[00:00:03] Nick: We always fail to look at the whole picture as a as a professional really. And that's just specifically there, but I think we see it in other healthcare fields too that everyone's kind of got this myopic view based on how they were trained based on.
[00:00:29] PODCAST INTRO: Welcome to “In The RACK” podcast, where we provide you with the practical framework for breaking PRs in all facets of health and wellness. We are just a couple of bros giving you the simple house in a world of complex wants. No filters, no scripts, no rules, just straight talk, talk tune. Now, let's get into the rack with your hosts, Dr. Chad and Dr. Nick.
[00:00:55] Chad: Alright, everyone. Welcome to another episode of “In The RACK” podcast. I'm not going to say the episode numbers now anymore, because it's getting lengthy. And we're up there. So I'm your host, Chad. And with me is my co-host and fellow physical therapist, Nick. You guys know what time it is, it's time to get a little “Reckless In The RACK”. Again, this is part three of our “Reckless In The RACK” series. Not really sure how many parts of the series we're going to have. That's a good and a bad thing. It's a good thing for the fact that we have a lot of stories, but also a bad thing that we have a lot of stories because that means that there's a lot of recklessness going on in this world. So if you have been following us, and you know that the “Reckless In The RACK” series is where Nick and I share stories from our patients, we like to share these stories, not only because they're reckless, but some of the stories may sound familiar to you. It's perfectly okay, if some of these stories may sound like it's your story, that's fine. That's the purpose, because that's why we're doing the series. So for all of you that are just following us now and don't know what the “Reckless In The RACK” series is, this is where we have a little story time. And it basically is where Nick and I share stories from our patients. And that's why we call it “Reckless In The RACK”. Some of these stories are pretty, what we call reckless. So, for all of you that are just joining us, in this episode, we are going to provide just a few quick stories and give our two cents on the story. So what do we get for our first story here, Nick?
[00:02:32] Nick: Alright, first one, if this is your first “Reckless In The RACK” listening to we give alias names. Usually they're either pieces of equipment or something. This individual is going to be Altra over the shoes we're very fond of here, zero drop very wide toe box, quick plug there. But anyway, this individual is going to be Altra today. This is a 58 year old male. I saw this person for pain in the balls of both feet. Now Altra had been dealing with this pain for the last two and a half years. And it basically started after he got a new job in Boston. So he's taking the train in from Salisbury area, so 45 to an hour long train, then he's got to walk a mile to work at the end of the day, he's got to walk back, hop on the train and get back so he's got a lot of walking through the city and he's going to work in a suit. So he's got tight shoes, narrow toe box, probably pretty elevated heel and dress shoes. And he developed this pain and the pain was largely between first and second metatarsal. So more towards the big toe side of the foot. And then it would kind of , disperse out both towards the big toe and towards the little toe on the other side across that pad of the front of the foot, the ball the foot there. And he was diagnosed with Morton's neuroma. Which sounds pretty accurate. And his early recommendation from the practitioner was rest, avoid barefoot and try these are facts. And to an extent, I'm okay with that advice. If you're saying this, try this for the next 48 hours, 72 hours, maybe even. But if that's your advice for months, years anyway, for the rest of your life, that's not good advice. So we need to do some load management. So many offload, many did provide an orthotic for a short period of time, we may need to be maybe wear some cushion underneath that foot for a period of time, or extra cushion. And then we need to start to wean off that and regain foots natural ability. So this individual is actually given really, really firm allocators, orthotics, really firm arch supports. And if you think about an archway, if we go ahead and buttress underneath it, all you're doing is putting more pressure to the front and the back of the foot. So where he's having pain in the ball of his foot, we're just shifting more weight onto that. And now we prop that arch up even more. There's a good chance that if he's wearing shoes with positive heel, so thickness in the heel relative to the toes, then we're only going to exaggerate that even further. So the orthotics could have offloaded for a period of time, but long term, probably not. And then you're just causing problems. If you think about an archway, like a classical stone archway, looks beautiful, you got all these little stones in a perfect alignment going up into the middle, which is called the Keystone, you can put all the weight you want on top of that Keystone. And that arch will support it, if you go ahead and put pressure underneath the Keystone and push up that are just going to collapse. So now you think about this individuals foot views got that firm our support, that's what it's doing. It's but you're saying from underneath. So that foot is actually getting weaker over time, because it's just getting that pressure from underneath to cause it to collapse. And then it collapses into something firm, which doesn't feel very good. So over time, he just gets more and more on the outside of his foot, which makes his foot stiff rigid. And now we're just developing other problems. And the problem is going away, it's not going anywhere. So the pain