this three K run today. And tomorrow you’re going to run six K there was always wicked load management.

Jimmy (36:31.125)
That’s about it. it’s. Mm hmm. Yeah.

Greg (36:54.681)
You know, the only reason we’re doing the manual therapy is just to calm stuff down, to keep you doing your race. It was never like, if you want to do manual therapy, but now just shut it down. Don’t do anything. It was always like.

Jimmy (37:05.619)
And, and also the explanation you’re so the explanation you can potentially tell the patient goes whatever way you want to take it about what you’re doing to them. And the way you just described it, it like you weren’t telling them you’re releasing this or you’re doing it, you’re correcting that or.

Greg (37:13.805)
Yeah. Yeah.

Greg (37:23.395)
This, mean, I would probably have colleagues that, that would say there’s like some adhesions or we’re getting the muscles to function better, you know, and I don’t, I never really agreed with that stuff, but I, this is the thing with, with people. Like if we think the spine is robust and can handle lots of load, people are also robust. They can hear that they have adhesion and a muscle and I don’t, think that’s wrong, but

It doesn’t really harm them. They’re like, that makes sense. I felt a knot in there. Okay. And then I’m getting it taken care of. Even though I think it’s false. I wouldn’t do it. I wouldn’t tell people to do it, but I also have like faith in people’s, you know, psychological resiliency sometimes. Except, but then there’s a small set of people who are totally fucked up because they think that they have all these knots and adhesions in their body. So again, I don’t, that’s why I don’t do it.

Jimmy (38:05.481)
Yeah, so I went through this

Jimmy (38:11.051)
Sure. Yeah.

Do you, yeah, and I feel like maybe I practice like just me in a solo clinic and I maybe see more of the people who are getting second opinions or they’ve seen a bunch of people. So maybe I’m seeing a subset of the patients who have been maybe hurt by that kind of language. Yeah.

Greg (38:36.118)
me too.

Jimmy (38:38.079)
So then it’s made me swing the other way where there was a point in my career, maybe four years ago, where I would took like a dry needling course. I was going to add it to what I did to, because my rationale was like, those people were going elsewhere to get that care. And it could be, maybe I could get, deliver a different narrative while doing it and encourage heavy load. I think I dry needled like three people and then stopped. I just couldn’t, I couldn’t.

Greg (38:58.435)
Yeah.

Greg (39:04.398)
Yeah.

Jimmy (39:06.003)
I don’t, it was just, it didn’t fit with the way I kept coming back to this question where I would say like over the past five years, was there ever a patient that I had that I thought didn’t get better because I didn’t do this?

Greg (39:17.325)
Yeah, I I spent $6,000 on an acupuncture course too. Cause it was medical acupuncture in Canada and all these famous Kairos would do it. I thought I was missing out. Maybe I put it off for years and then, then same thing 2008.

Jimmy (39:22.207)
Nice.

Jimmy (39:30.175)
Yeah. When was that? How long ago? Yeah. Okay. So do you think there are people, like if you reflect on your caseload, like are there patients where if they needed something like that, that you didn’t do, like a passive intervention, then they wouldn’t have gotten, or they didn’t get better because you didn’t do that.

Greg (39:36.163)
Harley did it.

Greg (39:53.079)
No, I think because I’m in the same case as you people are coming to me for second. I’ve actually when I’ve some people email me often first and if I can tell they’re looking for lots of manual therapy and I’ll tell them I’m not the right one for them. Yeah, but my whole point is like like not everyone wants to be active. They just want to be taken care of.

Jimmy (40:01.054)
Mm-hmm.

Jimmy (40:07.393)
Sure, yeah. Okay.

Jimmy (40:17.141)
Mm-hmm.

Greg (40:17.718)
And I get that. if you have neo-A and if we look at the research on manual therapy and neo-A, it is just as good as exercise and neo-A. And you have people who do not want to exercise and they just won’t do it, but they just want to have less pain and do more things with their dog or their family. And if manual therapy can do that for them, who am I to say it’s wrong? I find our profession is even

Jimmy (40:36.438)
Yeah.

Greg (40:44.195)
with researchers who shouldn’t be driven by bias. I think our clinical practice guidelines are so incredibly biased. Want to hear an example? So I think this is the new, this is the Achilles clinical practice guideline that came out. think it was Chiminetti who wrote it. They put exercise as the number one thing to do. They cited a system, a network meta-analysis that said that exercise is valid and all that stuff.

