E11: Reconciling Biomechanics & Pain Science

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<v Jimmy>Welcome to the Physio Insights podcast presented by Runeasi I’ll be your host, doctor Jimmy Picard. I’m a physical therapist, running coach, and team member here at Runeasi On this show, we have real conversations with leading experts, digging into how we

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recover from injuries, train smarter, and use data to better guide care. Whether you’re a clinician, coach, or an athlete, we’re here to explore what really matters in rehab and performance.

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Let’s dive in. Good morning, Greg. Welcome to the podcast. How’s your day going?

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<v Tim>It’s good. Thanks for having me.

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<v Jimmy>So I have been following you for, basically, my entire PT career. I’ve 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?

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<v Tim>Sure. So I’m a physio or a physical therapist at Toronto. I used to be a chiropractor. When I was a chiropractor, I was a researcher at the Cairo College. Before that, I did a master’s in spine biomechanics, primarily exercise biomechanics, undergrad in kinesiology.

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I still fancy my 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.

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<v Jimmy>But you’re still practicing and you’re teaching regularly. You have two online courses. And yeah, all fair we were talking about your course of reconciling pain science with biomechanics was one of the first courses I took probably ten, ten years ago. And I think that course is ten years old right now. That?

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Yes. So pretty incredible. And I remember back then I was a new grad. I had quickly become disillusioned with some of the 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 when I saw your course ten years ago, reconciling pain science with biomechanics, was really intrigued.

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Can you tell me a little bit about what prompted you to start that course?

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<v Tim>I had been teaching for forever, like, since I was in my master’s, and I was teaching at the chiropractic college when I was, you know, 24 or whatever after my master’s. And so I always like to teach, and then I 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?

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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 out of 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 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.

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Fine. I’ll, like, instead of just complaining about all these things and critiquing, I’ll show another model of of care. And and to be honest, I think I’m in the past ten years when I look on Instagram, I see that model as being accepted, and I it’s almost seems the standard now. Not the standard. Sorry.

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But, like, it’s popular.

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<v Jimmy>Yeah. It makes me wonder. Well, so it’s let’s say, like ten, fifteen years ago when I was a new grader 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.

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<v Tim>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.

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The people who were being in the pain science realized you couldn’t just throw a whole book at people. You 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 and simple interventions go a long way and you you can treat the whole person with with this type of approach.

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<v Jimmy>Yeah. So the title of your course being reconciling pain science and biomechanics.

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<v Tim>It’s reconciling biomechanics with pain science. Not that it matters, sorry.

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<v Jimmy>No. You’re fine. So, yeah, with the title though, like, are you trying to bridge the gap there? Or Yeah.

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<v Tim>Absolutely. Because that’s how I’d 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.

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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 we knew this stuff back then. Yeah. It was never meant to be siloed.

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<v Jimmy>So why why do you think like people like me coming out school where is it just the nature of, like, the the education system? Why were why was it everything still being taught the other way? Like, I graduated in 2014.

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<v Tim>So I’m the manual therapy thing has always angered me because now you have people this is this is now I’m being curmudgeon 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.

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And they say that they’re they’re leading this. And I’m like, you guys are part of the problem. You were teaching this twelve years ago, and you had no right to teach it. Yeah. You were out of date back then, and you shouldn’t have been doing it.

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And now I get angry because now now they’re acting like they’re the leaders. Like, we knew this twenty 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, not all of them well intentioned, but many of them. 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.

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<v Jimmy>Yeah. So I definitely feel like I swung very far. Do you feel like it was more balanced back, like, ten years ago, or were people swinging way far to this?

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<v Tim>That’s really hard to say. Like, I think profession wise, there there hadn’t been a massive swing to psychosoever, you know, explain pain or anything like that, whatever we call it. But individuals certainly did. So they didn’t they didn’t know what to do with their biomechanical approach. Yeah.

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So and my whole thing was no. No. No. Don’t get rid of it. Just just reframe it.

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<v Jimmy>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 gap between the two?

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<v Tim>It’s finding common threads. This is my favorite thing to do. I can’t remember if we did this ten 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 in 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 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.

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<v Jimmy>And maybe that was a little insecurity of my part by feeling judged because I wasn’t I was young, I lacked confidence. And I felt like sometimes with those clinicians who are giving fancy biomechanical explanations for why they’re having pain, it sounds very scientific, and it sounds like yeah.

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<v Tim>Yeah. You still see it now. It’s like we talked about people having a false precision, and that’s the idea. Like, no no one like, people say to me, they’ll get upset to me because they’ll say a lot of your clinical tests, you’re just doing them, and they’re not really informing your practice. Right?

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You’re gonna end 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 gonna give a calf raise. And then people are like, oh, make sure you get the foot intrinsics as well. And I’m like, well, if you do a calf raise, you’re gonna get the foot intrinsics.

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<v Jimmy>You know? Alright. So can we pause for a second? And can you explain, like, what false precision means?

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<v Tim>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 gonna see a lot of the same exercises.

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And the irony with giving recipes is most all of the research we have, they test recipes.

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<v Jimmy>Yeah. Yeah. That’s funny. Was just said that. I was just thinking it’s, herpes.

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Course.

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<v Tim>Look at all the Achilles tendinopathy research. It’s a recipe. Right? And there’s there’s there’s tailoring in there, but people hate that. People wanna think, no.

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I’m gonna 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 to the person.

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Right? Which is very biomechanical. And I my whole thing, if you remember in the course, is like, 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. Comprehensively.

