The Peter Attia Drive - #350 ‒ Injury prevention, recovery, and performance optimization for every decade

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

00:00:21.520 into something accessible for everyone. Our goal is to provide the best content in health and

00:00:26.720 wellness, and we've established a great team of analysts to make this happen. It is extremely

00:00:31.660 important to me to provide all of this content without relying on paid ads. To do this, our work

00:00:36.960 is made entirely possible by our members, and in return, we offer exclusive member-only content

00:00:42.700 and benefits above and beyond what is available for free. If you want to take your knowledge of

00:00:47.940 this space to the next level, it's our goal to ensure members get back much more than the price

00:00:53.200 of the subscription. If you want to learn more about the benefits of our premium membership,

00:00:58.020 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Dr. Kyler

00:01:05.960 Brown. Kyler is a sports rehab chiropractor who specializes in sports injury pre and post-surgical

00:01:11.880 rehabilitation and bridging the gap from rehab to performance. He is the co-founder, along with

00:01:17.260 myself, of 10 Squared, an Austin-based private member training program focused on building and

00:01:22.700 maintaining exceptional muscle capacities for the marginal decade. Originally, this was a conversation

00:01:30.440 that we recorded just for the 10 Squared audience, but once it got out there and we saw how much the

00:01:38.300 clients there appreciated it, we decided to repurpose it as a podcast for all of you. In this episode,

00:01:45.580 we discuss the principles behind injury prevention, recovery, and performance optimization,

00:01:50.180 including how small movement dynamics can lead to chronic issues. Discuss a framework for assessing

00:01:55.680 and treating individuals, heightening the importance of understanding from between movement

00:01:59.680 patterns, functional asymmetries, and personalized rehab approaches. Talk about some specific case

00:02:04.180 studies, including Kyler's work with professional athletes and others to demonstrate the benefits of

00:02:08.680 individualized strategies. The role of fear in movement and rehabilitation and how overcoming mental

00:02:14.020 barriers is just as crucial as physical recovery. Actionable strategies for you to assess your own

00:02:19.760 movement patterns and implement proactive training techniques to build strength and longevity.

00:02:25.260 Now, in addition to this conversation, Kyler also filmed a short series of videos in the gym

00:02:30.740 demonstrating exercises for common issues like lower back, neck, shoulder, and knee pain. These are

00:02:37.980 designed to help you put some of these concepts from today's episode into action. The videos are only

00:02:43.140 available to subscribers and can be found on the show notes page for this episode. So without further

00:02:47.960 delay, please enjoy my conversation with Kyler Brown. Kyler, wonderful to have you.

00:02:58.720 Yeah, thanks for having me. I want to kind of give folks a little bit of a sense of what you and I

00:03:05.320 came up with a few years ago in the throes of my recovery from shoulder surgery and why that gave us

00:03:12.680 this idea to take two things that seemed quite unrelated at the time. My recovery from an injury

00:03:18.600 coupled with this idea that I'd been marinating around this idea of a centenarian decathlon in a

00:03:24.260 marginal decade and why we decided to kind of put the best ideas or the themes of these together.

00:03:28.500 So how does that sound? Sounds great.

00:03:30.580 All right. So let's see, you and I met four years ago as soon as I moved to Austin. I don't even remember

00:03:36.020 what we worked on because I think it was just like preventative stuff.

00:03:38.860 You really wanted me to come over, I think initially just doing some DNS stuff, like some

00:03:43.000 routine maintenance things. And somewhere around the second or third visit, I was like,

00:03:47.440 what's going on with this shoulder? And that kicked off this whole conversation because

00:03:50.520 in my world, this idea of just doing one technique or providing one service isn't really a complete

00:03:56.320 approach. That's right. You're right. We were probably a couple months in maybe,

00:03:59.820 and it was clear that I was nursing this bad shoulder.

00:04:03.140 Um, and I knew what was going on because I had torn the labrum before the diagnosis. I remember

00:04:11.240 was actually made in 2009. I had my first arthrogram in 2009 for folks listening who don't know what

00:04:16.420 that is. An arthrogram is an MRI where prior to you going in the scanner, the radiologist takes a needle

00:04:23.220 about yay long, like four inches long, shoots the needle into the capsule and injects contrast so that

00:04:30.640 it really allows the MRI to show the labrum and how much it's detached from the glenoid fossa.

00:04:37.420 And so it was patently clear at that time I had a torn labrum. It was significantly torn,

00:04:41.020 but not as torn as it would be 13 years later, but I had largely avoided surgery by doing as much as I

00:04:47.660 could to strengthen the rotator cuff. And frankly, I was afraid to have surgery. That was the bottom

00:04:51.820 line is I didn't want to trade one problem for another, meaning I didn't want to trade pain and

00:04:57.280 instability for immobility. And I saw that as the trade-off folks listening, probably recall that

00:05:04.920 I had a podcast. I did a sit down discussion with Alton, who is the amazing surgeon Alton Barron,

00:05:10.660 who ultimately did the repair. But what I was most impressed by in that experience, which turned out

00:05:15.860 to be wildly positive was that immediately you and Alton started working as a team. And maybe you could

00:05:24.520 talk a little bit about what you guys decided to do in the six, I think it was eight weeks we knew

00:05:30.400 prior to surgery. We scheduled it such that you could do something before then. What was that

00:05:35.000 discussion like? Alton did an amazing job in a lot of ways, but one of the things as a rehab

00:05:39.680 professional that I really appreciated was how he didn't want to just cinch down that joint to where

00:05:45.040 his liability was so covered that that shoulder would be strong, but you lost a ton of function.

00:05:49.780 And I think that is one of the key things that he did for us was he did the right amount and he put

00:05:55.100 the staples and the sutures in the right places to where that shoulder would be functional. And we got

00:05:59.580 to your shoulder well before it became any kind of more significant structural compromise. So it's

00:06:04.060 really important window to do so. But I do remember that conversation because you had a date several

00:06:08.920 months out where you're like, I'm going to have to use my arm a lot. I need to be strong.

00:06:12.300 Basically, I needed to be able to hunt in September. So we backed out of that, said the surgery needs to

00:06:16.940 be no later than March. It was January. And then the question was, should you do the surgery right

00:06:22.920 away or do you use two months to prehab? And so tell me how you thought about that.

00:06:28.800 That conversation was one of my favorites because I've done this before where if we know the big

00:06:33.560 picture goal as well as the near term surgical date, and then we reverse engineer, okay, I want to

00:06:38.840 check off a certain amount of things preoperatively to where that joint is ready. And essentially in the

00:06:44.420 most simple terms, what you're looking for in that situation, especially with the shoulder,

00:06:47.760 because it's such a mobile joint, is you want to make all the muscles around the shoulder

00:06:51.560 just awesome. But we need to do so in a way that doesn't make the surgery more complicated or injure

00:06:57.080 you more. And so we did a lot of things where we didn't only use technology like BFR, but we also used

00:07:02.720 very aggressive approaches on your core stability, the way your scapula interacted with your ribs,

00:07:07.500 and all these things have an effect on how my shoulder moves. And if my really mobile shoulder that has a

00:07:12.980 torn labrum isn't stable and doesn't have a support infrastructure around it, you're always just

00:07:18.140 going to ask for more pain. But the best thing about that is the day you got the surgery, we jumped on it

00:07:23.000 really quick once things were healing from the surgery itself. All those other ancillary things

00:07:27.100 were actually functioning really well. So now we only had to really target the shoulder itself because

00:07:31.340 the rest of the human was really strong and ready. So the things that I remember, which are probably

00:07:36.140 fewer details than what you remember is one, how much rotator cuff work we did ahead of time,

00:07:42.060 particularly around supraspinatus. So we really got that muscle as strong as possible in eight

00:07:46.600 weeks. You know, anybody who's gone through that type of rehab, which I'm sure many people listening

00:07:50.220 have, it's uncomfortable. I mean, you're burning a little tiny muscle that is not used to working

00:07:54.100 that hard. The second thing that I remember, and hands down the most important thing, was what you

00:08:00.240 and Alton decided to do post-operatively completely shattered everyone's understanding of what we do with

00:08:07.680 these patients. So the traditional view is, especially, this wasn't a slap tear. The entire

00:08:13.280 labrum was hanging by a thread. And normally, as you said, a surgeon's primary objective is,

00:08:19.260 hey, I'm going to make sure that this is never unstable again. I'm going to cinch this down really

00:08:23.340 tight and you're going to be in a sling for four to six weeks. And that's going to give it plenty of

00:08:27.400 time to heal. All of that sounds great, but you'll never regain your mobility. You'll never regain the

00:08:33.840 range of motion you want, the healthy range of motion you had. And frankly, you'll probably

00:08:37.020 atrophy away. And so Alton said, no, we're going to have you out of a sling in 24 hours.

00:08:43.780 And I was like, how is that going to be possible? And yet we did. There's no way he could have done

00:08:48.980 that if you guys weren't partnering on this. How is that even possible? And why does that fly in the

00:08:53.640 face of everything we would think of? The broader picture here is what we touched on, the liability.

00:08:59.120 And it's really difficult for modern physicians and rehab pros to integrate. Professional sports

00:09:03.480 tries to achieve this as well, but they have time constraints and all these other constraints

00:09:08.120 with how many people they're working with. So ignoring all those layers, I think the most

00:09:12.300 important thing is to know Alton and I had these conversations in detail and he was really specific

00:09:17.260 about, okay, did we get the training we talked about? Is that supraspinatus, the serratus

00:09:22.220 anterior, all these other muscles that help stabilize, are those really good? And I had some metrics

00:09:26.520 I was able to discuss with him and he felt really confident in the stability of your shoulder.

00:09:30.200 So if we're speaking to a general population, I would say that no sling or sling decision was

00:09:34.800 based on what we knew exactly what we did. The other thing is that you followed everything

00:09:38.660 to a T. One of the big complications in rehab, athlete or not, is are people following the

00:09:43.160 rules? Are we going to take this athlete or individual out of a sling and are they going

00:09:46.980 to forget about it and all of a sudden go reach for the cereal or are they going to follow

00:09:50.740 the rules? And you were definitely a rule follower. So he and I had a high confidence

00:09:53.900 in minimizing the risk.

00:09:55.380 Truth be told, I learned a lot of that the hard way from my first orthopedic surgery back

00:10:00.460 in 2000 when A, I'm not even convinced I received post-operative instructions. And if I did,

00:10:06.440 I didn't read them. And I was breaking every rule there was. Mistakes were higher here in

00:10:11.340 a way. And I think I was very mindful. For example, people, myself included, when you have

00:10:15.820 surgery, you tend to go on YouTube to learn all about it.

00:10:18.180 Right, right.

00:10:18.740 And I'm like, okay, I want to see everything. I want to watch the post-operative. I want to watch

00:10:22.140 the rehab process. And so one of the big milestones you see for people with labral surgery is when

00:10:28.020 they basically can dangle the arm and rotate like a lightweight. And Alton was really clear,

00:10:33.700 like, you're not going to be doing that for a while. We're talking about range of motion

00:10:38.140 without stress on the repair.

00:10:41.440 Right. And very early on, pre-operatively and post, we were able to do very gentle but targeted

00:10:47.000 isometrics where there wasn't complexity in the joint itself, but we were loading the tissues in a

00:10:52.360 very articulate and specific way. And that's how you, again, put this support structure around it.