Jimmy (40:50.753)
Yes, please.

Greg (41:14.631)
they didn’t talk about acupuncture in the clinical practice guideline. It wasn’t really addressed yet. The same network meta-analysis that they cited showing how great exercise was also said that acupuncture was very high ranking as well. So they just kind of chose like what to discuss is very leading.

Jimmy (41:36.961)
So, all right, so then, so it sounds like if 10 years ago, what do you think that paper would have done with that?

Greg (41:45.269)
The same thing. I think our clinical practice guidelines, I always feel bad when I see like Rich William wrote a good one with a kneecap pain and I could, I feel like he was probably hurting cats because you could see, like I would see the author list. There’s like 10 of them. You can almost tell who wrote which sections because they want to get their bias in there. And it was incredibly biased.

Jimmy (41:46.401)
It would have biased exercise.

Jimmy (41:55.243)
Mm-hmm.

Jimmy (42:08.033)
Sure.

Is that just natural human tendency to be biased or what do you think that is there?

Greg (42:15.279)
Well, if you’re a researcher and you’ve dedicated 20 years of your life to like faulty movement patterns and you keep like Irene Davis and you keep using that word, you’re going to want to promote your stuff and you believe it as well. Like, I don’t think that these people are, there’s poor intentions. That’s part, like part of being a researcher is knowledge translation. You should be out there promoting it.

Jimmy (42:20.651)
Mm-hmm.

Jimmy (42:33.27)
Yeah.

Jimmy (42:41.183)
And so you’re really good. yeah, you are. No, I was, I was going to say, was just like questioning assumptions and you’re constantly like calling people out or like at least challenging things. recently, yeah, you put the one on like Achilles load or I think it was Achilles load, like different tasks. Like how much do we need to be this specific? what, why do you, why do you challenge people?

Greg (42:44.809)
Going all over the place here? Yeah.

Greg (43:01.294)
Yeah.

Greg (43:08.877)
I challenge myself first. want to know what I know and what, think why I know it. And so if you notice with my engagement online, I’m not really arguing with people who are super dissimilar to me. I don’t care. I’m not going to go argue with some whack job doing something that’s absurd. I’m going to argue with people who practice very similar to my style to almost fine tune what I’m doing.

Jimmy (43:21.525)
Yeah.

Jimmy (43:26.005)
Mm-hmm.

Jimmy (43:33.195)
Yeah.

Jimmy (43:37.227)
So it’s way to challenge yourself in a way. Yeah.

Greg (43:40.195)
Yeah. So I think what, what you might’ve just seen, like my, my big thing is that people will be like, there are, when someone runs, there’s five to eight times body weight on the Achilles tendon. Therefore we have to choose exercises that have five to eight times the body weight. And I’m like, well, why don’t you just run? Like if, running has that demand, the thing that should build them up like is running, but people will be like, you need to do.

These, this heavy calf loading single leg and then hopping, you need to do all these precursors before you can run. And I’m and they’ll, but they’ll justify it because of the loads during running. And I’m like, this is illogical to me.

Jimmy (44:12.213)
Mm-hmm.

Jimmy (44:16.928)
Yeah.

Jimmy (44:20.619)
But at the same time when you treat you’re still gonna do that. You’re still gonna load it. Yes.

Greg (44:23.181)
Yeah, I’ll tell you why though. So this is what, this is what I think. I think when you do those other exercises, hopping, heavy, slow loading, something like that. I don’t know, relaxation, stretching, whatever it happens to be. You build some other attribute that running doesn’t build. And somehow that has a carry over effect that helps people with their running.

Or the best example would be hamstrings strains and sprinting. The reason you can’t just play soccer to prepare your hamstrings is that when you’re playing soccer, you’re not sprinting enough at 95 % of your speed to get the best adaptations. So when you do have to sprint in soccer, you’re not ready for it.

So have to consciously add a sprinting or a Nordic program or a heavy RDL program, because the sport isn’t giving you the adaptations that you need. That would be for something like a hamstring tear. Running is different.

Jimmy (45:32.065)
So you, in a sense, so then you’re using a rehab to over prepare the tissue.

Greg (45:35.993)
That’s, that’s the idea or developing something else. This is the, this is the weird thing, like with running where people will be like, they started having less injuries when their sleep was better or something like that. Right. Or, you know, they, they were less focused on the perfectionism and getting every run in exactly as it, so something else changed. You develop some other attribute that makes someone healthy. Right.