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And 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 ank and the foot sorry, and the hip. That’s that’s what they all do. Yeah.

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And so but some people are like, oh, make sure 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 hallucis longus or some little muscle in the foot, and and we’re shifting the stress to the soleus.

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But if you know the biomechanics, you know that you’re really not doing that either.

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<v Jimmy>Alright. 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 and that we need to address with and if we don’t address, then they’re not gonna get better. And instead Yeah. The the alternative would be to I think you call it like the belt and suspenders model. It’s like That’s right.

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Just cover all our bases, do everything.

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<v Tim>That’s right. And then people say to me, well, Greg, you’re not tailoring it. I’m like, you kidding me? I’m just not there’s so many other ways to tailor it when you have that approach. Right?

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Because 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. Like, there’s so many different ways. And that’s what that’s what all of the research in strength and conditioning has told us. Like, there’s so many different ways to get strong and so many different ways to get hypertrophy.

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<v Jimmy>Do you think this is a problem that’s the way you just laid it out that’s unique to our profession? No. Okay. Do you see it in, like, the strength and conditioning world as well?

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<v Tim>Yeah. But they’re getting better too. They’re going through the same revolution, right, where people are, like, the whole set rep continuum.

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<v Jimmy>Right? 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.

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<v Tim>So I did a post literally eight years ago where 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 build the attributes you want, then you’re just shit. Yeah. If you think three by 10 is horrible, then you don’t know what you’re doing. Right?

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Yeah. I mean, you can also do three by seven. You know? Yeah. Be like, this is what I don’t like it.

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You’ll you’ll see strength coaches a lot in The UK for some reason who really are like, physios don’t understands understand strength and conditioning principles. And I’m like prove that because I what I’m guessing is your principles are wrong. Right? Yeah. They’re over complicating.

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They’ll be like, you did three sets of 10 And that if you listen to Stu Phillips or all the systematic reviews there, that’s true if you wanna get say it’s your bench press. You know, I get stronger on the bench press. Then you should be training 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 nonspecific chest movements, both of those set rep approaches will get you equally strong.

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You just get stronger at the, excuse me, at the specific task.

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<v Jimmy>You can do both

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<v Tim>is what I’m saying.

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<v Jimmy>Yeah. And then is there more of a would you almost break it up into, like, kinda 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?

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<v Tim>I think for performance, you need more to be more specific, but even that has a lot of leeway. That’s what I’m saying. You 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

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<v Jimmy>But what if if the if the task or the the event you’re training for is one rep max?

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<v Tim>Of course. Yeah. Then you if you’re a power lifter, you need to deadlift. Yeah.

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<v Jimmy>And lower reps is what you’re more specific to the task. Yeah.

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<v Tim>Of course. Yeah.

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<v Jimmy>So is there are there other areas within our profession that you see this false precision being prevalent and problematic?

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<v Tim>I 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

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<v Jimmy>Mhmm.

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<v Tim>With quant

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<v Jimmy>Like, quant

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<v Tim>quantifying. Quantifying it, which I which is weird because, again, I my master’s was in 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

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<v Jimmy>Well, now it’s more accessible. Can buy a dynamometer for a couple $100. Right?

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<v Tim>Yeah. I had a BTE system like it.

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<v Jimmy>And do you see what do you see the problem is there? Just

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<v Tim>The problem would be it’s not inherently a problem. I don’t wanna say it’s bad. It’s 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 from now. You just gotta keep practicing, and then it’s really important.

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It’s the elevating it as being superior when it’s not. You can absolutely do do strength testing and for force testing. And I kinda I I like it for, just gamifying it, and it’s fun, and people can see that stuff. But you can also people be like, oh, how do you know they’re getting stronger? I’m like, you serious?

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Because you just bench press more weight. Like, what the fuck? So it is a bit weird, but it doesn’t it doesn’t tell you what to address.

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<v Jimmy>Sure.

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<v Tim>That’s the thing. I had this debate online where someone’s like, oh, the they have a foot issue, and they’re like, hey. The hip is involved with with the foot. I’m like, yeah. No shit.

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That’s a truism. You you didn’t say anything. So I always make sure that I check the hip. And I’m like, are you checking the hip for? Range of motion or strength.

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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 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 they were at the norm.

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That’s the false sense of precision.

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<v Jimmy>So in that case, you would say, if it if they didn’t present with the deficit, we’re not gonna do anything about it, but they may still benefit from doing something.

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<v Tim>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. Mhmm. Because who cares if like, look at it this way. If you start strength training, your strength is gonna increase 20 to 30% in three weeks.

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Does that mean the joint is actually stronger, quote unquote, that it’s more resilient and can handle more stress? No. You’ve just learned how to, like, rate code and recruit your muscles better.

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<v Jimmy>Sure.

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<v Tim>Right? It’s it’s it’s so you can still benefit from the strength training. So I wouldn’t toss it out so quickly.

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<v Jimmy>So this goes back to treating comprehensively. And what if if the patient tells you like, hey. I can only do I only have I’m only gonna do five minutes of exercise. Are you gonna then be more specific or do you think it matters to

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<v Tim>So this is my favorite question. Because anytime someone like me says we can be kinda general, you always wanna say, well, okay. Let’s check that bias. And when when do we actually need to be specific?

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<v Jimmy>Yeah. Think start most of your courses

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<v Tim>start my courses with with Yeah. 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 soccer. That seems to be some and and that’s like a specific deficit that seems to be associated with future injury.

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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? Another one would be fear.

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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 even though there’s spine flexion during a squat.