wasn't going anywhere for Altra. And at a certain point, he ended up having a procedure called alcohol sclerosing. So basically, they just inject some alcohol into the nerve endings and try to kill the nerves with alcohol, which just listen to that they were killing the ends of the nerves doesn't really make any sense. Why don't we try to take a step back and figure out why these nerves might be irritated? And maybe start there, instead of all the nerves aren't working, let's just kill them. Doesn't really make any sense when you think about it that way. So we went through this that did take the edge off the pain, because now they've got no nerve endings. So that helped. But he still wasn't getting by this daily, nagging pain that wouldn't let him move. Normally, it was the worst when he was doing the activities he enjoyed, like hiking. So now he's dealing with other issues, depression, stuff like that, because he can't do the things he likes he loves to do. So that's a problem, so now comes to see us almost three years after the onset of this. And, obviously, we saw a lot of these things that I've mentioned before, we see he can't really get to that big toe. So now the big toe is super, super stiff, he's stuck in that supinated, that rigid foot position on the outside of his foot. So he can't pronate well and absorb shock very well. So now all that shock is getting driven into these areas that are painful. And it's not being dispersed evenly and optimally. And then he's lacking hip extension, because he's not progressing through that big toe and his foot muscles were so weak, you could just see it when he took his socks and shoes off, you could basically see all his extensor tendons just popping up because the muscles in between just weren't there. They're there, but they're just not working for him. So they got weak over time. So now he can't taller barefoot, all that kind of stuff. So basically, this individual could have probably nip this in the bud going back three years, if he was guided the right way, in a sense, let's offload for a couple of days. If you feel good, then I want you to start to gradually get back to some barefoot movement, let's get you in better footwear. I know it can be tough with dress shoes out there. There's not quite as many good options as with running shoes or other daily footwear but there are better options. And if you're looking for certain qualities in a shoe, like net zero, drop a wide toe box, you can make it happen. And that change alone may have been enough to help Altra deal with this pain early on during that first bit early onset. But kept in the shoes that were precipitating the issue, stops going barefoot and now loses that that natural mobility and activation and strength of the foot. So really, it was just this kind of snowball rolling down the hill that just over time, got worse and worse and worse. And then really never got any better at any point and just continued to be the same every day for the last two years. So now we got Altra work in the feet, he's getting back to barefoot, he can actually tolerate minimal issues already, which is pretty awesome. So he's been mixing in the Vibram five fingers to do yard work and stuff like that. And he gets sore at the end of the day, but that's to be expected. He hasn't used his feet in three years. So we would expect him to be a little sore. And we have a conversation early on that this this is going to be a long process. This was even though you haven't paid for the last two and a half years this was happening before that, this isn't something that was just caused by you wearing the dress shoes for those six months that was the icing on the cake. The straw that broke the camel's back, whatever saying you want to use that was that final straw there and this is something that's likely been going on for a long time. He does have some natural foot structure things that may have played a role in this and we're taking those into consideration right now. So he's got the strategies in place now that, if you do have a day, that's worse, let's offload for a day, or maybe to just see how it feels. So we have shoe options for now. So I've been feeling really good, I'm wearing these shoes from feeling about the same or , I'm wearing these shoes, if I don't feel very good, I'm wearing these shoes. And then they are thoughts in the closet just in case we got to offload a little bit more. So that allows Altra to continue the process of restoring his natural foot activation, mobility, all that stuff is natural, natural foot function. And he's still keeping the symptoms at bay with some of these other tools in his pocket that he can implement when he wakes up and say, it's this kind of day, this is where I'm going with this. So working on a ton of different stuff, but literally could have nipped this in the bud years ago, if we had a provider that was thinking more progressively and was thinking what's the underlying what's the root cause of this? And with most things, there's going to be numerous causes. There's going to it's going to be very multifactorial, but what factors can we target right now? And can we manipulate to help this individual one get out of pain in the short term, and then long term help this from happening again. And really what happened with Altra was threw a short term solution at a long term issue and he dealt with the repercussions of that. So we tried to use something like orthotics and rest. Now, it's kind of stuff that should be used for a very short period of time, we did it long term and said, “Hey, you're just gonna have to wear these effects for your life and actually made things worse.” So orthotics should very much be in most cases, majority of cases, a short term solution like crutches, we're only on them for a short period of time, then we're trying to wean off of them.