00:10:56.860 I always kind of describe it as like the roll cage in a car. We want all the muscles around that to

00:11:00.580 be ready to absorb force. So those joint structures that are getting the staples or whatever else in

00:11:05.500 there aren't stressed. We don't want to yank on those things while they're healing.

00:11:09.640 So in parallel to this, I'm continuing to sort of refine my thinking around the idea that we're

00:11:16.920 all going to have this marginal decade one day. And it does come across as sort of a depressing

00:11:22.020 thought. Nobody really wants to think about the idea that there will be a day when you knowingly or

00:11:28.140 unknowingly enter the final decade of your life. But at the same time, to act as though it's not true

00:11:33.660 won't make it not so. So I think it occurred to me that the more deliberate we can train for that

00:11:42.360 last decade, as though we are athletes, the more we can enjoy it. Because as I watch people in the

00:11:49.080 final decade of their lives, and I've had the both privilege and curse of seeing a lot of it,

00:11:55.300 I believe that the thing people complain most about is what's taken away from them physically.

00:12:00.500 Now, there are lots of people in the last decade of their life that are lonely because they were

00:12:05.180 miserable sons of bitches and their family, they don't have family or friends. All of those things.

00:12:10.360 There are many people whose cognition has failed them long before their body has failed them,

00:12:14.760 and that can be very distressing. But if I'm really thinking about this in terms of large numbers,

00:12:19.800 more than two thirds of people, I would say in the final decade of their life,

00:12:23.980 when they're really thinking about what's impacting the quality of their life,

00:12:27.100 it's this. It's the physical part. That's the thing I've lost that I miss the most.

00:12:32.440 And sometimes it could simply be freedom from pain, but more often it's restriction of activity.

00:12:36.820 Yeah, totally.

00:12:37.680 And that's my biased experience. You see much more of this. Tell me what you think.

00:12:41.640 It's really analogous to the pro athletes I've worked with as well, where it's really interesting

00:12:46.460 to see these mature athletes who've been playing their sport eight or 10 years,

00:12:49.560 and they're starting to kind of look at this reality that their career is going to be over.

00:12:53.020 And they start recalibrating how they train because they start thinking about the long term.

00:12:57.720 And what's really fun for me is when they start to get that perspective of,

00:13:00.880 it's not just about this weekend, it's about the long game here.

00:13:03.640 And I think to your point, a lot of people out there have the best intentions and they're maybe

00:13:08.860 even working hard, but there's no precision. Nothing's accounting for their specific details,

00:13:13.820 their nuances of their joints and how they move and how their body feels when they move and

00:13:17.800 their trust in their body and all these variables.

00:13:19.860 And a lot of people are either want to put in the effort and don't know where to start,

00:13:23.180 or a lot of people are putting in the effort, but it's not calibrated.

00:13:26.840 Yeah. And I kind of even began to observe that in myself, which was there were a lot of activities

00:13:33.540 that I was doing where I was doing them because I'd historically always done them.

00:13:38.560 We fall in a groove. This is a type of exercise I enjoy doing. This is a type of workout I enjoy

00:13:42.400 doing. And then I had to kind of take an honest assessment of some of these and say,

00:13:46.400 okay, for every activity, just like for every investment, there's a risk and there's a reward.

00:13:53.280 And the way you might think about investing in your twenties is probably different from how you

00:13:59.040 maybe should be thinking about investing in your sixties or seventies or beyond. And similarly,

00:14:04.980 the risk and reward changes over time. So for example, when you're 20, the risk is just inherently

00:14:12.140 lower because you have better tissue. We could go through all the reasons why inflammation,

00:14:16.720 everything that changes as you age reduces tissue quality and younger people. I'm sure you see this

00:14:22.300 all the time can just get away with doing things incorrectly. In fact, would you agree that sometimes

00:14:27.280 some of the most gifted athletes actually have horrible patterns of movement, but because they're

00:14:30.580 so gifted, it doesn't seem to matter. Yeah. I mean, specialization is one. Some people just

00:14:35.140 born jumpers and then you train it and they practice it when they play and they get better and

00:14:38.460 better at jumping. Absolutely. But moreover, it's almost like we're set up for failure. We're set up

00:14:42.860 with this baseline norm of I could bench press 225 when I was a senior in high school, but then

00:14:47.900 that individual is not accounting for the 20 years of lack of activity, lack of practice they've

00:14:52.900 atrophied. And then they jump right back into the gym and then they hurt things or they feel like

00:14:56.360 they quote, can't do it anymore. And the reality is it's all about capacity. If you don't use it,

00:15:01.080 you lose it. And a lot of us aren't really thinking about what have I actually actively lost

00:15:05.800 from an activity standpoint. Is it jumping? Is it mass? Is it strength? All those variables that

00:15:10.000 you spoke to. But I definitely see this a ton on the injury and pain side. Injury doesn't show up

00:15:14.780 out of nowhere. It has reasons why it shows up and it's compounded by emotional stress and all these

00:15:19.560 other kind of multifactorial things. When our brain perceives threat, we feel pain. Absolutely.

00:15:24.300 Sometimes that's a physical threat. Like I haven't jumped in a long time. I started jump roping.

00:15:27.580 All of a sudden I wake up, my Achilles is sore. That doesn't mean I ruptured my Achilles,

00:15:31.360 but it does mean I was not prepared for that movement because I've been on the shelf for a long

00:15:35.140 time. And so I think a lot of people with that investment strategy analogy is fantastic. And

00:15:40.520 they should really incorporate that is making sure they're accounting for all the buckets that their

00:15:44.640 body needs to do, not just with what they want to do, but what we know people need. Demographics,

00:15:50.080 Western society, age, all these things play a role to like, if you pull up the stats,

00:15:54.540 a lot of people will have, oh, high risk for a low back or high risk for an ankle or whatever.

00:15:58.980 Yeah. The jumping is a great example because if I go back to when I was in my sort of training peak,

00:16:03.240 so basically age 13 to 20, call it those years when I was training a lot, jumping was an enormous part

00:16:10.700 of what I did. There wasn't a day that I wasn't jumping. So for example, I was skipping rope 25

00:16:15.680 minutes every single day. You know, lots of those are doubles. So you're really up there. Absurd

00:16:20.560 amounts of plyometrics. And then from basically 20 to my mid forties, didn't jump at all. Not a single

00:16:28.000 jump. That became one of the realizations was, oh, you've lost a lot of tissue pliability.

00:16:36.220 As one example, now something that I do a lot of is low level jumping. You're right. Sometimes I get

00:16:43.620 really worried. I'm like, oh man, I don't want to have an Achilles rupture. Like that's the middle

00:16:47.400 aged man injury. Oh yeah. Playing soccer with my kid and I'm just waiting for it. Yeah. Right.

00:16:52.260 In my private practice, I see this all the time. But what I always tell people to do is like,

00:16:55.880 look at your kids. If you go to a coffee shop with your kids, I guarantee one of them will run

00:17:00.140 and jump off a rock and like do a twist and land it. When was the last time one of us did that?

00:17:04.940 Right. And that's why they say maintaining play and always playing games and increasing that to where

00:17:10.260 it's randomized games. You're actually reacting to things because there's the neuroplastic effects

00:17:14.400 as well. But just for the tissues, rehearsed load on the Achilles and the foot. If you go and get a job

00:17:20.700 and you drive to work and you sit at your cubicle all day and you drive home and you didn't jump,

00:17:24.300 that times five or 20 years is going to cause a lot of lack of capacity in your tissues that you

00:17:29.480 don't want to learn the hard way. That's right. Because all I'd been doing in the intervening

00:17:33.920 25 years was swimming, cycling, hiking, which is fine, but it's still not jumping. It's not reactive.

00:17:41.460 And so part of what made me start to realize this was as my kids got old enough and I was now playing

00:17:46.380 sports with them, when you play basketball, soccer, and baseball with kids, you realize exactly what

00:17:52.700 you just said. It's not a predictable movement. It's never the same movement exactly twice.

00:17:57.060 Yeah. Three-dimensional, short, long, quick, slow. Yeah. I mean, a lot of variables there.

00:18:01.760 Which actually gets to this idea that people listening to us are probably very familiar

00:18:05.600 with, which is the centenarian decathlon. Give me some of the things on your centenarian decathlon.

00:18:10.280 For me, wrestling with my kids, which means getting down on the floor,

00:18:14.200 having the flexibility, wrestling with my grandkids.

00:18:16.720 Wrestling.

00:18:17.460 Yeah.

00:18:17.700 That's big.

00:18:18.280 Just like play, right? Because not a pile driver.

00:18:21.020 Depending on the kid. If they're my grandkids, maybe. But that's definitely a goal of mine is

00:18:25.560 that bonding that you get when little kids are wrestling on the ground. And I saw my dad recently

00:18:29.600 doing that. And I thought that was really cool. He's over 70 and he's on the ground

00:18:33.080 messing with my three-year-old and it was just cool to see. And that's how I added that to my list.

00:18:37.400 It was hard for him, right? It wasn't easy, but he got down there and he could do it and he didn't

00:18:40.620 suffer from it. That's one of mine for sure. As you know, I fell in love with rucking over the last

00:18:44.880 couple of years. And so I want to be able to really crank out some mileage, especially in

00:18:48.780 national parks as I get older. I'm not looking to be an ultramarathoner per se, but I really want

00:18:52.980 to be able to hike long distances, probably with a pack on it.

00:18:56.460 When you're in your marginal decade, how many pounds would be your expectation? Give me some

00:19:00.620 numbers. How many miles? How many pounds?

00:19:02.380 Yeah. I think my numbers will be a little distorted because I'm a pretty big guy. I'm 6'3 over 200.

00:19:06.200 So I should be able to carry at least 20 pounds without worrying about too much for four to six miles.

00:19:10.980 Okay. I like that goal.

00:19:11.920 Yeah. I mean, I want to be reasonable. And this is on what kind of terrain?

00:19:15.180 Not too technical. I'm not thinking boulders and rocks, but I definitely like to go hills,

00:19:19.660 up and down, dirt track, all that kind of stuff without having to worry about it.

00:19:23.200 Okay. What else?

00:19:24.400 Another one is I grew up being an athlete. My youngest seems to be the more inclined to be

00:19:28.380 an athlete. So as I age, I want to be able to hang with him as long as I can. So that means

00:19:31.980 throwing, hitting a baseball as long as possible. Who knows how their careers will evolve from an

00:19:37.280 athletic standpoint, but odds are they're not going to be pro. So I really want to keep that base

00:19:41.780 to where I can keep playing with them as long as I can. But to me, it's all about being able to still

00:19:45.340 play with the grandkids because family is one of the most important things out there. And

00:19:48.160 if your grandpa is sitting there and could do cool stuff, I think that serves as a great role model.

00:19:52.840 Whereas if you're suffering from an injury or not healthy, then they want to hang out with you.

00:19:57.380 But at the same time, kids want to go do stuff and I don't want to be left out.