Jimmy (45:51.713)
Mm-hmm.

Greg (46:05.709)
So did, it could be, but it’s also within exercise. That’s the idea. Like some, I call it the halo effect. You know, like I…

Jimmy (46:05.985)
outside of exercise.

Jimmy (46:10.721)
Yeah.

Jimmy (46:16.289)
And again, this is like…

We don’t know what’s happening. Yeah.

Greg (46:24.419)
That’s it. We don’t. And so I acknowledge my uncertainty and I acknowledge that I don’t know what mediates recovery. So I’m gonna add these other things to develop these other attributes just because I don’t know. All right.

Jimmy (46:33.313)
Mm-hmm.

Jimmy (46:39.681)
Okay, so then if you’re working with a runner, for instance, they tell you, so your bias is active intervention loading it, they tell you, like, I’m not gonna do any PT exercises.

Greg (46:52.239)
I say, no problem. Here’s the attributes that we think that we need that might help. Could be tendon stiffness. could be bone density. It could be variability in movement. I’ll be like, well, how about if we do this in your warmup? We’re going to add a hopping program. I’m going to get you to run backwards. You’re going to run sideways. So what are you doing if you’re running sideways? You work in the hip abductors more or something like that. If you’re hopping and you’re up on your toes or when you run, you’re normally running on your

a heel strike, can you do some form fart lex where you run on your forefoot for a while? So what are you doing there with like the bone and the Achilles and the soleus? Do know what I mean? You’re changing stuff up. We’re going to add a sprinting program if you want, right? Hills, right? now we’re, if you work back to think, well, what are the, maybe the attributes that we need to develop to help with injury or performance? I think you can get them other ways besides in the gym. And now this person who says, I’m never going in the gym. I just want to run. You’re like,

Jimmy (47:44.406)
Yeah.

Greg (47:51.001)
Can we change up your running just a little bit?

Jimmy (47:53.654)
Yeah. Or you have the opposite where it’s like you’re, I feel like this happened to me recently. I’m doing the eval and I’m think I know what I’m going to do with this person. And then I get to you like, what else do do besides running? And they list out their gym program and it’s exactly what I would have prescribed. then you’re like, shit, that was my plan. Now what do I do with this person? Right.

Greg (48:10.809)
Yeah.

Greg (48:18.169)
So I can, so this is, someone asked me before, I don’t know if you’re looking for an answer here, I’m just jumping in. Someone said, Greg, what do do for like screening, you know, for injuries? I’m like, screening’s really hard. That’s, that’s the holy grail. Like, and I, I thought about it. I’m like, cause I do do stuff. And I said, you know what I do? Like, I just never really thought of it consciously. I look in someone’s program, right? And I just say, what are they missing? Right.

Jimmy (48:20.661)
Ahem.

Jimmy (48:24.478)
I am, yes.

Greg (48:47.619)
And that’s the screen, right? What are they not getting in that program?

Jimmy (48:52.799)
So are they not wearing a belt or are they not wearing a suspenders? And then give them it.

Greg (48:57.391)
Yeah, essentially like, so in their program, often they might just be training heavy slow load. I’m like, you gotta, you gotta add a power day here. Right. You’re not doing any single leg work. Let’s do that. Or with runners, they’re usually doing 15 reps. I’m like, you gotta, you know, take more rest and do more weight. That’s what you’re missing here.

Jimmy (49:07.329)
Sure.

Jimmy (49:14.187)
Sure.

Yeah. No, that’s great. Yeah. So then with, I’m just curious here, why do you think runners get injured so frequently?

Greg (49:32.087)
so I have no idea. I think, I think everyone who pushes them, one runners are often a little older. That’d be one thing. So they’re a little bit more, more prone. have to admit that, runners who pick it up later are often like athletes from other sports, which is always an issue. So they put, probably push themselves too hard because they’re, they’re kind of fit. Right.

Jimmy (49:44.704)
Mm-hmm.

Jimmy (50:01.377)
Yep, so they have the ability to push themselves hard. Add a new sport,

Greg (50:02.185)
yeah, yeah. And that’s, that’s the big one. And, and this is, this is the check on movement optimism. I, I don’t believe everyone has the ability to run a hundred miles a week and be healthy, even if they took four years to get there. I know people don’t like to hear that. And that might surprise people coming from me because I’m all about adaptability, but I’ve also always said like it’s finite.