[00:11:49] Chad: It's so common, actually you've sparked my, this isn't actually not even my story. But I just saw this patient the other day. So that's why I have to say, but it's almost a very similar situation. She came in, she had an ACL tear, nine months ago, and kind of going through her history. It was like, she went through all our physical therapy. And she was like, “I think I'm done. But I feel like I'm still a little weak”. And nobody ever looked at the rest of her lower body or lower her body, I should say, because her feet were so weak, she was in these huge max cushion hokas. She was like, “I've had plantar fasciitis, I've had an aroma removed, I've had hip pain, I actually just had this hip injected not too long ago, on the same side of the ACL tear, I'm like, “Man, looking at our feet almost similar in terms of like, we just could not control this pronation but nobody ever took the time to look at her feet”. How important is the ground? So she's not reacting to the ground? Well, I wonder why you had the ACL tear. So it's pretty wild how we as providers are missing this, it's shocking and disappointing. Because now, like you said, we could have nipped this before this ACL tear even happened and everybody was like, “Now we just got to strengthen this knee, but in actuality it was really coming from the ground the whole time”.
[00:13:02] Nick: And that's probably an individual that will likely have recurring tears like that, that's what you'd see that as if they continue on doing those types of activities, you're not going to prevent 100%, that's just the reality of it. But can we do better to increase people's likelihood of staying healthy throughout whatever activity they enjoy? Absolutely. But we always fail to look at the whole picture as a as a profession, really, and this is specifically to physical therapy, but I think we see it in other healthcare fields, too, that everyone's kind of got this myopic view based on what how they were trained, based on probably how their brain works to how their brain processes information. It's just easier to look at things in isolation. But we have to take a step back and say this is what I see, this is what I found. This is when I'm thinking, test that theory as long as it's safe, and then see if it's working. If it's not working, don't keep doing it and drawing.
[00:14:04] Chad: Well, so that brings me on to my story. And this woman, we're gonna call her Mac. And that's only because I'm looking at my MacBook right now. And I like that name. I was running low on the aliases today. So she is a 44 year old female, and she actually had a rotator cuff tear that she had repaired about three months ago. And she was going through her traditional course of physical therapy two to three times a week. She kind of got to this point where she was feeling like she was not progressing. Like most of our patients, when they call they're like, “Man, I'm just upset and disappointed. I feel I should be further along”. And that was kind of sparked by the last appointment that she had with her doctor and I'll get that in a second. But as she called us, she was like, “I'd love to know that you guys do a lot of like progressive treatments. I'd love to come in and see you guys”. And really get so we did the evaluation on her, and I will say that when I saw her for her initial evaluation for her being three months post op rotator cuff repair She was probably a solid four weeks behind. And that's mainly because she still had significantly limited shoulder range of motion. She really hadn't even started any type of strengthening yet, which is kind of mind boggling that should have already been started. And this was all based on where she was getting treated in what when the types of treatment she was getting. So going deeper into my evaluation, her telling me about the fact that she was only getting like 15 minutes of physical therapy with her physical therapist, which is kind of disappointing, but it's also not shocking, it's so standard. So she was doing the same exercises over the last four to six weeks. In fact, she told me during the evaluation that she was so sick of moving the cane over her head and for what it basically means is, it's a traditional exercise that we use, it's active assist, and you're basically taking a cane legitimately, and you're holding it on both sides with each hand, and you're trying to raise that up over your head in a supine position. So you're on your back, and she's three months out, and she's still doing this, this is kind of wild. So anyways, she ended up seeing her doctor, and her doctor looked at her and said, Man, you are behind. And he actually said to her, “I think that your physical therapist is being a little too conservative with you”. I want you to go back and