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<v Jimmy>Great. Alright. So there’s a there’s a time and a place for being specific. And maybe another example in the running world, like a bone stress injury.

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<v Tim>Yeah. So that is actually my favorite topic because that that’s the debate of, if we want people to run, we 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?

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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.

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<v Jimmy>Mhmm.

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<v Tim>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 him.

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<v Jimmy>Chris was on the podcast as well. It hasn’t been released yet, but his his his episode’s coming out. But yeah. So 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?

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Did you?

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<v Tim>Yeah. Yeah. Yeah.

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<v Jimmy>Because we’ve we’ve jumped into, like, maybe a prescription there in a sense where it’s like

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<v Tim>This is like old school. So, you know, in in the mid two thousands, the Silbernigo research said with tendinopathy, you can keep doing the tasks that you love, 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 the pain gets a seat at the table, but it’s not the CEO.

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It’s in the car. It’s not driving a car. So for some reason, the bones 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 edema in their feet without pain? How often do we see some sort of a bone stress injury reaction in there and and no pain? So we do know that the correlation isn’t that great.

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And so what we’ve kind of done is is said, no, pain is the best guide here. And I would say it’s probably because the risk, like, is so much greater. So then you have people like like me who are questioning this, and then you have colleagues of mine at the running, clinic like JF Esculier and Blaise Dubois who’ve been teaching for ten years. Like, if it’s a low risk stress fracture, you can load it and treat it like a tendinopathy.

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<v Jimmy>And load it with some running.

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<v Tim>Some running. Even with the hurts. And so what Steph talked about was a military paper where that’s what they did in lower stress fractures. 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.

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<v Jimmy>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’s what’s the what are the potential downsides you see of that approach?

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<v Tim>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 the big assumption with our 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 you’ll you’ll be antinociceptive, and you’ll you’ll modulate at 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.

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I’ve had a few people through the years who have sort of this bony type pain and they 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 instead it’s healed. Yeah. Was like, and they got better. And so

00:22:29.265 –> 00:22:30.625
<v Jimmy>it’s I’m thinking of a It’s

00:22:30.625 –> 00:22:32.145
<v Tim>hard. It’s hard. I’m not saying this is easy.

00:22:32.620 –> 00:22:49.715
<v Jimmy>I’m thinking of a patient I have currently with just a tibial stress fracture. Stress yeah. Stress fracture stress reaction. And we I followed the the approach of zero pain and talked to her about that. And she’s definitely developed some like hyper vigilance around this.

00:22:49.715 –> 00:23:12.450
Some like 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 try to run. She’s experiencing symptoms that are freaking her out and she’s it’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. I didn’t.

00:23:12.930 –> 00:23:33.800
I probably did the Tampa passing scale. I can’t remember where your 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 by stressing zero out of 10 pain, have I, like, set her up for this path of just being, like, hypervigilant?

00:23:34.120 –> 00:23:42.360
<v Tim>Yeah. It it’s possible. It’s 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.

00:23:42.795 –> 00:23:55.195
Mhmm. Where where do we think the source of nociception is? I’m pretty sure if you look at like Tissue? Well, xenovitis, but there’s also like some bony edema perhaps. That’s a that’s a what’s his name?

00:23:55.195 –> 00:23:59.580
The Dye’s research. Right? There’s actually the bone that gets sensitized.

00:23:59.740 –> 00:24:00.380
<v Jimmy>Interesting.

00:24:00.380 –> 00:24:10.455
<v Tim>And so we nudge into kneecap pain. Although 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. Yeah.

00:24:10.695 –> 00:24:11.015
<v Jimmy>But that

00:24:11.015 –> 00:24:12.695
<v Tim>was like 11 ago. Yeah.

00:24:12.695 –> 00:24:14.375
<v Jimmy>Time flies. Yeah. Okay.

00:24:14.455 –> 00:24:29.730
<v Tim>But you know what? Remember with her paper, I don’t know if that her it doesn’t matter. That was only where there was a decrease in pain at four weeks at eight and twelve. There’s no difference. So just so people know this paper, both groups end up doing hip and knee exercises after four weeks.

00:24:29.890 –> 00:24:44.745
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 twelve weeks in the long term, it didn’t matter. Is that what you recall from?

00:24:44.745 –> 00:24:50.585
<v Jimmy>Yeah. That’s the one. Yeah. Yeah. But then like, I guess clinically, you’ll see like, it just makes sense a lot of times.

00:24:50.585 –> 00:24:57.250
Somebody’s just super reactive and you don’t want to load the knee if it’s right there. The symptoms are so high.

00:24:57.490 –> 00:25:11.865
<v Tim>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 basing on a tissue. Perhaps the other way to let something guide your treatment is, well, are they an endurance coker? Right?

00:25:11.865 –> 00:25:23.625
That’s why things are so jacked up. So they’ve already tried to push, to push, to push and they haven’t, and they haven’t taken any time off. So it’s your pain that then helps guide what you’re going to do.

00:25:23.690 –> 00:25:35.290
<v Jimmy>I was just going say, it’s funny you bring that up because that is the patient I had in mind that I was thinking about was this endurance coper and any, like, we tried to load her knee, it was just blowing up because she had already been doing that.

00:25:35.450 –> 00:25:42.815
<v Tim>Yeah. And then your other patient is an avoidance coper. Right? And you say, no, no, no more you’re avoiding, the more sensitizing you get. So we got it.

00:25:42.815 –> 00:25:52.015
We have to start loading it here. We can’t fully trust what you’re feeling here. Yes. So there’s it. And then, and again, the tissues like, it’s going to give you a little bit.