00:20:01.080 I agree. I think as much as I think there are probably examples where the wise old grandpa or

00:20:06.400 grandma can sit inside and tell stories to the kids. I mean, there's value in that,

00:20:11.320 but I think there's even more value in going to their world. They typically don't want to come

00:20:16.220 into your world. You typically have to go into their world. So you have to be able to go fishing,

00:20:19.780 hike. And again, people listening to us who have young kids should not waste the opportunity to

00:20:26.160 observe what young kids do. There'll be different technologies in 25 or 30 years,

00:20:31.540 but I think the principles will be the same. Kids like to play and therefore playing with my kids

00:20:38.800 today is giving me a dry run of what I want to be able to do in 30 years.

00:20:42.900 Yeah. And if you aren't building up these areas of need or you're accidentally letting these certain

00:20:48.740 athletic kind of movements fall by the wayside, all of a sudden you're like, oh man, I can't do that

00:20:53.040 anymore. I love coaching my kids' basketball team. And one of the other kids on our team,

00:20:56.640 their grandpa was out on the court with us one day. He was, I think, 74. He wasn't doing windmill

00:21:02.540 dunks or anything, but he was moving and he could shoot. And every kid there, their eyes lit up.

00:21:07.140 They're like, grandpa can shoot. That's crazy. That was a cool moment. That's why I put on my list

00:21:11.180 of just playing with kids might be my whole CD. My wife might have something different to say about

00:21:14.920 that. But I think for me, it's like, if I can play and if I can do all those things, then I'm doing

00:21:18.820 pretty well. When I first introduced this idea of the centenarian decathlon to the first of our

00:21:24.480 patients. This is before, of course, we started 10 squared. One of the bits of pushback I got a lot

00:21:29.540 was, especially from people who were in their 30s and 40s, they were like, Peter, I'm not that

00:21:36.800 interested in my 80s and 90s. You keep talking about making me a kick-ass 80-year-old. I want to

00:21:43.480 be a kick-ass 40-year-old. What's wrong with that? What's the flaw in that logic?

00:21:48.760 To me, it's everyone's drawn to this high performance, be awesome right now. And that's like a boom

00:21:53.460 bus strategy. You might pull it off, but you're high risk and eventually you'll hit the wall for

00:21:57.600 a race car. But if we're thinking long-term, then by default, if I'm going to be an awesome 70 or 80

00:22:03.320 year old, I kind of have to be an awesome 45 or 55 year old. We're going to be doing things now that

00:22:08.300 make you crazy strong, that help your lean muscle mass, that burns your fat, all those health risk

00:22:12.800 things. But you're also going to be way more prepared for whatever life throws at you. And if your buddy

00:22:17.220 talks you into going skiing or going to do a volleyball game or whatever else, you're going to be way more

00:22:21.840 ready for it. If you're thinking long-term and building this crazy robust foundation, rather

00:22:27.160 than just chasing the newest technique or the newest technology. Yeah. The analogy I used with

00:22:32.500 people at the time, because archery is something I enjoy, is that what we're trying to do is train you

00:22:38.960 to be exceptionally accurate at a hundred yards. And you're telling me that you don't care about a

00:22:44.920 hundred yards. You just want to be accurate at 40 or 50 yards. And I'm telling you, trust me,

00:22:50.420 if you're an ace at a hundred yards, it's like shooting fish in a barrel at 40 yards.

00:22:55.660 And this is where the analogy is actually has a deeper layer of truth, which is that's a very

00:22:59.740 non-linear thing. A hundred isn't just twice as difficult as 50. It's four or five times more

00:23:06.880 difficult. And similarly to be really fit and healthy in your nineties is a dramatically more

00:23:15.220 demanding feat than just to be a fit 50 year old. Yeah. There's a lot stacked against you.

00:23:20.420 Plus variables that we're not prepared for, or we could roll our ankle, but give me somebody

00:23:25.540 who's strong all day. And if they sprain their ankle coming out of the bar, they're actually

00:23:29.780 going to sprain it less odds are. So all this insulation and capacity we put around us with

00:23:34.800 the individual goals is crucial to prevent injury. And these injuries can stack up and

00:23:39.340 cause a lot of trouble. And then we get less healthy. And that's how you get these multipliers

00:23:42.920 where I was on track to be really good, but this knee arthritis or this multiple meniscus

00:23:47.160 repairs I had to get because I wasn't stable caused me to actually lose my hiking ability.

00:23:51.600 And then all of a sudden I got less healthy. Let's fast forward a little bit. Basically,

00:23:55.920 as I'm kind of getting better from the shoulder thing and realizing how fortunate I feel to

00:24:01.100 have had this experience where I've known Alton for a while, then I met you. It's this great

00:24:05.280 connection. I say, Hey man, what do you think about this idea of we build this separate little

00:24:10.040 business that just focuses on the training piece that's outside of my practice, outside of your

00:24:15.640 practice, but integrates it with everything that's necessary to train a person for the marginal

00:24:20.000 decade. So you bring in all of the cardio training, you bring in all of the strength

00:24:24.440 and conditioning, you bring in the coaches to integrate the whole thing. So, okay, we're doing

00:24:29.220 that now of all the things we do in 10 squared. I still think that your domain is the hardest for

00:24:35.640 people to wrap their heads around. I think people understand, Oh yeah, you guys will help me get a

00:24:38.760 high VO two max and you'll boost my zone too. And you're going to make me stronger and blah, blah,

00:24:43.280 blah. How do clients look at you? What do they figure is going on with you?

00:24:47.000 It's funny you say that because the assessment takes two days and we're looking under the hood

00:24:51.560 a lot in a lot of different ways. It's funny how they evolve like their perspective of it, because

00:24:55.920 what I was kind of forced to do in my career was I had experience working with teams and all that

00:25:00.460 other stuff, but I kind of became an off season person for these athletes. And by default,

00:25:04.520 I had to almost become a strength coach, not because I wanted to, or that was my goal,

00:25:08.240 but because these athletes needed that bridge from I'm injured to, I might be injured to,

00:25:14.320 Hey, I've got the green light for performance. All humans are moving up and down that spectrum

00:25:18.120 based on our recovery and all these variables. So what's been fun at 10 squared is I get to do

00:25:23.140 all the assessment I want. And it's not really a clinical assessment. On the one hand, we're of

00:25:27.720 course looking at things that either have pain or that individual member has had a previous injury

00:25:32.500 with, and we're accounting for that. And we're making sure that's on track or could be improved.

00:25:36.560 And we add those things, but then I also get to play around and look at what else is weak.

00:25:41.180 What is this individual at risk for? So one example is we have a client who loves to surf.

00:25:45.780 He's got a shoulder issue. So by default, surfing and swimming on a surfboard is a different

00:25:50.380 position than a traditional freestyle stroke. So we had to make his shoulder uniquely robust in

00:25:55.380 certain directions. And so that's part of his strength program. One of my biggest pet peeves in the

00:26:00.080 rehab world is when people give someone 30 exercises that are really tedious and boring and no human

00:26:05.780 sticks to that. They might do it for a week or two, but if it's not bridging to what they love and what

00:26:09.580 they want to do, it won't get there. So if we can bake in ensuring that all the strength training

00:26:14.380 won't make them worse, and then also make sure that we're baking in their little corrective exercises

00:26:19.360 or improving the gaps, that's where you make a huge difference into how someone feels,

00:26:23.560 but also how they can perform. What are some of the things you see, and I'm not asking this to be

00:26:28.920 critical of what other rehab professionals do, but as a person listening to us who says, look, man,

00:26:34.840 I've been not getting better. I've had fill in the blank injury. So I've had tennis elbow that won't

00:26:40.400 get better. I've had lower back pain that's just not getting better, shoulder pain that's not getting

00:26:45.060 better. How do you help that person think about whether or not there's an underlying structural

00:26:49.700 problem that needs a surgical intervention or a more direct intervention versus you're not being

00:26:55.780 instructed to do the right things and, or you're being instructed and you're not doing it? How do

00:26:59.020 you walk somebody through that tree? Obviously it's a heavy lift with a lot of details. I think the

00:27:03.060 first rule is the medical community. So your orthopedic surgeon or your neurologist, and then your rehab

00:27:07.960 pro have to be in sync and have a relationship. And how often is that happening? I mean, it's very rare.

00:27:13.120 What's really interesting is the philosophy and the individual just spirit of either surgeon or the

00:27:18.540 rehab pro, they have to be kind of committed to the service oriented field. If they're just doing it

00:27:22.560 for money, they're going to do scale and they're going to do like the PT mill that there's four

00:27:26.620 clients with one therapist and that therapist is probably doing the best they can, but they're

00:27:30.320 just kind of outnumbered and they're not accounting for those four different people all at once. So

00:27:34.020 first off, it has to be one-on-one. You cannot tell me that you're rehabbing you the same way you

00:27:39.840 could rehab my grandma who had a shoulder issue. Are you saying that, it's going to sound like an

00:27:44.560 ignorant question. Are you saying that in some facilities, one PT will work with multiple

00:27:49.740 clients at the same time and put them through the same workouts, even if they're quite different?

00:27:53.340 Yes. Oh yeah. Typically it's a very cookie cutter approach. Usually it's an insurance model thing

00:27:57.920 where they know that these certain exercises and putting ice or stim is going to be reimbursed by

00:28:03.640 the insurance company. So the PT clinic is going to do that on everybody, regardless of what they

00:28:07.620 need. So that's one of the biggest pitfalls is it's never one-on-one. It's not custom. I mean,

00:28:11.980 in the same way I've had pro athletes come in and we're supposed to do a shoulder rehab that day

00:28:16.660 and the night before they did a ton of stuff to their shoulder. So guess what? I'm not doing

00:28:20.840 anything. They actually need to recover that day. It needs to be customized. To go back to your

00:28:24.600 original question of how do people navigate this world? I think your rehab clinic needs to do more

00:28:29.720 than just offer services. They need to offer a plan. This idea that, okay, this is what I offer. I offer

00:28:34.940 cupping or dry needling or whatever it could be. One service doesn't ever fix anyone and it definitely

00:28:40.300 doesn't increase their capacity over time. The magic word of capacity is what it's all about.

00:28:44.200 Are you building me back to what I want to do? So if your rehab clinic is a bunch of passive

00:28:49.180 modalities on tables and a bunch of techs doing ultrasound and stuff, that's a red flag for me

00:28:54.260 because they're not going to build you to get stronger and stronger. Number two is the orthopedic

00:28:58.260 needs to actually be hunting down that physical therapy. So a lot of times what I see in the

00:29:02.880 orthopedic world is they have to give their clients something for rehab guidance because they're not

00:29:08.500 totally sure if their client's going to go do rehab. Can they afford one-on-one and all these

00:29:12.420 other factors? So they give them this handout. Well, a lot of times this handout is from 30 years ago

00:29:17.400 and it's the same five or six cookie cutter exercises, but then there's no accountability.

00:29:21.900 There's no nuance. So there's just a lot of holes in this path to trying to get your shoulder or your

00:29:27.480 back or your knee from it hurts. Do I need surgery or not? Built all the way back up to I can do whatever I

00:29:32.300 want. Now, is this taking the extreme example at the other end, which is professional athletes.

00:29:37.260 You work with a lot of them. You work with golfers, football players,

00:29:40.960 basketball and baseball players typically, right? Is there any other type of athlete I'm missing?

00:29:44.100 You know, I've had some incidental tennis people, a lot of runners too.

00:29:46.960 Yep. Now, some of those athletes come with deeper pockets than others and come from leagues.