tell your therapist to push you a little bit more. So she's like, “I'll go tell him that”. So she went, told him, “Hey, listen, your doctor said that, I say you're a doctor, because they're part of the same practice. I'll get into that in a second”. And you're not pushing me hard enough, the doctor says he wants you to be a little bit more aggressive with me. And he turned around and said, “Well, that doctor doesn't know what he's talking about, blah, blah, blah, and then kind of goes and now we've got a pissing match between the orthopedic surgeon and the physical therapist”. And just listening to the story and seeing the patient mashing aside with the doctor on this one. And it's, that doesn't happen very often, but I'm doing it today. So she's completely okay, he was being way too conservative. She's four weeks behind, she doesn't even have full range of motion. And so basically, what I'm getting at is that she was receiving her PT at an Orthopedic Group that is associated with the orthopedic surgeon. So what we call pops is what we call physician owned physical therapy services. So your physical therapist works in the same location, or the same building as the physician, the physician has a financial benefit, they're in a financial gain for sending you to his “Physical Therapist” because they are technically practicing under the license of the physician. That's how that works. So for all of you that have heard of these places in your area, I don't want to say they're bad, but there, they could be better. And the only reason why I say that is because they claim that they will normally provide this level of supervision, or if they're like, “Hey, come to my PT, we'll keep a close eye on you”. And that shit never happens, it never happens. Typically, in an organization like this, the physicians and therapists deliver the care under the same umbrella. So they're working under this, which is like super gray. And we actually have this law in place which nobody abides by. And I don't even know why it's a law because it people don't even abide by the law. It's called the “Stark Laws”. And the Stark Laws were put in place for this very reason, they were actually put in place to limit the ability for a physician to refer to their own type of health care or health care professional. So the Stark Law, it actually prohibits a physician's referral for certain designated health care services to an entity if the physician has a financial relationship with that entity being that physical therapy service. Now, not all of these physicians are some, not all of them, but some of them will tell you that they have a financial relationship, but that never happens. In fact, what they're actually supposed to do is they're supposed to provide you a list of other places in the area, where you can go and receive physical therapy services, that's part of the law but that shouldn't ever happens. I bet 95% of the people listening to this have talked to the doctor in a situation like this and have not received a list of other places to go to. In fact, I've actually heard of people that would tell me that their doctor wouldn't do the surgery if they didn't go to their physical therapy place. That's fucked up. That's messed up. That's bad. So in terms of the Stark Rule like, “Alright, why is this still happening?” Well, I'll tell you why. The way they get around this is there's exceptions to the stark rules. And the exception is that if the patient receives some form of “Supervision” from the referring physician, and they're in the same location, then it's considered an exception to the Stark Rule, complete bullshit. So anyways, moral of the story there is you can go anywhere you want. You don't have to go to the doctor put it this way, if the doctor is telling you that you need to go to their place, you need to find another doctor. So anyways, seeing this patient, she told me that whole story. So she goes back, she tells the PT, the doctor says you, “You're being too conservative, and the PT gets all pissed off and says he doesn't know what he's talking about”. Now she's like, “I don't know who to believe. You're telling me that this guy is being too conservative”. And he's telling me that hit the doctor isn't always talking about. So now she's super confused. She's not progressing. And now she's starting to feel overwhelmed. And she's starting to feel frustrated. The fact that she's like, “I don't know what to do”. So that's when she called us. And now thankfully, we've been seeing her for last three weeks and she's been crushing it. But moral of the story is, don't go to a pops if you don't have to.
[00:20:51] Nick: They just try and capitalize healthcare.
[00:20:55] Chad: Pretty much.
[00:20:57] Nick: Alright, one more story?
[00:20:59] Chad: One more story.