Jimmy (50:31.105)
Yeah, yeah, there’s a, and it’s individual, yeah.

Greg (50:31.864)
Right?

Yeah. And we don’t know what that is. that, and that, that, that, that level that people can tolerate will fluctuate over months. So sometimes you just get unlucky. Like I prefer the idea that we’re always just managing injuries with runners to keep them running.

Jimmy (50:42.966)
Yeah.

Jimmy (50:50.389)
Yeah. Which is, which can be hard when I feel like I, on my case load right now, I have a few 40 plus year old runners who seem to expect running to be a hundred percent pain free. And it’s challenging and I’m, I have my injuries and so I can like share those with them and tell them like, if I were to wait to be pain free, I wouldn’t be running ever.

Greg (51:03.995)
yeah, no way.

Jimmy (51:20.939)
probably for the rest of my life. Yeah, I feel like that’s a hard one for me to get down when they’re expecting to be 100 % pain free and it almost feels like they’re giving up if they, do you know what I’m saying? It’s like giving up. So when you’re talking to somebody like that, how do you handle that?

Greg (51:35.32)
Mm-hmm.

Greg (51:43.695)
I would always ask like what do they expect? I want to know and if they say that I’m saying there’s another way to look at this we just kind of like that that pain is unavoidable and I always kind of apologize because my I say my profession is kind of mess people up because we’ve given this message that people should be pain-free and that’s really not not true, right

Jimmy (51:54.432)
Yeah.

Jimmy (52:04.993)
And maybe you’ve also experienced years of being pain-free as a 20-year-old, right? And it’s like you expect, it’s like, I feel like a lot of, I see a lot of people who seem to have trouble like evolving as they age and accepting it in a way. And it’s like, they feel like they are giving up and there’s all this longevity talk and things like that. And I think.

Greg (52:09.284)
Yeah.

Jimmy (52:29.265)
I feel like when I talk about it, that’s my worry that I feel like I’m telling them to like give up on that.

Greg (52:35.459)
Yeah. Give up and just accept that I know. No, it’s, it’s honestly your, your, the, other way I start the course is I say, what, what’s the hardest thing, your biggest clinical challenge. And that’s mine is how do you tell people that you should have some pain sometime and that’s normal. Yeah. And, and that I, in the persistent pain world, I think there’s a subset of people where the more you fight the pain, the worse you make it. And the example.

Jimmy (52:49.855)
Yeah, and keeping it optimistic.

Greg (53:04.481)
Yeah, it’s trying to fall asleep. As soon as you want to fall asleep, you’re not falling asleep.

Jimmy (53:09.151)
Now, or like I had a long conversation with a good friend. We talked about this where it’s like when you’re trying to find a partner in life, like a girlfriend or whatever, the more you try, the less it’s happening. Yeah, it’s like, he’s like, yeah, anyways. But yeah, it’s another similar thing. And it’s like, you see these patients that are like, the other example I used to see a lot when I worked in the clinic.

Greg (53:21.968)
yeah.

Greg (53:26.862)
No, that’s it.

Jimmy (53:36.706)
like for somebody else with a like post-op total needs, you have that group that just like seemed to do everything perfectly type A, they’re doing their homework three times a day, whatever. And then those people seem to be way more likely to tighten up and need a manipulation. And it like, they were just like, like they just wanted success so badly that they were like handicapping themselves somehow. That’s an anecdote, but.

Greg (53:54.218)
interesting.

Greg (54:03.855)
Yeah. Yeah. Yeah. No, no, I’ve, I’ve, seen that stuff. So that that’s always a challenge with those people. And I just, I think you can tell them that, but they need to like join a run club and start talking to people. we need more examples of that. People need to know that it’s okay to have these niggles. You’re always going to work around them. Like, it’s funny. They brought that up. I was in bed last night. I couldn’t sleep. I was lying on my stomach and my back hurt and my back always hurts when I lie on my stomach.

Jimmy (54:21.087)
Yeah.

Greg (54:33.871)
for 25 years now. And I don’t think anything of it, because it’s always been like that. It never hurts any other time, just with back extension. And I’m like, someone who wasn’t me, what would they think about this? Like, would they think that there’s something seriously wrong with their back, that this isn’t normal?