00:29:52.640 So when you're talking about the NFL players, for example, is that problem completely solved?

00:29:57.940 No, not at all. Still not. There's a lot of environmental problems. So one of the biggest

00:30:02.240 issues with all these people, and I have friends that work with all these professional teams that are great

00:30:07.260 and they're handcuffed because they only have their athlete for so long. So you all of a sudden get

00:30:11.940 this multiple cooks in the kitchen problem where even if everyone has no ego and the best of

00:30:16.460 intentions and they're most science-based people, they're still not sure, okay, what'd you do last

00:30:20.380 week? What are we trying to do? Are you in a contract year? Like there's so many variables for

00:30:24.280 pro athletes. So in a weird way, professional sports is wellness upside down. It's how can we get the

00:30:29.400 most out of this athlete, this commodity for their contract? And that's not really a long-term play.

00:30:34.000 What's been really interesting at 10 Squared is we've had some pro athletes approach us with

00:30:37.620 this idea of, hey, can you guys be my reliable, you're invested in me only and be my oversight?

00:30:43.680 Where are my gaps? Is this okay? Should I play through this pain? Because there are times you

00:30:47.760 play through pain, there's times you don't. But the most important thing is this idea of having

00:30:51.500 one person driving the bus who knows all your variables. Because if someone comes to us and

00:30:56.980 changes their centenary decathlon, like they want to change one item, like, hey, I really want to start

00:31:01.180 doing jump rope every day. And then we look at their testing. We're like, look, you're high risk

00:31:05.220 for Achilles. Let's bake into your program some really good, articulate, smart strengthening to

00:31:10.460 get you there rather than just hope it works out. So how do you guys do that? I didn't ask her in

00:31:16.400 advance if we could do this. So we might have to edit this out of the discussion. Can we use my wife

00:31:20.680 as an example? My wife is a client at 10 Squared. Great example. So Jill's a runner, like a little deer.

00:31:26.120 Runs, runs, runs, runs, runs. Built for it.

00:31:27.520 Yep. I'm very hands-off. Anything that has to do with her, actually, by design.

00:31:32.400 Can you tell us a little bit about her? And what did you learn when you did an assessment of her?

00:31:36.180 And how did that impact how she works with the other members of the team on the cardio side,

00:31:41.460 on the strength and conditioning side? Yeah. Other than saying that she's a saint for

00:31:44.660 having signed up with you. You want me to talk? Okay. Jill's a really great example because she had

00:31:48.880 some pain when she showed up. So my job immediately is evaluate that pain. Is that a structural

00:31:54.420 insufficiency? Are we worried about a real injury here? Or is that just an annoying nuance?

00:31:59.760 Based on the testing I did, so I did my clinical exam, but way more detailed than I normally would

00:32:04.720 in my private practice because at 10 Squared, we have the time. And we want to remove confirmation

00:32:09.140 bias. So we don't want me to just say, oh, your hamstring hurts. Let's order an MRI. Let's test it

00:32:12.680 six ways and in a smart, conservative way. And if all six of those indicate that, then we're going to do

00:32:17.500 an MRI. So with Jill, we saw some proximal hamstring issues. She's of course, like you mentioned,

00:32:22.180 endurance athlete, her profile, her demographics, her running history, all pointed to there might

00:32:27.980 be a tendinopathy there. And then based on my testing, it reinforced that. So I said, let's get

00:32:32.580 an MRI. Let's really evaluate this tendon because we knew in the near term within a year, she wanted

00:32:37.560 to run Boston. And as a injury person, I saw this as, look, she's okay now, but it hurts. Once we start

00:32:44.240 stacking up her mileage, that thing's going to get in the way. There's another detail here that I do

00:32:47.820 recall, obviously you recall as well, but it might be worth pointing this out to the listener. So

00:32:51.980 she normally only runs one marathon a year. Last year, she ran two. She ran her Boston qualifying

00:32:58.760 marathon, which I think was Chicago or Houston or something like that. And then got into the London

00:33:06.440 marathon and went and ran that seven weeks later and started to get for the first time ever, a little

00:33:12.900 bit of knee pain. Yes. The other knee. The other knee. So can you explain why you didn't think that

00:33:19.540 was a coincidence? Very much so. So that story perked my ears up, that history. And I saw her for

00:33:25.500 knee pain in brief to get her through London and that kind of stuff. But the way runners move, a lot

00:33:29.580 of people don't appreciate, but running, even though I'm moving straight ahead, is technically a

00:33:33.500 unilateral or single leg rotation propulsion drill. Explain what that means because it's

00:33:37.880 counterintuitive. It really is. So golfers are actually the same. Their single leg actually rotates to

00:33:42.600 create that torque. So what happens is my favorite term that's out there right now is called the

00:33:46.620 spinal engine, which really speaks to this reciprocal movement of the spine on top of the

00:33:51.520 pelvis and then my feet through the ground. So those three domains, if you will, work in unison to propel

00:33:58.480 me forward. It's a lot like with sailing, like you put the sail relative to the wind and it points me

00:34:03.240 in direction. All three of those domains have to work in sync. And so when I all of a sudden see an

00:34:08.420 athlete like Jill, she wasn't new to running. She definitely added her volume in a short window,

00:34:12.580 which is a great recipe for injury. But that right knee flaring up told me, okay, there's something

00:34:18.140 going on at either her feet or her pelvis that's not in sync because she essentially with her mileage

00:34:22.840 overloaded that right knee and created a repetitive stress injury. So that's why I was saying earlier,

00:34:27.780 injuries don't just show up for fun, right? The great almighty above didn't say, Jill,

00:34:31.500 right knee pain today. And so whenever you see a story like that, and then you do the evaluation

00:34:36.860 and the way her pelvis was rotating, the way her core and her spine were set up,

00:34:41.020 and also the way that left hamstring was affecting her motion, she was basically dumping into that

00:34:46.700 right knee over and over 10 miles for someone like her, no big deal. You stack up two marathons pretty

00:34:51.660 close with that much mileage, all of a sudden that right knee really flares up. And so the right knee

00:34:55.740 flare up was actually an indicator of something else going on functionally. And it wasn't only about

00:35:00.680 making her knee better, which is what traditional medicine does is like, okay, rest it, ice it,

00:35:04.560 maloxicam, treatment, rehab, chiro, whatever. And then the knee's better. And then traditionally,

00:35:09.600 those people go run again and three or five months later, it comes back. So we need to look at these

00:35:13.560 asymmetries everywhere else, not just the side of pain. And so if the knee is caused by the hamstring,

00:35:20.020 what do you think is the cause of the hamstring injury? And why are women, middle-aged women,

00:35:25.140 so susceptible to this injury? Yeah, great question. I think demographically,

00:35:29.700 a lot of middle-aged women, it's getting way better, but don't strength train, number one.

00:35:34.080 So the health of their tendons and the muscle fibers and the mass of the muscles just aren't

00:35:38.380 normally as high and as strong as someone else, especially if they're an endurance athlete.

00:35:42.260 Runners nowadays know that they need to cross train, but how they're doing it and what it looks

00:35:46.060 like is still a big gap in my opinion. So using the word cause is always tricky in biomechanics

00:35:50.720 because it's always kind of like the snake eats the tail, like they're all kind of intertwined.

00:35:54.080 But the most simple way of describing it is that tendon overuse, what we found out with her MRI is

00:36:00.240 that she had a true tendinopathy, damage to that proximal hamstring tendon, as well as one of the

00:36:04.920 hip rotators that inserts on the same site next to that hamstring had a little damage and irritation.

00:36:10.020 That area was a byproduct of the way she was rotating through her pelvis and the way that

00:36:15.980 spinal counter rotation was happening. Jill has a tiny bit of scoliosis, which sets her up for that

00:36:20.720 asymmetry. And so her brain subconsciously was basically forced with the decision of,

00:36:25.860 do I jam my right low back or do I really try to pull with that left hamstring? And that combination

00:36:31.720 over time created a little fraying in the tendon. And the other thing I would add to this, which I

00:36:36.340 suspect any woman listening to us who's had kids will appreciate is even though Jill is tiny, she said

00:36:43.780 her body never went back to pre-pregnancy. So if she talks about how she used to run before 2008,

00:36:52.460 so our first child was born in 2008 and she ran a bunch of marathons before then, and then she's

00:36:57.840 run a bunch of marathons since, and she weighs the same. She's been very fortunate in that regard that

00:37:02.320 her body weight hasn't changed in that period of time, but she says she cannot biomechanically do what

00:37:09.480 she used to be able to do. Now, when I hear that, I assume her pelvis was mechanically changed having

00:37:15.940 kids and she feels it, but she can't articulate it, nor can I necessarily, but she just says there's

00:37:20.540 something different. She felt like she used to float and now she feels like she runs.

00:37:25.360 Yeah, right. She's colliding. I could definitely see that. And I think a lot of women feel that way.

00:37:29.520 My wife had the same experience. I think one of the biggest crimes in modern medicine today is that

00:37:34.600 a running back, if we blow an ACL, we know exactly what to do. And there's a protocol and everyone's like,

00:37:39.280 okay, in eight months, this athlete will be back. But women, everyone cares about the baby.

00:37:43.760 The baby's born. Even the mom cares about the baby. They sacrifice their own body just to make

00:37:47.460 sure this little creature grows up and gets everything it needs. And so this focus on what

00:37:52.700 women need the first year after is very lacking in my opinion. I hope somebody is listening to us,

00:37:57.800 by the way, and is thinking of another type of a 10 squared, which is what are we doing for women

00:38:02.740 immediately post baby vaginal and C-section is two totally different operations or two different

00:38:08.940 things. There should be really robust rehab paths to get them back in amazing shape immediately,

00:38:14.500 as opposed to, we'll come back to this in 10 years.

00:38:17.940 The complexity of what they deal with is fascinating because not only do they just add weight by adding

00:38:22.860 this human, the relaxing hormone creates areas of stress and laxity that will shorten up and tighten

00:38:28.480 up over time, but it affects different women differently. Some women's feet change in that environment of

00:38:33.760 more relaxing and carrying more weight. The arch and the foot gets affected. And so in a way I

00:38:39.500 always look at it as like, okay, all these areas suffered a little bit of what you might call as

00:38:43.080 an injury, but let's look at it like, okay, it's a natural process, but how do we account for all

00:38:47.700 these layers? Like no one out there is telling women to do foot strengthening when they're two

00:38:52.720 months pregnant, but they should be.

00:38:54.260 I wouldn't have thought of it until you just said it now.

00:38:55.760 Yeah. Literally women, just like we did for your shoulder, if you find out you're pregnant,

00:38:59.240 you should start doing some foot strengthening things, some core stability stuff. There's a ton

00:39:03.440 of things you could do prehab. Then after, obviously, you know, God willing to see how it

00:39:06.880 goes and get the baby good, but then you start trying to strengthen the right way.

00:39:10.800 And I think there's something about the pelvic floor that is absolutely decimated in pregnancy

00:39:15.400 or delivery more to the point. And I deep down believe, no pun intended, that that's a part of

00:39:20.640 what has gone wrong in her hamstring. And I see this in many of her friends. This is a very common

00:39:25.100 complaint. And it doesn't present as even a hamstring injury. It presents as either a knee

00:39:29.580 injury, like an ischial tuberosity pain, which is like the sit bone. And they say, oh, it's just

00:39:33.900 not comfortable sitting. Yeah. I don't want to sit.