[00:13:02] Nick: So this individual, we're going to call skier. And the main reason for that is, this individual's goal is to get back to skiing. So this is a 50 year old male. So similar story in that is, it's post-op, and they come to us saying their PT has gotten kind of stagnant. So this individual had ACL reconstructions about six months ago. And his goal is to go skiing, so he just has a six month follow up with the surgeon, and the surgeon is like, “Oh, you look great, you'd be able to ski by Christmas, which would be about nine months out”. And you the patient was uneasy about that. So he's like, “I don't know about that. So I gotta go get a second opinion, in terms of physical therapy, because his physical therapist was like, oh no, we'll get you scanned by Christmas”. So he comes in, and ask him what he's doing with PT. I still don't like raises, still doing all the table stuff, which if you want to do it as a warm up, I can see it, and it's fine. But I asked me, have you done any lunges or anything, not a single one in six months? And if this individual wants to ski at nine months, which is probably a little early. In my opinion, you better be doing squats lunges, you better be loading up that that lower extremity in both very controlled, overloaded ways. So with heavier weight, and then also a little bit more unpredictable in terms of plyometric. So you're, you're making them move and decelerate and accelerate, because they're going to have to do those things on the slopes. So this individual had never done a lunge. So came in and actually looks really good, looked really good. And I was very happy about that. But the one thing I could really see with all his movements, as I'm putting him through this assessment was that he was just unsure, he pretty much almost stopped and asked the question about the movement. Before we did it, showing me that his competence with movement overall, like lunging, and things like that was not very high. And I want his movement confidence to be very, very high. If we are getting back to skiing, especially in three months, we don't want him to be second guessing things. Because he has to make split second decisions about the terrain, where he's going things like that when he's skiing. So now it's much, much more variable and dynamic and unpredictable. So we need to put him in those types of situations as opposed to lifting his leg with a really heavy ankle weight on the table, very, very predictable, not really overloading. There's no minimal force of gravity on his whole body. So we need to get him up and moving. But this was a situation where he had mentioned to his, so similar to Chad's story, he had mentioned to his physical therapist about doing lunges. And the PT said, I don't want you, I don't want you doing that yet and the surgeon did say the same thing. So the, the, in this story, the surgeon and the PT, we're on the same page. But from the surgeon’s perspective, the surgeon is also just trying to protect his product, which is the surgery. So if we just want to think about it very simply, if a surgeon is doing surgery and repairing something, that's his product. He wants to be very, very protective of that. So he will tell the individual extreme lengths to make them overly cautious. So they don't do anything silly, because most times they don't know. Now the PT comes in and the PTs job is to actually blur that line a little bit. We are here to say, “Look, I know your surgeon doesn't want you doing that, but I'm here I'm watching you. It's going to be very controlled”. I'm going to show you how to do it. I'm going to cue you, I'm going to correct anything if we need to, and so on so we can progress that individual under our supervision and then get them into that if they look good, let's keep going. If they don't, let's scale back, let's regress, but there was no collaboration, no cooperation between the two and it resulted in this individual being ready for things he was probably ready months ago because of the way he looks. When I saw him, and he just kept on doing the same thing. And he was loading up like leg press and leg extensions, which is great. And that's probably helped this individual in scared in why he did looks so strong and stable, and some of his movements, but he just lacked that confidence because he hasn't done anything yet anything dynamic. So big thing there is, if you're a physical therapists out there, you don't have to follow the protocol in the blueprint, it's there just as a guide. It helps much more in the early the acute phases. And then, as the days go on, the weeks go on, you use that less and less and less and less and less and it's just a guide to refer to if need be. But you have to make those decisions based on how that individual is presenting, you can't just blindly follow this protocol, because those are just there, as a baseline, even just to give you some ideas, maybe but not there for you to follow to a tee because if that's the case, a skier is not gonna be ready to ski till next ski season. If we just keep doing leg lifts for a year, he definitely won't be ready in nine months, let alone this ski season in 12 months, but we need to be able to look at this individual. He's progressing really well. He was probably ahead of schedule throughout the whole thing. And we could have started lunges pretty early on, and he would have been even better off right now. But now we're a little bit behind the eight ball. Luckily, he's not too far behind the ball so we can get rolling. Will he be ready in nine months? We'll see. We don't know we can't make that. We can never make that that decision right now at six months. We can make a guess and say I know the way you're looking. Now, if you continue to progress, I think you could be out there skiing in nine months, but we'll make that decision come nine months. But we have to be able to blur that line a little bit and say, “Oh, you look really good. Let's move. Let's move on. Let's get you going with the next step”. It's still good to have protocols and steps and phases in place. So you can follow a structured plan and progression. But if someone has passed this step, you better move to the next step. We're not staying at this step just because we have to wait the next month till we get to the next one. If that person's checked off all the boxes on that step, let’s go to the next one.