00:25:52.630 –> 00:26:10.325
I don’t want to say it’s totally irrelevant, but this is another idea of people getting mad at me because they’ll misrepresent what I say when diagnosis, I’ll say diagnosis doesn’t matter that much. And I’d say for the vast majority of things, doesn’t provided they’re safe. Yeah. That’s what a diagnosis. I believe that a proper diagnosis is the tissue.

00:26:10.565 –> 00:26:21.820
Like saying, telling someone there’s spinal flexion intolerant is not a diagnosis. That’s bullshit. No, no shit. It’s like you could have knee pain be like, oh, I’m knee flexion intolerant. Sure.

00:26:21.820 –> 00:26:50.370
That’s not a diagnosis. But I still wanna know you wanna know the serious stuff. So like with knee pain, I don’t know if I did this in the course, but I don’t do this anymore. I 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.

00:26:50.370 –> 00:26:59.810
<v Jimmy>Where alright. So in those cases, you 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?

00:26:59.890 –> 00:27:04.495
<v Tim>So I how I like to practice is I like local load

00:27:04.735 –> 00:27:05.055
<v Jimmy>Mhmm.

00:27:05.055 –> 00:27:25.150
<v Tim>And distal load around it. So I 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.

00:27:25.150 –> 00:27:25.390
<v Jimmy>Sure.

00:27:25.815 –> 00:27:32.775
<v Tim>Even though I know the research isn’t strongly supportive of it. Yeah. I still can’t say it isn’t, so I do it.

00:27:32.855 –> 00:27:52.060
<v Jimmy>So in that case, like, my bias, 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 Yeah. Double leg movement, single leg movement, and injury is.

00:27:52.465 –> 00:28:02.865
<v Tim>That’s belts and suspenders. That’s comprehensive capacity. That’s treating above and below and at and at local. Local and regional and then global, which is running or whatever it happens to be your volleyball.

00:28:02.865 –> 00:28:26.345
<v Jimmy>Sure. Yeah. I’d like to take a moment to thank our sponsor, Runeasi. Runeasi is a running and jumping analysis tool that helps provide objective data on things like impact loading, dynamic stability, and symmetry. I’ve been using it in the clinic for the past three years and I love how easy it is to add to my evaluations.

00:28:26.665 –> 00:28:56.955
Not only that, but it backs up my clinical reasoning and helps me with my decision making process when I’m doing exercise prescription. So if you’re a physical therapist or running coach, head on over to runeasi.ai and book a demo. If you’re lucky, it will be with me. The way that you’re describing practicing and that I just did, there’s, like, a lot of acceptance, a lot of uncertainty. How do you feel how do you feel like we, as a profession, handle uncertainty?

00:28:57.195 –> 00:29:16.625
<v Tim>Not well, like like, consciously, But I think subconsciously, we do it okay. We end up because the way I Elaborate. So here’s the idea. Like, Achilles tendinopathy, I would argue I I think I give exercises that try to increase the stiffness of the Achilles tendon. That’s what I do.

00:29:16.865 –> 00:29:50.735
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 is 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.

00:29:50.735 –> 00:30:09.985
So I wanna make sure I cover them because there’s no risk in 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.

00:30:09.985 –> 00:30:12.305
But there might be a small subset who need it.

00:30:12.465 –> 00:30:12.945
<v Jimmy>Sure.

00:30:12.945 –> 00:30:19.265
<v Tim>Okay. So that’s how we handle it. We we just if it’s not harmful and and it has secondary benefits, we treat comprehensively.

00:30:20.065 –> 00:30:22.065
<v Jimmy>And that’s how we deal with uncertainty?

00:30:22.065 –> 00:30:22.305
<v Tim>Yeah.

00:30:22.890 –> 00:30:44.545
<v Jimmy>And that includes uncertainty with diagnosis and uncertainty because we really don’t know with the diagnosis per se. We’re kind of guessing, but it’s our best guess. People don’t like that word guess, but it’s our hypothesis. And then we’re also unsure with like how this individual is going to respond to what we give them.

00:30:44.705 –> 00:30:53.520
<v Tim>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, it doesn’t matter. We take care of all of that.

00:30:53.520 –> 00:31:05.280
<v Jimmy>Okay. So that’s how you explain it. Because I feel like sometimes when I’m when I’m working with the patient, I there’s a little bit of insecurity on my part that that presents like a lack of confidence to the patient.

00:31:05.360 –> 00:31:16.375
<v Tim>So so you need to develop arrogant ignorance. Because I’ll say that to people and I’ll say, you know what? You might go somewhere else and they’re gonna 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.

00:31:16.375 –> 00:31:17.175
<v Jimmy>No. Yeah.

00:31:17.175 –> 00:31:17.415
<v Tim>You get

00:31:17.415 –> 00:31:26.460
<v Jimmy>certain subsets of clinicians who yeah. Very specific. I’m thinking of even, like, dry needling and things like this. Yeah.

00:31:26.460 –> 00:31:27.020
<v Tim>False precision.

00:31:27.020 –> 00:31:44.865
<v Jimmy>At times, I especially in the running world where they want runners want a fix. They want a quick fix, and they often put up a little fight about, hey. 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.

00:31:45.290 –> 00:32:14.915
<v Tim>I would this is 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. And so I would not be I would it’s okay to do manual therapy for these patients.

00:32:15.510 –> 00:32:23.910
<v Jimmy>Sure. Where if I had to nail you down for, like is is there a negative component to or could there be a potential Of course.