Jimmy (54:47.041)
Sure.

Jimmy (54:50.815)
Yeah. How many mattresses would they buy?

Greg (54:54.821)
huh. I just go, I sleep with a body pillow. go on my side or I just lie on my stomach. I’m like, I don’t care. My back hurts. It’s no big deal. That’s like four out of 10. Go up to six, but I’ve always had it. I just don’t actually here right now. There, can make it hurt right now if I really arch my back, but I don’t care.

Jimmy (55:03.231)
Yeah. Yeah, yeah. Yeah.

Jimmy (55:13.385)
And so you’re saying that when you’re saying like, what would somebody else do? Because you have just accepted it and you’re saying, and you’re not freaked out by it.

Greg (55:20.033)
Mm-hmm, and I have no suffering. It doesn’t influence anything. Someone else might think, my God, I need to get this fixed. And then they focus on it and they do bird dogs and all this manual therapy work and they spend thousands of dollars and they think they’re better, but then they go to sleep one night and like, there it is still, you know, there’s something really wrong there.

Jimmy (55:37.984)
Yeah. Yeah, I think that’s that may be back to that question about like, what’s the biggest challenge as a clinician? It’s like helping people accept some of these situations. And it’s like almost so I consulted you for some HIPAA, which is pretty severe. And for me, like that diagnosis was one that I couldn’t fight. I just had to accept because there’s structural changes there. And because of the the concrete

how concrete that was, it’s easy for me to accept and just adapt around it. But when the diagnosis is more vague, maybe it’s like a lot harder to accept.

Greg (56:12.91)
Yeah.

Greg (56:17.303)
For sure, for sure. Yeah, and it’s a big challenge. And related to yours, that was always my knock on the pain science. People would be like, you have hip OA, you can have hip OA and no pain at all. So this is all in your brain. And I’m like, that’s bullshit like that. That’s not what the pain science says. It says, sure, some people can have hip OA changes and no pain.

Jimmy (56:35.135)
Yeah. Yeah.

Jimmy (56:40.339)
Yeah.

Greg (56:44.259)
but others is contributing to it and it increases your chance of having it. And I swear, if you start blaming the brain there, all the, like, you’re going to make people sort of feel like, okay, I can fix this. And then how frustrated do they get?

Jimmy (56:57.889)
That’s how, yeah, so maybe initially they’re very optimistic leaving the clinic, but then maybe you’re setting them up for failure down the road because of the expectations not being met.

Greg (57:06.083)
failure and frustration, yeah, and then suffering. This is the idea of like, if you’re really honest, like, no, no, you should have some pain in your hip. That makes sense. Okay, how can we help you cope with this? Right, you should have some pain when you’re running sometimes. Okay, how can we help you cope with this? What are your goals? Yeah.

Jimmy (57:13.003)
Mm-hmm.

Jimmy (57:18.774)
Yeah.

Yeah.

Yeah. So two things I want to end with is this concept of when we work together, you had this idea of like, you called it going nuclear. Do you remember this? Can you explain that?

Greg (57:36.975)
Yeah, yeah, kind of. I’m not sure because I do it’s when you take an extreme approach so it might be sometimes you go nuclear did we shut it down? Okay.

Jimmy (57:44.306)
Yeah. So for me was to, yeah, for, and I don’t know if you remember, but like the anxiety that that provoked in me was huge because I’m your typical compulsive exerciser and you were like, go to the gym and just get jacked in your upper body.

Greg (57:57.143)
Right. Yeah. Okay.

That’s right. That sounds like me. Okay. Yeah. Yeah. Yeah. Yeah. So that, was the issue. So that was cause I must’ve thought you were an endurance goper that we had to be like, no, no, you can’t even like do graded. You’re not elliptical. You won’t, you can’t trust yourself. No. Yeah. That’s the nuclear option.

Jimmy (58:09.13)
Yes.

Jimmy (58:16.659)
No, yeah. But it was so like, again, the anxiety that that provoked and it was extremely hard for me to do. But like in hindsight, it was the only thing, if we go back to your model of like calm things down, build things up, this was the only way for me to actually calm it down was to completely like eliminate it. And even now,

Greg (58:35.747)
Yeah. Yeah.

Jimmy (58:40.927)
Because I have this structural change. From time to time, I have to tell myself I need to go back to this, drop the bomb on it, go nuclear, shut it down, let it calm down.