[00:27:24] Chad: And I think you've said that perfectly man. Protocols are our guides, and a good physical therapist will be able to guide you along that protocol, based on if you're advanced for the phase that you're in, why waste your time and the doctor's time, frankly, with messing around with stuff that could be progressed. And that's kind of what was happening to my patient. And that's unfortunate, but it's the therapists out there that are following that guide, or that protocol. And they say, “Well, we can't do that until week three, even though they're way past week three, and you get a close enough relationship with these doctors that the doctors don't even send the protocols anymore”. They're like, “Dude, just go see, Chad, Nick, they know what's up, they know what I like, they know what to do, just listen to what they have to say”. But you're right, the doctor will tell the patient a certain thing, because they know that the patient is not able to understand how much they can progress themselves at that point in time, but they know the therapist can. And if it's an uncontrolled environment, then it should never be an issue. I agree with you.
[00:28:28] Nick: 1,000%. It's really a safety net is what it is from the surgeons perspective. Again, they're just protecting their, their product. And I hate to use the word product in this sense, because we're talking about people's bodies, but if we scale back and look at it, that's the surgeon does the surgery, and they want to make sure that what they did the work they did is not ruined or traumatized in any way.
[00:28:53] Chad: Now well said, that's good for stories today. So what do we got going on for next episode, I think we got another guest speaker come on another?
[00:29:04] Nick: We got another guest. We got a guy by the name of Jackson Frey. He's a good friend of ours. And he's the man, he is a sports performance coach out in the Chicago area, Chicago, Illinois, and he works for a gym, named “GVM Performance”. They do all different athletes, but he's more recently beginning been getting more involved with hockey athletes and local club teams and things like that. So he works exclusively. I think it's the Chicago jets club hockey team out there. So he's huge on creating positive culture in the gym making the athletes accountable. So he's big on teaching them how he wants things to look. And then he has the athletes coach each other up, which is really, really cool. So we'll be talking to him a little bit about that. He's big on just optimizing movement overall and the quality he loves, loves training. The speed and sprinting, which is will be fun to talk about a little bit. So to begin, he went to Springfield College. We were classmates and undergrad and then he went elsewhere for grad school, but it'll be a good talk with Jackson. So he's coming in actually from the Chicago area, he will be in the area for a wedding. So we'll sit down with him and probably get a lift in with him.
[00:30:21] Chad: We'd love to get out of lifting with him. He came and visited us last year. He's a good guy. If he was moving back here, it could have been part of the profile. That was close, we almost got loose close. But now we're happy for him. But we're looking forward to that one. So, Jackson, bring you a game, because we're lifting men. So moral of the story, “We have a long ways to go with progressing the field of physical therapy unfortunately. Fortunately, you are becoming now more of an informed consumer. And you can make those decisions as to who's progressing and who's not progressing so that you can progress”. We do understand that the healthcare system will never be perfect. But it seems that we hear these stories all too often. And that's why we continue to have “Reckless In The RACK” series over and over and over again. The best thing that we can do for you is just bring awareness and that's the intention with this podcast. We want you to understand the in’s and the out’s, we want you to understand what your options are, and learn from either our mistakes or other people's mistakes. So listen, if you are a healthcare provider, and you are listening, we just ask that you don't be reckless with other people's health. And for all of the patients that are listening, you shouldn't put up with people who are reckless with yours.
[00:31:41] PODCAST OUTRO: Thank you for joining us “In The RACK” this week. Make sure to subscribe so you don't miss out on any future episodes. You can also find us online at proformptma.com, or on social media at ProForm PTMA. And remember;
“If you train inside the rack, you better be thinking outside the rack”.