00:32:23.910 –> 00:32:25.750
<v Tim>But the it’s all in your narrative.

00:32:25.830 –> 00:32:26.870
<v Jimmy>That’s what I mean. Yeah.

00:32:26.870 –> 00:32:53.390
<v Tim>I So always worked in manual therapy clinics, which was ton of they’re all chiro’s and physios that did that. Long sessions. And and and what was great, I’m just thinking of the good people there, is they’re always like, oh, we’re gonna do this manual therapy, and you have to do this three k run today, and tomorrow you’re gonna run six k. There was always wicked load management. You know, the only reason we’re doing the manual therapy is just to calm stuff down to keep you doing your race.

00:32:53.390 –> 00:32:59.085
It was never like, you’re gonna do manual therapy, but now just shut it down. Don’t do anything. There’s always like

00:32:59.245 –> 00:33:14.970
<v Jimmy>And and also the explanation, you’re so the explanation you can potentially tell the patient goes whatever way you wanna take it, about what you’re Yeah. The way you just described it, like, weren’t telling them you’re releasing this or you’re do you’re correcting that or

00:33:15.450 –> 00:33:38.600
<v Tim>I mean, I would probably have colleagues that that would say there’s, like, some adhesions or we’re getting the muscles to function better. I never really agreed with that stuff. But 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 in a muscle, and I don’t I think that’s wrong, but it doesn’t really harm them.

00:33:38.600 –> 00:33:45.560
They’re like, oh, 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.

00:33:45.560 –> 00:34:00.095
I wouldn’t tell people to do it, but I also have, like, faith in people’s, you know, psychological resiliency sometimes. But then there’s a small set of people who are totally fucked up because they think that they have all these knots. Sure. Again, I don’t that’s why I don’t do it.

00:34:00.095 –> 00:34:22.280
<v Jimmy>Do you yeah. And I feel like, be I’ve I’ve practiced at, like, just me in a solo clinic, and I maybe see more of the who are getting second opinions, or they’ve seen a bunch of people. So I maybe I’m seeing a subset of the those of the patients who have been maybe hurt by that kind of language. Yeah. So then it’s made me swing the other way where I think I dry needled like three people and then stopped.

00:34:22.655 –> 00:34:35.695
I just couldn’t I couldn’t I don’t it was just it didn’t fit with the way. I I 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?

00:34:35.695 –> 00:34:40.450
<v Tim>Yeah. I know. I spent $6,000 on an acupuncture course too.

00:34:40.530 –> 00:34:54.655
<v Jimmy>Nice. Do you think you think there are people like, if you reflect on your caseload, like, are there patients where if they they needed something like that that you didn’t do, like a passive intervention, intervention, then they wouldn’t get gotten or they didn’t get better because you didn’t do that.

00:34:54.975 –> 00:35:08.150
<v Tim>No. I think because I’m in the same case as you. People are coming to me for second I’ve 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 I’ll tell them I’m not the right one for them.

00:35:08.150 –> 00:35:09.110
<v Jimmy>Sure. Yeah.

00:35:09.110 –> 00:35:19.030
<v Tim>Yeah. But my my whole point is, like, like, not everyone wants to be active. They just wanna be taken care of. Mhmm. And I get that.

00:35:19.030 –> 00:35:49.770
So if you have neoA and if we look at the research on manual therapy in knee OA, it is just as good as exercise in knee OA. And you have people who do not want to exercise and they just won’t do it, but they just wanna have less pain and do more things with their dog or their family. Yeah. And if manual therapy can do that for them, who am I to say it’s it’s wrong? I find our profession is even with researchers who shouldn’t be driven by bias, I think our clinical practice guidelines are so incredibly biased.

00:35:50.275 –> 00:35:51.395
Wanna hear an example?

00:35:51.475 –> 00:35:52.595
<v Jimmy>Yes, please.

00:35:52.835 –> 00:36:17.750
<v Tim>So, I think this is the new this is the Achilles clinical practice guideline that that came out. I think it was Ciminetti who wrote it. They 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. They didn’t talk about acupuncture in the clinical practice guideline.

00:36:17.750 –> 00:36:33.760
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 kinda chose, like, what to discuss.

00:36:34.080 –> 00:36:41.280
<v Jimmy>So alright. So they Very leading. So it sounds like if ten years ago, what do you think that paper would have done with that?

00:36:41.280 –> 00:36:42.080
<v Tim>Same thing.

00:36:42.080 –> 00:36:43.600
<v Jimmy>It would have biased exercise.

00:36:43.600 –> 00:36:56.455
<v Tim>Think and I could I feel like he was probably herding 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 wanna get their bias in there.

00:36:56.535 –> 00:37:00.935
<v Jimmy>Sure. And is that just natural human tendency to be biased, or what do you think that is there?

00:37:01.640 –> 00:37:19.255
<v Tim>Well, if you’re a researcher and you’ve dedicated twenty years of your life to, like, faulty movement patterns Mhmm. And you keep like Irene Davis and you keep using that word, you’re gonna wanna promote your stuff. And you believe it as well. Like, I don’t think that these people are there’s poor intentions. Yeah.

00:37:19.255 –> 00:37:25.255
That’s part, like, part of being a researcher is knowledge translation. You should be out there promoting it.

00:37:25.255 –> 00:37:27.575
<v Jimmy>And so you’re you’re really good. Yeah. You are

00:37:27.815 –> 00:37:29.015
<v Tim>going all over the place here? Yeah.