00:39:36.200 Oh yeah. One of my favorite orthopedic surgeons in town, he called me and he's a hip ortho,

00:39:39.720 great guy. And he's like, hey, you got to help me out here. My wife has the same issue

00:39:43.760 and she's been doing traditional PT for like eight months and it's no better. And she's about to fire me.

00:39:48.440 She's like, what are you doing? But it's a very common thing. And that's, what's been really

00:39:51.640 cool for me to see these pelvic floor specialists that are arising. It's really cool field, ton of

00:39:57.480 expertise with it. I am not an expert in pelvic floor by any means, but you touched on the pelvic

00:40:02.140 floor is very much a big player in how we pressurize our intra-abdominal stability. It's basically the

00:40:08.700 flooring of that whole canister that we're supposed to create with proximal stability. And so if the

00:40:13.520 diaphragm or the pelvic floor isn't doing its job, then our body's going to immediately start to

00:40:17.600 compensate and create rotations and tilts around things.

00:40:19.940 Let's talk for a minute about the core. I hate the term because it's so misused,

00:40:25.160 but the way we talk about it is probably most closely aligned with how DNS thinks about it,

00:40:30.520 dynamic neuromuscular stabilization. So maybe just say a moment about it through the lens that we

00:40:35.200 think about the core as a cylinder, as opposed to quote unquote abs.

00:40:39.620 Yeah, exactly. I think that's the starting point that I wish everyone could automatically

00:40:43.600 understand is that if you have a really prominent rectus abdominis at six pack, that has nothing to do

00:40:48.640 with how you stabilize your trunk, especially if I'm doing things in multi-planes like tilting and

00:40:53.020 rotating. So it's not just your obliques either, but it's the deep stabilization system that not only

00:40:57.880 pressurizes with our diaphragm, the pelvic floor, but it's also all the small muscles up and down my

00:41:02.520 spine, including like multifidi. Do all those muscles kick on and create stiffness in the right

00:41:07.140 way at the right time? I think a lot of times people are accidentally over coached into thinking

00:41:12.140 they only need stiffness because the second step to that is, okay, now I can activate that deep

00:41:17.080 stabilization system. I have that bracing. I'm pressurized. I'm using my transverse abdominis, all these other

00:41:22.000 structures down there. Now, can I do that with motion? And that's where you start looking at someone

00:41:27.260 kicking or running or throwing. That needs to be a dynamic system, not just a stiff system. And I think a lot of

00:41:33.760 people, they don't have the first one. So they see a ton of these exercises like the DNS three month or dead

00:41:39.500 bugs or whatever else you want to call them that create deep core stabilization, but they don't see

00:41:43.380 the next step after that, which is, okay, now how do I maintain that pillar and that strength? And

00:41:48.480 then I get a free shoulder blade or a free hip to move. And one of our shared clients, he had a lot

00:41:54.440 of radicular nerve pain from a disc issue and he was convinced he had some of that. But one of the most

00:41:59.880 fascinating cases for me in recent memory, because with him, we were able to actually find a trigger

00:42:04.740 point that referred pain that mimicked that radicular nerve pain. So when we literally pressed

00:42:10.200 on his glute minimus, he got a referral that he thought was a tribute to his back. So that was a

00:42:14.960 window towards, okay, that's a muscular issue. That's not your spine causing trouble. And then we

00:42:18.940 gave him these stabilization drills, which helped that glute just relax for once. What we see all the

00:42:23.740 time in the clinic setting is muscles are meant to be a muscle. My bicep is meant to contract and relax.

00:42:28.720 It's not meant to be a shoulder stabilizer, but if my stabilization isn't doing its thing,

00:42:33.440 then that bicep and the trap and all these other muscles try to help. And that's where we lose

00:42:37.980 freedom of movement because your body's essentially perceiving a little threat, a little instability.

00:42:42.140 And so it tightens other structures up. So then I see people coming into our office saying,

00:42:45.800 will you dry needle this or work on me or do soft tissue work? They go to the stretch place.

00:42:49.940 That's going to be a six hour benefit. But if we activate this deep stabilization system

00:42:54.280 and get all the parts moving in unison and in sync, all of a sudden those movement problems go away

00:42:59.480 and you're much more robust and strong. Yeah. There's so much I want to say on this.

00:43:03.440 I don't want to lose the thread, but I'll sort of say two things that seem unrelated,

00:43:06.920 but they're quite related. The first is I wish there was another word for stability that didn't

00:43:11.580 imply static. We think of that as things that are not moving. So rigid, stable, et cetera.

00:43:18.520 But the truest way to appreciate stability is kinetic stability. That's why in the book,

00:43:24.120 which I know you haven't read, but if you do read it one day, no, I've been too busy.

00:43:27.980 Yeah, I know. The section of the book where I write about stability, the analogy I use much

00:43:33.000 against the desire of my publisher who hated it was that of a race car. Because again,

00:43:39.760 you're thinking like, how does a race car explain stability? But if anybody's driven a race car,

00:43:43.960 or if you haven't, if you can take my word for it, one of the fundamental differences between a race

00:43:47.940 car and a street car is that in a race car, you're transferring much more of that horsepower to

00:43:54.540 the tires than you are in a street car. In a street car, a lot of energy seeps out because

00:44:00.180 the chassis is not very stable. And you might say, well, why? Well, in the case of a car,

00:44:06.400 it's because it's more comfortable. Race cars are not being optimized for comfort. They're being

00:44:09.700 optimized for performance. If you're optimizing for performance, you actually want more stability

00:44:14.920 in the chassis and the suspension so that you're transmitting more force to the tires and the tires to

00:44:21.980 the surface. And similarly, when you think about an individual who has stability, they are able to

00:44:27.980 transmit force much more directly to the outside world, and they are able to receive force more

00:44:35.780 safely from the outside world. And that's why no matter how long you ever gave me, I could never

00:44:42.300 throw a hundred mile an hour fastball. And it's not that I don't have the strength. I'm sure that if

00:44:47.300 you put a 20-year-old version of me next to a pitcher, I could have outdone him in every measure

00:44:54.160 of strength, but I didn't have the stability to be in motion and stabilize the capsule of my shoulder

00:45:02.380 and transmit force like a whip through my arm. You wouldn't look at a pitcher and think that's

00:45:07.960 stability, but it's remarkable stability. Dynamic stability. Absolutely. And there's a ton of analogies

00:45:13.840 I've heard over the years. I'm not a car expert like you, but one of the ones I've used a lot in

00:45:17.760 my practice is for a while, I had this really old truck that we were working on, and it was like a

00:45:21.920 mid-80s Chevy kind of thing. And when you turn the wheel from, my hands are at, let's say, nine and

00:45:27.500 three, it wouldn't turn until my hands got to like 12. The steering on that thing was sluggish. So that

00:45:32.840 dynamic stability, it wasn't very good. Whereas like an F1 car or go-kart, that thing moves with

00:45:37.240 micro movement. So if you translate that to the human body, anybody listening, if I said, hey, do a skater hop

00:45:43.040 where you leap laterally from one side to the other, how you land, can you stick that landing

00:45:48.300 or are you falling over as you go? And there's a million variables involved there, but the big

00:45:53.040 ones of course are your rate of force. Can you absorb that? Can all your tissues, the arch, the

00:45:59.220 Achilles, the IT band, the hip, your core, can all those tissues kick on at the same time to create

00:46:04.880 stiffness? Number one. And a precursor to that is where's your balance? To generate that first force,

00:46:10.560 were you organized or did you have to like throw your head and hands a weird way to generate the

00:46:14.780 force? But now I'm not in an optimum landing position. So what a lot of times you see in youth

00:46:18.980 athletes is people rush to put strength on them, but a really good strength coach can put strength

00:46:24.360 on a college athlete, you know, in eight weeks. But do they have speed? Do they have organized

00:46:28.980 movement? Are they quick in all planes of motion? Is their balance really good? Because now my nervous

00:46:34.420 system, my software is ready to absorb all these things. And then you put strength on top of that,

00:46:38.900 that's a great athlete. And a lot of these genetic people that are just naturally really good,

00:46:43.180 they have some of that underlying ability to where they can land and organize well.

00:46:47.420 And then later they put strength on. Pick a sport and you can show me somebody who

00:46:51.000 was really athletic and they weren't really big and strong, but you can put the strength on later.

00:46:55.860 And that's one of my biggest personal passions is these 14 to 15 year olds who just get berated in the

00:47:00.660 gym and then they tweak their back. I had one local team where it was a golf team and about 30% of

00:47:06.920 their athletes had a stress fracture in their lumbar spine.

00:47:09.600 Oh my, what?

00:47:10.560 Yeah, it was absurd.

00:47:11.600 How is the strength coach not getting fired?

00:47:13.920 So I reached out to the head coach and the strength coach and to give all these people a

00:47:18.300 little bit of a pass, they're not really equipped because they're managing 200 kids. I think it's

00:47:23.460 just a bad setup. You have 200 athletes that you're supposedly managing a program for and you're

00:47:28.340 not watching technique. Whether or not you know what you're talking about, it's a whole nother

00:47:31.440 argument. But like the idea of, okay, we're going to do a high performance on a 14 year

00:47:35.260 old and put strength on them, but no one's watching technique or teaching them the foundations

00:47:38.360 of lifting. While at the same time, they're 14, we should be making them quick, athletic

00:47:42.260 and coordinated first because that's a platform you want to build an athlete on. You don't

00:47:46.280 want to make a kid really slow, but really strong when they're 15. It's really hard to

00:47:49.740 train speed as you get older.

00:47:51.100 So when a client comes in at 10 squared and you do an assessment, how do you gauge how far

00:47:56.060 they are away from being able to do the dynamic movements? How are you gauging? What are

00:48:02.420 you testing? What are you looking for to say, yeah, this person could start doing

00:48:05.680 plyos? Like for example, one thing I love doing, I don't have this on my centenarian

00:48:09.660 decathlon list because we're being so strict about that only having 10 things, but I have

00:48:15.200 kind of a side list of things that I want to be able to do. Like I want to know how late

00:48:20.100 in life I can maintain certain metrics. And one of them is how late in life can I still

00:48:25.060 do a broad jump of my height? So why is that something I enjoy doing? Because it combines

00:48:29.780 two things. It combines the concentric strength and power to be able to leap. But even more

00:48:36.440 importantly, and at least as difficult as it requires the eccentric strength to land

00:48:40.820 and decelerate really quickly. How do you know when you look at someone, if they're ready

00:48:44.720 to do that, for example?

00:48:46.680 We did a ton of work. The literature and the science is out there to a degree for you stack

00:48:50.800 things on top of themselves. So you start with isometrics, you progress people to more explosive

00:48:55.600 or compound movements. So let's assume that I don't have any injury risks at all.

00:49:00.600 And you would determine that based on just my history?

00:49:03.060 No, and testing. History, testing, demographic risk. There's a lot of variables we look into

00:49:08.000 for having concern about musculoskeletal injury. That's number one. But yeah, every person is

00:49:12.460 different that way. And we've had people come in who've had multiple surgeries and injuries.