Greg (58:47.631)
Yeah. So the other approach is the opposite for some people, where I like to tell people who are like really hesitant, we’re slowly building or running or whatever it is they do. I’m like, you know what though, you’re also allowed to go nuclear and just hammer it and go and do a half marathon. You know?

Jimmy (58:52.417)
Mm-hmm.

Jimmy (59:02.559)
Yeah. Yes. No, I’ve had somebody recently where that was the exact approach. And I feel like you hear all these stories. I have one personally where in college training, like fast mile, I had a bunch of like Achilles pain and I was just getting so frustrated with the pain. One day I was like, I am just going to go run as hard as I can and try to blow this thing up. And the next day I was gone.

Greg (59:26.487)
Yup.

Greg (59:32.097)
I know, I’ve heard-

Jimmy (59:32.801)
Or you see people like pre-surgery, they’re gonna get like this, I have another buddy, a hip surgery he was scheduled for. Last run, he did something like that. And then I was like, woke up, he was like, my hip feels great, canceled surgery and never, it’s been great.

Greg (59:45.903)
No, I know it. No, no, I’ve seen a ton of that. I was just telling a patient about that yesterday. Uh, I, when I was, I was away in Norway once and someone’s like, yeah, I had a patient like that, you know, five years of Achilles pain. said, screw it. And did the, was only running like five to 10 K. It was there’s runs and he did like a 80 mile rock run trail thing. And then that, that cured him. I don’t know.

Jimmy (59:48.737)
.

Jimmy (59:59.948)
Mm-hmm.

Jimmy (01:00:04.479)
Yeah. How do you explain this? Yeah. Which that’s the hard part, but I think it sounds like the first step is like deciding where they fall on this spectrum of coping strategies. Yeah. And then doing the opposite.

Greg (01:00:18.659)
Yeah, yeah. That’s the tailoring. Yeah, that’s the other rehab trick. That’s the George Costanza School of Rehab. Whatever you’re doing, do the opposite.

Jimmy (01:00:26.313)
Yes, what do you, I was going to say, yeah, nice. Yeah. Awesome. All right, Greg, I think that’s a great place to put a pin in this. You have a bunch of resources online. have your two courses that are both available online. think you’re, are you still doing the thing where you allow it as a credit towards the in-person event? Yeah.

Greg (01:00:46.315)
Yeah, I’m amazing. That’s the best thing I do ever.

Jimmy (01:00:49.845)
Well, two great, I’m going to shout outs for your course. Like both, I’ve taken both. I’ve taken your in-person one and I’ve taken both online courses and the cost is very affordable, very reasonable. feel like every PT should take these courses. where did, where can you find them?

Greg (01:01:07.119)
Yeah, just greglayman.ca. what our deal is, because I want people to go in person. I like having discussions, obviously. And so when people buy the online course, it’s like the running is like 300 bucks or something or 297. If they buy that and any in-person running course in the future, that $300 can be used as a coupon toward the in-person cost. So it doesn’t disappear. That’s the whole thing.

Jimmy (01:01:33.697)
sweet.

Greg (01:01:36.035)
And then if you do take the in-person course, you automatically get the online course as like a reference.

Jimmy (01:01:36.086)
Yeah.

Jimmy (01:01:41.521)
that’s amazing. It’s like, I love the online course model right now. And especially when you do both, because then like I’m constantly going back, pulling up a lecture, reviewing it. Yeah. Yep. There you go.

Greg (01:01:43.267)
Yeah, I know it’s what I said.

Greg (01:01:55.097)
That’s why it’s lifetime access too, my lifetime. So if I die, better go screen capture it or whatever.

Jimmy (01:02:02.175)
Nice. Download all the slides. There you go.

Greg (01:02:04.953)
Can you, yeah, I think you get those. I get the video too.

Jimmy (01:02:09.25)
Yeah. All right. So there, and then you’re on Instagram. Is it just at Greg Lehman? Yeah. And then Twitter. I think you’re pretty active on Twitter as well. Yeah. Awesome. Well, everybody go check out Greg. Thanks for joining us. And yeah, hope you have a great rest of your day.

Greg (01:02:13.549)
Yeah. Yeah.

Greg (01:02:19.523)
Yeah, there’s only seven of us now on Twitter.

Greg (01:02:30.019)
Great, thanks. Thanks everybody