00:37:29.650 –> 00:37:48.565
<v Jimmy>I would I was going to say I was just like questioning assumptions and you’re constantly like calling people out or like at least challenging things recently as you put the one on like Achilles load or I think it was Achilles load, different tasks like how much do we need to be this specific? What why do you why do you challenge people like that?

00:37:48.565 –> 00:38:00.920
<v Tim>I challenge myself first. I wanna 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.

00:38:00.920 –> 00:38:01.480
<v Jimmy>Yeah.

00:38:01.720 –> 00:38:15.465
<v Tim>I don’t care. I’m not gonna go argue with some whack job doing something that’s absurd. I’m gonna argue with people who practice very similar to my style Yeah. To almost fine tune what I’m doing.

00:38:15.865 –> 00:38:19.065
<v Jimmy>So it’s so it’s a way to challenge yourself in a way. Yeah.

00:38:19.065 –> 00:38:46.555
<v Tim>So I think what what you might have 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 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.

00:38:46.555 –> 00:38:48.795
You need to do all these precursors before you can run.

00:38:49.150 –> 00:38:49.710
<v Jimmy>Mhmm. I’m

00:38:49.710 –> 00:38:51.870
<v Tim>like, this is illogical to me.

00:38:52.350 –> 00:38:55.390
<v Jimmy>But at the same time, when you treat, you’re still gonna do that.

00:38:55.630 –> 00:39:23.930
<v Tim>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 carryover effect that helps people with their running. Or the best example would be would be hamstrings strains and and sprinting.

00:39:23.930 –> 00:39:54.440
Right? The the 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 you 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 that you need. That’s that would be for something like a a hamstring tear.

00:39:54.440 –> 00:40:17.780
Running is different. 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 they something else changed.

00:40:17.780 –> 00:40:21.540
You develop some other attribute that makes someone healthy. Right?

00:40:21.620 –> 00:40:22.900
<v Jimmy>Outside of exercise.

00:40:22.900 –> 00:40:29.485
<v Tim>It could be, but that’s also within exercise. That that that’s the idea. Like, some I call it the halo effect.

00:40:29.485 –> 00:40:33.725
<v Jimmy>And that again, this is like a we don’t know what’s happening. Yeah.

00:40:33.725 –> 00:40:46.880
<v Tim>We don’t. And so I acknowledge my uncertainty, and I acknowledge that I don’t know what mediates recovery. Mhmm. So I’m gonna add these other things to develop these other attributes just because I don’t know.

00:40:46.960 –> 00:40:57.645
<v Jimmy>So then if you’re working with a runner, for instance, and they tell you so your bias is active intervention loading it. They tell you, like, I’m not I’m not gonna do any PT exercises.

00:40:57.965 –> 00:41:12.400
<v Tim>I say, no problem. Here’s the attributes that we think that we need that might help. Could be tendon stiffness. It could be bone density. It could be variability in in movement, I’ll be like, well, how about if we do this in your warm up?

00:41:12.400 –> 00:41:21.845
We’re gonna add a hopping program. I’m gonna get you to run backwards. You’re gonna run sideways. What are you doing if you’re running sideways? You work in the hip abductors more or something like that.

00:41:21.845 –> 00:41:37.380
If you’re hopping and you’re up on your toes or when you run, you’re normally running on your heel strike. Can you do some form fart legs 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 you know what I mean? You’re you’re changing stuff up.

00:41:37.460 –> 00:41:48.495
We’re gonna add a sprinting program if you want. Right? Hills. Right. So now so 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?

00:41:48.735 –> 00:41:57.695
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 wanna run. You’re like, can we change up your running just a little bit?

00:41:57.695 –> 00:42:14.860
<v Jimmy>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 thinking I know what I’m gonna do with this person. And then I get to you like, what else do you do besides running? And they list out their gym program, and it’s exactly what I would have prescribed.

00:42:16.005 –> 00:42:19.925
You’re So like, oh shit. That was my plan. Now what do I do with this person?

00:42:20.165 –> 00:42:32.740
<v Tim>So I can so this is someone said, Greg, what do you do for like screening, you know, for injuries? I’m like, oh, screening is really hard. That’s that’s the holy grail. Like I and I thought about it. I’m like, because I do do stuff.

00:42:32.740 –> 00:42:41.300
And I 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?

00:42:42.145 –> 00:42:47.825
Right? And that’s the screen. Right? What are what are they not getting in that that program?

00:42:47.825 –> 00:42:53.185
<v Jimmy>So are they are they not wearing a belt, or are they not wearing a suspenders? And then give them it.

00:42:53.585 –> 00:43:01.630
<v Tim>Yeah. Essentially. Like and 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.

00:43:01.710 –> 00:43:02.670
<v Jimmy>Sure. Sure.

00:43:02.990 –> 00:43:05.790
<v Tim>Take more rest and do more weight. That’s what you’re missing here.

00:43:08.055 –> 00:43:14.215
<v Jimmy>No. That’s great. Yeah. So then with I’m just curious here. Why do you think runners get injured so frequently?

00:43:14.215 –> 00:43:21.815
<v Tim>So I have no idea. I think I think everyone who pushes them runners are often a little older.

00:43:21.895 –> 00:43:22.215
<v Jimmy>Mhmm.

00:43:22.215 –> 00:43:35.150
<v Tim>That’d be one thing. So they’re a little bit more more prone. We 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.

00:43:35.565 –> 00:43:56.440
And that’s that’s the big one. And and this is this is the check on movement optimism. I don’t believe everyone has the ability to run a 100 miles a week and be healthy even if they took four years to get there. I hope you would 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.