00:49:16.100 And then we've had other people come in who they're high risk for injury, but overall they're

00:49:20.460 pretty good package to work with. There's not a lot of medical concern, if you will. So ignoring

00:49:24.240 all the medical side of it, I really like following the principle that the exercise is the test.

00:49:29.200 Because we basically look at everything about four to five different ways. But if I watch

00:49:34.140 someone do, let's say a wall squat.

00:49:36.380 So just to be clear, people understand a wall squat is just level one. It's isometric.

00:49:40.220 Isometric load. It's what we all used to do in like high school practices where it burns

00:49:44.660 your quads and your patellar tendons. And we can even set you up to where you're in the right

00:49:48.180 position. So that's going to tell us a comfort with the position. Number one.

00:49:52.240 Is failure constituted by pain or not doing it for a certain length of time?

00:49:57.600 Every metric we have has a qualitative and a quantitative associate. So the quantitative,

00:50:02.960 we have minimums. It's either time or percentages of body weights for every test or distances,

00:50:07.520 like you mentioned on the broad jump. But then there's also like, how does it look?

00:50:10.960 And then the how it looks one is the vague part of the movement world. So you're going to have your

00:50:15.460 coach and myself both looking at it. But then we have other ways where we're confirming that with our

00:50:19.760 motion capture machines, with our force plates, with our videos that analyze the movement. So

00:50:24.680 there's a lot of ways to confirm. You can also see these things cross over. So how does someone do

00:50:29.340 on the double leg versus single leg? Gives us a really nice window to, okay, where's the lack?

00:50:34.640 Great example, two leg, really strong. They're solid. We put them on single leg and they're

00:50:39.760 abnormally less functional and weak and don't have the range. So I'm immediately thinking, okay,

00:50:44.260 there's a balance control issue here. Cause on two legs, I'm really stable, but on one leg,

00:50:48.600 I'm significantly less stable and it's much more complex for the body. And so if their scores,

00:50:53.440 even though they're strong and their quads have that capacity, but when they're on single leg,

00:50:57.040 they're not strong and they can't stabilize. That gives me a window right away to saying this

00:51:00.680 person has a major balance risk or things like that. And in the case of that individual,

00:51:05.100 do you not progress them? No, we find their floor and we build from there. So some people will have

00:51:11.100 really cool, robust Instagram where the exercises for one region, but another area we're filling in

00:51:16.240 gaps, we're building foundations and we're basically building them up from wherever those

00:51:20.140 floors are. And the key for us is this big grid we have, where we have every category movement we

00:51:24.260 care about, and then we build them from their floor. So I'm really visual person, but I always say,

00:51:29.040 okay, we have this baseline floor, maybe for their upper body pull, they're on the third floor,

00:51:33.080 they're bad-ass, they're killing it. But then their core stability in one plane is like in the

00:51:37.320 basement. Like I'm worried about a lumbar stenosis or a nerve issue. So that takes precedence first,

00:51:42.120 because I don't want this person to experience pain and I want to build them up to where they're

00:51:45.300 all on the first, second, third floor of the building. Okay. So let's go back to Jill for a

00:51:49.020 minute. So we have this diagnosis, which is, okay, we've sort of figured out why your knee is hurting.

00:51:54.020 We now have a radiographic diagnosis that completely comports with what's being seen on the physical exam

00:51:59.640 and symptoms. These are stubborn injuries. What was the next step?

00:52:03.660 The next step was immediately, you have to have a parts approach first. If I have a

00:52:07.100 damaged part, we got to make sure, does that need intervention or not? How are we going to

00:52:10.980 address that? So with Jill, we knew her foundational underlying movement patterns or dysfunctions,

00:52:16.300 if you will, that were contributing to that. So we put a package together for her program

00:52:21.440 that was all of those underlying structural functional issues that didn't make the hamstring

00:52:26.340 worse. We started building those right away while we considered platelet-rich plasma. And she actually

00:52:32.320 ended up going for it to create essentially regeneration of that tendon at the damaged site,

00:52:36.180 which she did perfect with. We had to have a lot of come to Jesus conversations about you cannot run

00:52:42.160 too soon. If we're going to go through all this trouble and financial costs, we want to make sure

00:52:47.000 that that can heal as much as it can. So everything we did in her programming was to ensure we didn't

00:52:51.800 flare that up. And then conversely, we really communicated with not just the strength team at

00:52:57.020 10 squared, but also her physical therapist offsite and her running coach. And all of us had to put

00:53:02.560 together this six month plan where her running coach didn't accidentally flare it up because he

00:53:07.120 doesn't have a window to everything we're doing. He definitely needs to talk to the PT as did we

00:53:11.300 to where she could quote, get medically cleared. I should know this because I live with her,

00:53:15.120 but I don't remember exactly how long she actually had to stop running. I know that it was right after

00:53:20.140 the first and second PRP injections, but does eight weeks sound about right?

00:53:24.200 Yeah. So because of her timing for the race and she wants to run Boston, we had a little extra

00:53:30.560 runway. So the more healing time you can get, the better. We have a lot of people who are like

00:53:34.540 really impatient dying. If you're a pro athlete, you might not have that luxury, right? But that's

00:53:38.280 what's been fun for me about 10 squared is I don't have all these environmental constraints. I could

00:53:41.660 just get to look at people. Right. When you're training for an event that's 30 years from now,

00:53:46.420 you don't have to take shortcuts. Yeah. Let's take a breath and be really detailed.

00:53:49.460 And so with Jill, the PM and R docs and the physiatrist will always kind of give you different

00:53:53.920 amounts, but usually two rounds for her issue. So you do one round of PRP, basically do nothing.

00:53:59.740 And then you do another round about two weeks later, and then you slowly let that heal and

00:54:03.940 you start to add physical therapy. So with Jill total time, we were doing a ton of stuff around

00:54:08.820 the area of the injection right away. That's imperative. You don't stop everything. You just

00:54:12.960 protect the area and you train everything else. So that is going to be one of the reasons why we get a

00:54:16.780 lot of success with her. And then back that up with, we really did targeted physical therapy

00:54:21.480 for that site to promote the healing. So the physical therapy side, they're using a ton of

00:54:26.720 things like BFR, dry kneeling where necessary, everything you can to just help those parts heal,

00:54:31.580 foster that growth hormone, foster that protein synthesis, build that muscle up without a lot of

00:54:36.240 force in the tendon. All those things that a traditional physical therapist that knows what

00:54:39.820 they're doing, they can crush that. Yeah. And she for eight weeks had to swim.

00:54:43.480 She was pleasantly open-minded. It's hard for every athlete to not do their sport. I get that,

00:54:48.660 but I've delivered that medicine over and over for a long time. And so she swam. So she didn't

00:54:53.260 lose any true cardio, right? She lost a little bit of running strength, but someone with her

00:54:57.140 background and her base, and then keeping everything else really strong, she's going to

00:55:01.240 hit the ground running and she's running now and doing really well. And so I always say I have two

00:55:05.640 athletes. I have an athlete that I have to encourage, like it's okay. Those tend to be more your

00:55:09.280 traumatic, acute, like ACL type people where you got to show them in the lab and show them in the

00:55:13.820 gym that it is okay. Keep pushing. You're good. And then I have the other athletes where you have

00:55:17.960 to hold them back. And so Jill's going to be that one, like, let me go, let me go. And we have to

00:55:21.940 play bad cop just enough where science supports that. So where she doesn't flare it up again,

00:55:27.120 because we need her to have a nice, smooth progression. I'd rather her be really balanced

00:55:30.800 and athletic and strong and feeling good on race day, not like a bunch of junk miles and that tendon

00:55:35.340 in the knee starting to hurt her again and stuff like that. All right. So let's pick another type

00:55:39.280 of client that you'd see at 10 squared, which is maybe somebody who comes in who doesn't have a

00:55:45.000 great training history. They've never really been an athlete, but the thesis really resonates.

00:55:49.960 They sort of go, you know what? I get it. Like, I feel fine now, even though I'm not particularly

00:55:54.180 athletic and I'm not training a lot, but I'm young enough that it hasn't caught up with me yet.

00:55:59.680 You know, I'm in my forties or whatever, but I now accept that when I do my test,

00:56:04.560 because those people don't typically do very well on the assessment. You can't hide from not

00:56:08.420 having done the work. So how do you think about where to start when there is so much work to do?

00:56:14.380 So you talked earlier about this is on the second floor. This is on the first floor. This is on the

00:56:18.680 penthouse. This is in the basement. We're going to focus on the basement. Well, what do you do when

00:56:21.760 everything is first floor basement? Number one, we got to build the habit. That's a big part of this

00:56:27.240 is when your coach is basically in contact with you every day, as much as you want

00:56:31.180 to help bend and twist and develop that formula. So where that person is actually encouraged to do

00:56:36.900 it, they enjoy it, they like it. I've had people tell me, yeah, this core stuff makes sense, but I

00:56:41.500 just hate getting on the floor. Okay, we got to pivot and change the program. If I just try to

00:56:45.860 convince you to do an exercise that you hate doing, it's not going to last. That's number one.

00:56:50.240 Number two is we want to really mitigate the risks of injury. You get some momentum going on the

00:56:54.580 psychological habit side and then, oh, I pulled my hamstring. I'm devastated. So we got to get those

00:57:00.000 foundations going. But then usually we look at the medical risk side. So some people, the CPAD test was

00:57:05.660 terrible. Their VO2 numbers are bad. In our society, you got to have a good heart. We want to get that

00:57:10.300 off the table from a risk factor. So we'll probably really put that routine cardio in, in a manner in

00:57:16.240 which we don't flare up the things that could create an injury. So one client we had recently,

00:57:21.720 he didn't know it. He didn't bring it up. He's never had leg or foot issues at all,

00:57:25.720 but his testing, his calves, he's a big fall risk. His calves were crazy weak. His balance wasn't good

00:57:31.720 because he didn't have strength. And he's definitely a high risk for an Achilles.

00:57:34.760 How old is this person?

00:57:36.060 52.

00:57:36.840 You wouldn't expect to see that in somebody so young.

00:57:39.020 Yeah, but he's just poured himself into his career and really successful, really smart, cool guy,

00:57:43.500 but he just hasn't trained a lot of stuff. And he had kind of a health scare,

00:57:47.180 which is what motivated him to like get organized. Let's get this stuff right.

00:57:50.240 It was interesting to see his really successful analytical brain use that scare to be like,

00:57:55.060 okay, I got to get sorted out. You can see he operates his business the same way.

00:57:59.100 Problem identification, what's the solution? Problem solution, problem solution.

00:58:02.460 So with him, he didn't know he had any of these risk factors, but he was a textbook for having a

00:58:07.660 fall or blown out his Achilles because of the weakness and the lack of capacity and strength he had.

00:58:13.500 And if you were to handicap that, how many years away would he have been from something like

00:58:18.120 that being quite likely? Is this something that's going to happen before he was 60?

00:58:21.540 Yeah, he's definitely in that bucket of, he could have been, it's a little fear mongering,

00:58:24.900 but like he wasn't set up to like having to change direction quickly or maybe trips off a curb after

00:58:29.840 dinner in New York. He could have had something like that easily. Big guy too. So top heavy,

00:58:34.620 just like me, big tree fall hard. So with him, he wasn't even aware of that weakness,

00:58:39.000 but the last thing we're going to do is give him a running program.

00:58:41.520 We got to design his CPET stuff and his VO2 max training and his own two training

00:58:45.960 around these inefficiencies with his body. And so the workout in the gym needs to link up

00:58:52.160 perfectly with those risks. And also what is the most important thing for him right now?

00:58:56.300 Is that difficult to communicate to clients because do they ever feel like, Hey, I'm not

00:58:59.880 doing enough? Oh yeah. A lot of people are overwhelmed, but what's been really nice is the

00:59:04.540 data, but then the calibration. And so what's been really cool with some of our clients we've had for

00:59:08.620 several months now is consistency is always the name of the game, especially when we're playing

00:59:12.900 the long game like we are. And if someone's going on a two week vacation, we want to know

00:59:17.680 where are you staying? What does the gym look like? We will change your workout so that you can keep

00:59:23.360 doing it while you're on vacation. And if you tell us, look, guys, I'm going to be really active

00:59:26.740 in the day. I kind of want to decompress. I've been working in my basement garage really hard for

00:59:30.400 three months. Great. Let's take care of the total human. Let's give them a 30 minute small thing

00:59:35.300 to where it can almost have that lightning of the mental load just decompressed, but he's still

00:59:39.860 making gains and he's still building that up. That's what's been fun for me that I almost never

00:59:44.600 got the chance to do, even though I wanted to with some of my athletes, because there would be so many

00:59:48.720 variables in the way. With this, if we get a video of your gym and we know, okay, they don't have a

00:59:52.840 bench that goes to incline, but we do have TRX and they have a treadmill that goes to incline, but they

00:59:58.020 don't have a bike. We can change their workout to where they keep marching along and it's an agreeable

01:00:02.200 way for them. And it's not just like, oh, I was on vacation. I didn't work out for two weeks

01:00:05.160 because you get muscle atrophy. If you don't work out for two weeks, we go backwards. That's a

01:00:08.820 bummer. Yeah. This idea about foot reactivity is so important. I've been much more attentive to it

01:00:14.960 in the past couple of years. And I've noticed the number of times when I've lost my footing and

01:00:21.660 regained it. So I've never had a fall. It's never resulted in anything because it's been

01:00:25.940 caught. But I keep thinking to myself, this is the type of slip that can be devastating because

01:00:32.780 these are really type two fibers that are doing it. And the type two fibers atrophying as we age

01:00:37.240 are the types of jumping things that we do sufficient to preserve it. If you're someone

01:00:41.300 like me and you, who part of our CD involves probably walking on uneven surfaces one day,

01:00:46.960 whether for you it's rucking, for me it's maybe going out and hunting or something like that,

01:00:50.520 you're not walking on pavement and you're not even just walking on beautifully manicured grass.

01:00:55.580 Yeah. It's slanted to the side. It's like pebble gravel.

01:00:58.720 You're always going to lose your footing somehow and you have to be able to regain it.

01:01:03.500 What are the most important exercises that you need to be doing to maintain all of the

01:01:09.020 characteristics of tissue and nervous system to preserve?

01:01:12.860 Yeah. I think the best way to answer that is more principle-based. So I think number one is we

01:01:18.020 behave in a three-dimensional space. So this idea of only doing calf raises, my toes pointed straight

01:01:23.500 ahead, insufficient. Because to your point, there's going to be moments where my toes are out or one

01:01:27.800 toe is out. So we want to do all these strength exercises in multi-planes of motion. And that

01:01:32.880 doesn't mean even in a static position, but that's like a lunge, lunging to the side,

01:01:36.820 lunging backwards. You want to train in a three-dimensional space, number one. So

01:01:40.620 all of your training should account for that. If we're just doing bicep curls and calf raises,

01:01:44.780 it's like I'm on these railroad tracks, but the minute you make me go sideways or rotate,

01:01:48.140 it's trouble. So three-dimensional, number one. Number two would be to get motor unit recruitment

01:01:53.760 to really make sure that those muscles are firing. You need to do really heavy loads or things that

01:01:59.540 are really fast to get that nervous system to like wake up and respond. The problem with that is not

01:02:04.140 a lot of us are ready for that. So what you usually start with is really long hold isometrics.

01:02:09.820 So we put you in these different positions and find ways to resist that and pull and create

01:02:14.840 stiffness and remodel those tendons. So we're essentially making those parts ready to start

01:02:20.700 going into the danger zone that is explosive, powerful movement. I shouldn't say danger zone

01:02:25.120 as much as I should say like a higher ask. Risk zone. Yeah, risk zone.

01:02:27.840 So heavy overcoming isometrics, they call them. One of my favorites is that mid-thigh pull. It's kind

01:02:33.160 of a standard in the sports science world where you have a bar and you basically calibrate the machine

01:02:37.520 to where the bar is about the mid-thigh and it's almost like the very top of a deadlift and you just pull,

01:02:43.060 but the bar doesn't get to move. And the sensory input is like the four stacks and they're measuring

01:02:47.740 your balance, your force and all these other cool metrics. But holding that over time, we're now

01:02:52.360 isometrically loading the heck out of my grip. We're loading the heck out of my shoulders.

01:02:56.000 We're getting into my feet, my quads, my hips, and I'm just holding that for time. That sets all

01:03:01.280 these tendons up. And you just do this with a super, super heavy loaded bar that's too big for you to

01:03:05.480 lift? Not necessarily. You can actually do an empty bar, but you pull it up against the safety bars of the

01:03:09.200 rack or something like that. Isometric thigh pull is the thing to look up, but there's a lot of ways

01:03:13.520 to load these heavy isometrics because that gets your tissues ready and you build that up over

01:03:18.380 several weeks and that tendon adapts and now it's ready to resist force. And then the way you bridge

01:03:23.600 that is you start doing deloaded plyometrics. So now maybe we do some sort of like a band assisted

01:03:29.080 pogo where I'm actually pulling on a band overhead, pulling down on that band, it essentially lightens me

01:03:34.240 because the band's going to pull me back up. And now I get to train that speed and that quickness

01:03:38.840 through the ground, but it's not my full body weight. And so that's a great way to bridge from,

01:03:42.960 okay, now I've got the parts ready. Now can I deload the amount of force and train the speed?

01:03:48.240 Once I've got the speed going in the parts, now I just get to become an athlete and do body weight

01:03:52.500 and beyond. And so that's where you see these really high level athletes, even at early ages,

01:03:56.740 their trainers know how to build that paradigm up and bridge it across to where you don't get any

01:04:01.460 injuries along the way, but you get a really springy force resistant person. So many of us,

01:04:06.340 like we touched on initially, don't train pogos. We don't train plyometrics. If you go out to the

01:04:11.700 local men's or women's soccer league, how many people there are over 40? Not very many. Now there's

01:04:16.580 a lot of reasons why that is, but we're not playing games and we're not reacting to stuff. And so we need

01:04:21.480 to make the gym a safe space where we can recreate these things and essentially test out these movements

01:04:25.900 so I don't lose it. And maybe just to even things out so Jill doesn't think I'm picking on her

01:04:30.240 injury. Let's talk a little bit about my limitations. So the thing that's probably been my biggest source

01:04:35.320 of nag in the past 12 months has been foot ankle. Like let's talk a little bit about those injuries,

01:04:41.100 why they're occurring. And again, they're not debilitating. They don't actually prevent me

01:04:45.960 from doing a single thing, but because I'm sensitive, I just want to know, is this a harbinger

01:04:53.060 of something? What's your assessment of what's going on? And how would you even describe it? Would you

01:04:57.160 describe it as my ankle? Would you describe it as my navicular tailored joint? Where's the actual

01:05:02.060 issue in me? So with you, without getting your foot out, you have a very mobile foot. You're

01:05:07.420 swimming background. Swimmers have really great mobile feet. Show me a soccer player who had their

01:05:11.460 foot strapped in cleats for 10, 20 years versus a swimmer. Very different setups. So it really speaks

01:05:16.220 to how tissues adapt over time. So your feet have a ton of motion in them. They are not restricted.

01:05:21.100 You also do a lot of barefoot work in the gym, which is helpful for you. Your feet are actually

01:05:24.620 pretty strong too. If we test your big toe and your smaller toes, you don't test outside the

01:05:28.700 normal limits for strength requirements, but your biggest gap is that multi-positional stiffness and

01:05:34.360 that ability to create force absorption through your tissues. And you're actually set up for that

01:05:39.260 because you can move so much. You don't find those end ranges, either the bony end ranges or those

01:05:44.440 tendons can't grab because there's so much play in that pattern. So what you accidentally do all the

01:05:49.460 time is you'll go on a ruck or you'll go on a hunt where you're off-road and you're getting all

01:05:53.440 these angles. You'll slowly flare up a tendon and tendons are notorious for not hurting.

01:05:57.920 And thank you for not telling everybody the last cause of injury.

01:06:01.440 I would never.

01:06:03.260 Just for the listener. I don't know why, but I somehow decided two months ago to pick up a pogo

01:06:09.140 stick. Never done it in my life. Somehow decided, hey, is that in the bonus Centenary Decathlon for you?

01:06:16.420 Yeah, I was like, I'm going to add another activity. Pogo sticking up and down the driveway.

01:06:20.820 Yeah. That goes in the bucket of you should have called me first.

01:06:23.220 Like what a, I mean, the second I started, I was like, oh, not a good idea. I'm just glad

01:06:28.840 your feet not at the other end. So because your feet are so mobile, tendons are notorious for,

01:06:35.180 they don't really hurt at the time, but they hurt like crazy the next morning. And what you always

01:06:38.980 routinely say, which is really common if you're plantar fasciitis or patellar tendonitis is when

01:06:43.280 I first get up, it's really stiff and creaky and sore and hurts. And that's because tendons love

01:06:48.320 blood flow. They love movement and they love motion. And so all those chemicals that come

01:06:52.120 with inflammation, if we're just sitting around or sleeping, that's the opportunity to get stiff

01:06:56.200 and really sore and achy. With that kind of symptom pattern, you're not really lost on what it is

01:07:01.840 because that's classic tendon. You can walk, we can load it. There's no failure. So we're not worried

01:07:06.520 about a muscular strain or any other damage, but that tendon gets really hot and spicy, especially in

01:07:11.320 the mornings. If you're not creating that stiffness. Just to be clear, we are nine or 10

01:07:16.680 weeks ago since my pogo sticking debacle. It's no longer as bad, but every single morning when I get

01:07:22.540 up, there is still incredible and sharp pain right at that tendon. Why is this taking so long?

01:07:29.900 Well, tendons are one of the slowest things to heal. And I guarantee if we really zoomed in and

01:07:33.680 looked at all of it, you probably have a little tendinopathy in those tendons, a little damage here and

01:07:37.380 there that could be contributing to that irritation. But the most important thing is understanding the

01:07:42.500 tendons take months to regenerate. You and I've had a pretty consistent attack with it, but we finally

01:07:47.480 got you on a really good rehab program you're doing yourself where we're loading the heck out of it with

01:07:51.660 these isometrics and we're building the load more and more. And we're loading those isometrics in

01:07:56.460 different positions. So one of the ones we do with you a lot is that front foot hover, but you're

01:08:00.980 actually plantar flexing. So where you're driving, you're doing as much of a calf raise as you can

01:08:04.760 in that split squat position. And then we make you hold that while you do that split squat.