00:43:56.760 –> 00:43:59.160
<v Jimmy>Yeah. Yeah. There’s a and it’s individual. Yeah.

00:43:59.160 –> 00:44:13.695
<v Tim>And we don’t know what that is, and that and that that that that level that people can tolerate will fluctuate over months. Yeah. So sometimes you just get unlucky. Like, I prefer the idea that we’re always just managing injuries with runners

00:44:14.095 –> 00:44:14.335
<v Jimmy>Yeah.

00:44:15.030 –> 00:44:15.830
<v Tim>To keep them running.

00:44:15.830 –> 00:44:26.630
<v Jimmy>Which is which can be hard when I feel like, on my caseload right now, I have a few 40 year old runners who seem to expect running to be a 100% pain free.

00:44:27.425 –> 00:44:28.625
<v Tim>Oh, yeah. No way.

00:44:29.105 –> 00:44:52.930
<v Jimmy>It’s challenging, and 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, probably for the rest of my life. I feel like that’s a hard one for me to get down when they’re expecting to be 100% pain free. It almost feels like they’re giving up if they do you know what I’m saying? Like Mhmm. It’s giving up.

00:44:52.930 –> 00:44:55.730
So when you’re talking to somebody like that, how do you handle that?

00:44:56.235 –> 00:45:16.740
<v Tim>I would always ask, like, what do they expect? I wanna know. And if they say that, I’m saying there’s another way to look at this. We just kinda like, that that pain is unavoidable. And I always kind of apologize because my I say my profession has kinda people up because we’ve given this message that people should be pain free, and that’s really not not true.

00:45:16.740 –> 00:45:36.605
<v Jimmy>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 I feel like it when I talk about it, that’s my worry that I feel like I’m telling them to, like, oh, give up on that.

00:45:37.010 –> 00:45:46.130
<v Tim>Yeah. Give up and just accept that. I know. No. It’s it’s honestly you’re you’re the the other way I start the course is I say, what what’s the hardest thing, your biggest clinical challenge?

00:45:46.130 –> 00:46:04.905
And that’s mine. It’s how do you tell people that you should have some pain sometime? I, in the persistent pain world, I I think there’s a subset of people where the more you fight the pain, the worse you make it. And the the example, yeah, is trying to fall asleep. As soon as you wanna fall asleep, you’re not falling asleep.

00:46:05.250 –> 00:46:40.720
<v Jimmy>Now or like, I had a long conversation with a good friend and we talked about this where it’s like when you’re trying to find a partner in life, like a a girlfriend or whatever, the more you try, the less it’s happening. But, yeah, it’s another similar thing. And it’s like, see these patients that are like, the other example I used to see a lot when I worked in the clinic, like for somebody else with a post op total needs. You have that group that just like seem 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 in need of manipulation.

00:46:40.880 –> 00:46:50.735
It’s like they were just like like they just wanted success so badly that they were like handicapping themselves somehow. That’s anecdote. But Yeah.

00:46:50.895 –> 00:47:00.495
<v Tim>No. No. I’ve I’ve seen that stuff. So that that’s always a challenge with those people. And I I just I think you can tell them that, but they need to, like, join a run club and start talking to people.

00:47:00.495 –> 00:47:08.960
We need more examples of that. People need to know that it’s okay to have these niggles. You’re always gonna work around them. Like, it’s funny they brought that up. I was in bed last night.

00:47:08.960 –> 00:47:23.345
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 for twenty five years now. I don’t think anything of it because it’s always been like that. It never hurts any other time just with back extension.

00:47:23.345 –> 00:47:29.825
And I’m like, someone who wasn’t me, what would they think about this? Like, with that this isn’t normal?

00:47:29.825 –> 00:47:31.425
<v Jimmy>How many mattresses would they buy?

00:47:31.870 –> 00:47:40.110
<v Tim>I just go I sleep with a body pillow. I 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.

00:47:40.270 –> 00:47:47.905
That’s like four out of 10. Can go up to six. Yeah. But I’ve always had it. I just don’t actually hear right now.

00:47:47.905 –> 00:47:50.465
There, I can make it hurt right now if I really arch my back.

00:47:50.465 –> 00:47:53.905
<v Jimmy>And so are you you’re not care when you’re not freaked out by it.

00:47:53.905 –> 00:48:10.320
<v Tim>And I have no suffering. It doesn’t influence anything. Someone else might think, oh 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, oh, there it is still.

00:48:10.480 –> 00:48:12.240
You know? Yeah. There’s something really wrong there.

00:48:12.715 –> 00:48:28.640
<v Jimmy>Yeah. Think that’s that made me 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 I consulted you for some HIPAA I have, which is pretty severe. And for me, like, that diagnosis was one that I couldn’t fight.

00:48:28.640 –> 00:48:45.065
I just had to accept because there’s structural changes there. And because of 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.

00:48:45.065 –> 00:48:53.865
<v Tim>For sure. Yeah. And it’s a big challenge. Again, and related to yours, that that’s that was always my knock on the pain science. People will be like, you have hip OA.

00:48:53.865 –> 00:48:59.550
You can have hip OA and no pain at all. So this is all in your brain. And I’m like Yeah. That’s bullshit like that. Yeah.

00:48:59.550 –> 00:49:15.655
That’s not not what the pain science says. Yeah. Sure. Some people can have hip OA changes and no pain, but others, it’s 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 gonna make people sort of feel like, okay.

00:49:15.655 –> 00:49:18.935
I can fix this. And then how frustrated do do they get?

00:49:19.175 –> 00:49:27.800
<v Jimmy>That’s all. 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 that Failure

00:49:27.800 –> 00:49:32.920
<v Tim>and frustration. Okay. How how can we help you cope with this? Yeah. Okay.

00:49:32.920 –> 00:49:36.200
How can we help you cope with this? What are your goals?

00:49:36.360 –> 00:49:47.245
<v Jimmy>Yeah. So two things I wanna end with is this con concept of when we work together, you had this idea of like, you called it going nuclear. Do you remember this?

00:49:47.405 –> 00:49:48.765
<v Tim>Yeah. Yeah. Kind of.

00:49:48.765 –> 00:49:59.830
<v Jimmy>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, god.

00:49:59.830 –> 00:50:04.310
<v Tim>Yeah. Yeah. That we we had to be like, no. No. You can’t even, like, do graded.

00:50:04.310 –> 00:50:07.510
You’re not elliptical. You won’t you can’t trust yourself.

00:50:07.915 –> 00:50:14.395
<v Jimmy>No. Yeah. No. Yeah. It was so again, the anxiety that that provoked and it was extremely hard for me to do.

00:50:14.395 –> 00:50:24.770
But I like, in hindsight, it was the only thing if we go back to your your model of, calm things down, build things up. So the only way for me to actually calm it down was

00:50:25.010 –> 00:50:25.250
<v Tim>Yeah.

00:50:25.410 –> 00:50:37.650
<v Jimmy>To completely, like, eliminate it. And even now, because I have the structural change, like, from time to time, I have to, like, tell myself I need to go back to this, like, drop a bomb on it, go nuclear, shut it down, let it calm down.

00:50:38.185 –> 00:50:54.630
<v Tim>So there the other approach is the opposite for some people Mhmm. Where I like to tell people who are, like, really hesitant, we’re slowly building their 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. Yes.

00:50:54.630 –> 00:50:55.030
You know?

00:50:55.030 –> 00:51:08.310
<v Jimmy>No. I’ve I’ve I’ve had somebody, yeah, recently where that was the exact approach. And I feel like you you hear all these stories. I have one personally where in college training, like, fast mile. I was I had a bunch of, like, Achilles pain.

00:51:08.310 –> 00:51:19.345
And I was just getting so frustrated with the pain. One day I was like, I am just gonna go run as hard as I can and try to blow this thing up and the next day I was gone.

00:51:19.345 –> 00:51:20.225
<v Tim>I know. I’ve heard Or

00:51:20.225 –> 00:51:30.880
<v Jimmy>you see people like pre surgery, they’re gonna get like this. I have another buddy, a hip surgery he was gonna scheduled for. Last run, he did something like that. And then was like, woke up. He was like, my hip feels great.

00:51:30.880 –> 00:51:32.960
Canceled surgery and never it’s been great.

00:51:33.040 –> 00:51:35.360
<v Tim>No. I know it. No. No. I’ve seen a ton of that.

00:51:35.360 –> 00:51:46.975
I was just telling a patient about that yesterday. I I went I was I was away in Norway once and someone’s like, The patient like that, you know, five years of Achilles pain. He said, screw it and did the it was only running like five to 10 k.

00:51:47.055 –> 00:51:47.455
<v Jimmy>Mhmm. It was

00:51:47.455 –> 00:51:50.735
<v Tim>a real thing. And then that that cured him.

00:51:50.895 –> 00:52:02.630
<v Jimmy>How do you explain this? Yeah. But that’s the hard part, but I think it sounds like the first step is like deciding where where they fall on this spectrum of coping strategies. Yeah. Doing the opposite.

00:52:02.790 –> 00:52:05.270
<v Tim>Yeah. That’s that’s the other rehab trick.

00:52:05.825 –> 00:52:15.905
<v Jimmy>Awesome. Alright, Greg. I think that’s a great place to put a pin in this. You have a bunch of resources online. You have your two courses that are both available online.

00:52:15.985 –> 00:52:19.300
I think you’re are you still doing the thing where you allow it as a credit towards

00:52:19.620 –> 00:52:22.660
<v Tim>Yeah. I’m amazing. That’s the best thing I do ever.

00:52:22.900 –> 00:52:36.205
<v Jimmy>Well, two great I mean, two shout outs for your course. Like, 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. I feel like every PT should take these courses.

00:52:36.205 –> 00:52:37.565
Where where can you find them?

00:52:37.725 –> 00:52:53.520
<v Tim>Yeah. Just greg lehman dot c a. And what our deal is because I I I want people to go in person. I like I like having discussions, obviously. And so when people buy the online course, if it it’s like the running is like $300 or something or $2.97.

00:52:53.760 –> 00:53:08.105
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 and then if you do take the in person course, you automatically get the online course as like a reference.

00:53:08.425 –> 00:53:13.385
<v Jimmy>Alright. So there and then and you’re on Instagram. Is it just that greg leeman? Yeah. Yeah.

00:53:13.385 –> 00:53:21.760
And then Twitter. I think you’re pretty active on Twitter as well. Well, everybody go check out Greg. Thanks for joining us. And yeah, hope you have a great rest of your day.

00:53:21.760 –> 00:53:23.600
<v Tim>Great. Thanks. Thanks, everybody.

00:53:28.480 –> 00:53:41.945
<v Jimmy>That’s it for today on the Physio Insights podcast presented by Runeasi. Would you like to share an interesting case, insight, or have a thought about the podcast? Comment below, and don’t forget to follow us for more episodes.