01:08:10.200 So it changes the whole angle and the relationship. We'll make a series of videos, of course, to go

01:08:15.280 along with this, but explain that exercise because it looks ridiculous. Nobody's doing that on

01:08:19.680 Instagram. They are, but they're drinking the Kool-Aid. Yeah. All right. But it's a complex

01:08:24.060 movement. So we've got a plate in front of me. Yep. Just basically creating a step. Like a 45 bumper

01:08:27.460 plate. So we're two and a half, three inches up. Yep. But my front foot, just ball of foot and toes are on

01:08:33.620 there. I'm in a split squat. Yep. What am I doing with that front foot? I'm lifting it

01:08:38.280 into plantar flexion. Yeah. For you, the goal was your toe off was one of the problems. So what

01:08:43.660 happens with you is when your foot, your heel lands, you're driving your body forward, your foot's

01:08:47.640 behind you. You would do like a little bit of a rotation out and create like a little bit of a

01:08:51.640 whip through where it wasn't nice and pure rotation rolling through the foot and the toe. It was complex

01:08:56.580 and putting extra stress at the ankle. That times 10,000 steps a day will really pick at that 10 and make

01:09:02.480 it sore, which is why you wake up the next day hurting. So what we're trying to do is put these

01:09:06.540 tendons at different lengths and then putting a lot of load through them. And then the complexity

01:09:11.480 we're adding isn't necessarily at that joint, but we're actually adding motion and complexity above

01:09:17.220 with the lunge and also the requirement of you having to stabilize centrally in that mid part of

01:09:23.040 your body while that foot is locked in. So someone with a really mobile foot, you tend to really use

01:09:28.600 that foot for everything. And that's how you spice up those tendons. And I'm essentially putting that

01:09:32.520 foot in a position where that tendon has to heal and it has to get stronger, but then I'm making the

01:09:37.320 other parts of your body reach that complexity and meet the demand. So this is the second time I've

01:09:42.320 had this flare up. The first time I had it was probably a year and a half ago when I really started

01:09:46.420 increasing rucking volume. This was caused by kind of an acute incident, which was the pogo sticking

01:09:51.240 where I clearly over plantar flexed or dorsiflexed, I guess was probably the extreme dorsiflexion that

01:09:57.260 did it. What do you think was driving it on the rucking side? And more importantly, what does this

01:10:02.060 mean for me? Long-term? Yeah. Because right now it doesn't matter. If this keeps happening and I'm in

01:10:07.320 my 80s, this is the difference between reacting and not reacting and being able to get around and not.

01:10:13.140 So how do I prevent this from being a lifelong problem? That dorsiflexion or bring your toes up,

01:10:17.860 the pogo, when it's a sudden acute force like that, you probably also just create a little bit

01:10:21.760 of a joint irritation. It's analogous to jamming your finger. If you move those two joint structures

01:10:26.040 together really hard quickly and your body can't absorb that force, that'll get a lot more sore

01:10:30.360 than if it's just kind of a slow, repetitive stress like the rucking. The pathway is, and you've

01:10:35.040 noticed the relief, like when we do the manual therapy and things like that, that's a nice short-term

01:10:38.520 like, oh, it feels a little better, a little less pain, great. But the bigger picture and the ask of

01:10:43.340 your body is teaching it, how can it respond to this and how do I build that force in those tendons

01:10:49.220 to where not only does that tendons start to regenerate and heal, but then it's also ready

01:10:53.620 to react to all the things you do. So knowing for you specifically that you love to use those feet

01:10:58.980 and the more barefoot you are, like you're more likely to do that, we need to do a ton more quick

01:11:03.520 work with you that's deloaded to train all those tendons. I mean, there are so many tendons in the

01:11:08.280 lower leg and the ankle. We need to train all those tendons to get quick and stiff in different

01:11:13.160 positions so you don't jam the joint or create a stress in the tendon. Should I be doing less

01:11:17.940 barefoot activity? No, I don't think so at all. I think that's a pathway to frailty. You want to

01:11:22.940 stimulate the receptors in the bottom of your foot. Do I want you running on like a river barefoot with

01:11:27.300 sharp rocks? No, because that's going to cause other problems. But I think having you barefoot makes

01:11:31.220 your foot mobile and strong. But then if we piggyback that with this specific type of training for where

01:11:36.240 your gaps are, it's a huge payoff. Let's look at the other side. Most people don't have your

01:11:41.240 situation. More often than not, people have a really rigid foot that's weak and stiff. So we're

01:11:45.880 actually going with a whole other direction where we're trying to get motion in the foot. We're

01:11:49.340 teaching that foot to separate rear foot and forefoot. How do those people present? What's the

01:11:53.320 pain or what's the injury they present with? Interestingly, they actually get a lot of symptoms up the

01:11:57.700 chain. Our foot has so many bones and all these articulations where we're supposed to comply to the

01:12:01.520 ground. If that shock absorption goes away, like let's say I'm wearing these big goofy running

01:12:05.780 shoes that they sell now, they have the rocker where it's all just like patching holes in the boat

01:12:09.640 rather than optimizing movement. If we have a foot that is stiff, those force factors go up through

01:12:17.120 the body. So now my knees, my hips, and my spine have to figure out that force distribution because

01:12:22.000 one of my best shock absorbers is the foot and the ankle. If that's not doing its job, everything

01:12:25.820 else pays the price. So I see a lot of people, let's say the soleus is weak, their lower part of their

01:12:31.020 calf. So that control of their tibia as either walk or lunge isn't there. So that ankle just walks

01:12:37.440 up and then they send all that force to their knee. That's why one of my favorites is anyone

01:12:41.860 with a chronic knee issue, I'm going right at that foot and ankle first because if the foot and ankle

01:12:46.400 isn't up to the task, then my knee's going to take a beating. So I don't want to jinx myself and I hope

01:12:50.760 I'm not doing it by saying this. Is this why despite all the crazy stuff I've done, all the miles I ran

01:12:56.600 growing up, never really had a knee issue, but boy, do I get these feet issues?

01:13:01.200 I mean, it's a good theory, but absolutely. Yeah. You're really good, wide, mobile feet.

01:13:05.960 Your knee gets to be a knee. If that rotation, that pivot joint that's supposed to happen at the

01:13:10.860 ankle isn't pronounced to the amount you want and it isn't mobile enough, then that knee and that

01:13:16.240 force vector is going to happen at the upper tibia and the femur where now you start to get these

01:13:20.780 little meniscus things that showed up out of nowhere. That torsion has to happen somewhere.

01:13:24.160 Yeah. Let's talk about something that you touched on a few minutes ago, which is around

01:13:28.160 fear. We see this a lot. We see this in the medical practice where we have patients where we're

01:13:32.700 overseeing all their training. Sounds like you see this at 10 Squared as well, where you have clients

01:13:37.020 that are just coming in for obviously the training piece of this. So is there any common thread to

01:13:40.860 this or does it come in all walks of life? I've seen it in former athletes who are injured,

01:13:45.480 but the injury is so bad that they just never quite want to go back down my path, especially if

01:13:49.680 they've had multiple re-injuries. I assume you see this in people who are not necessarily athletes.

01:13:52.940 So what do you think is going on there and how do you work up the confidence to accept

01:13:56.760 that the pathway back isn't necessarily pain-free or injury-free, but it's more of a trajectory that's

01:14:04.040 going to get better? Yeah. I love what you just showed there. The graph is always going to have

01:14:08.340 peaks and valleys. When your brain perceives threat, whatever that could be, maybe your dad

01:14:13.060 hurt himself playing football, so you're scared to play football. But when your brain perceives threat,

01:14:17.440 not only is your heightened awareness up, your nervous system is kicked up, but we're more

01:14:21.600 sensitive to pain. So certain things hurt more when we're ill or when we're stressed than if we're

01:14:27.640 not. And if we stick to just movement themselves, a lot of people are afraid of certain movements

01:14:33.320 because it hurt me in the past or they heard it could hurt them, or maybe they just haven't done

01:14:37.900 it a long time. So they're nervous about it. So you can actually empower people if you show them

01:14:43.040 there's a rational reason why that fear could be there or why that pain is there. Pain does not always

01:14:49.280 mean injury. Pain is your brain telling you, hey, I don't like what's happening here, but it doesn't

01:14:53.320 always mean you're broken or busted. Another thing to think about is your image isn't always a death

01:14:58.700 sentence. If we MRI a hundred thousand low backs, there's going to be wear and tear, especially if

01:15:03.120 you're over 30 years old. Same goes for every other joint in the body. Does that mean we design your whole

01:15:08.060 clinical plan around that? No. We really need to think about, okay, how much is there? What do they want

01:15:13.480 to do? What are their strengths? What are their weaknesses? All those things we already spoke to. So

01:15:17.400 when there's fear involved, you really have to address that because the individual needs to know

01:15:22.440 that A, you have a plan for them, that you understand their fears. And then B, we got to

01:15:27.060 account for those fears in one way or another. So this is not data, but in my private practice,

01:15:31.580 the amount of low back flare-ups, just your traditional back spasm, not a surgical candidate,

01:15:37.360 just high back pain, but no damage. The amount of those people that have come in when their wife's

01:15:42.160 about to go into labor, or they're worried about getting fired from their job, where they have

01:15:46.340 an emotional mental stress in their life, the amount of those people is infinite. I've had

01:15:51.280 thousands of people come in and going, my back flared up out of nowhere. And then you start to

01:15:54.520 dive in, like, what else is going on? And they're really worried or stressed about something.

01:15:58.500 The goal there is you can't always fix those external, cultural, psychological, emotional

01:16:03.000 things, but we can address them and identify them. And sometimes they need therapy. They need other

01:16:06.960 things to address those. But more importantly, we need to empower that individual and give them

01:16:11.440 rational reasons why you're like, hey, this might be why you flared up in that glute or in that

01:16:15.700 mid back. And this is what we're going to do about it. And if you outline those plans for people and

01:16:20.440 give them the tools, now you've equipped them to actually help themselves. This whole game of,

01:16:25.600 I'm going to take an x-ray view and look, oh, there's one little bone spur, but now I'm going

01:16:30.140 to scare you into like a 40 visit package to my chiropractic clinic or something. That game needs to go

01:16:34.720 away fast because the only thing you're doing is making people feel more frail, more afraid, and you're

01:16:39.480 actually only helping the bottom line of your business. You're not helping that individual. So it's really about

01:16:43.520 empowerment with education. What is it that you would see when somebody comes in that would make

01:16:48.240 you say, actually, we need to immobilize you? Is that something that's only going to be on an exam

01:16:52.680 where you see a motor weakness, for example? Immobilize how? Like put them in a boot? Let's

01:16:57.140 look at the lower back. So if somebody shows up with a lower back complaint to you, what's going to

01:17:01.500 make you say, no, actually the answer is seeing a surgeon or complete and total rest. What is kind of

01:17:08.020 your algorithm on people presenting with lower back pain? Yeah. I mean, low backs are great. So number one

01:17:13.100 is for the neuros out there, if there's weakness or you don't have bowel or bladder function and

01:17:18.320 things like that, right away, get evaluated, right? Because the way nerves work, if there's

01:17:22.640 pressure on nerves, it could over time create permanent damage. Now, a lot of nerve pain is

01:17:28.080 sensory, that electrical sciatica type stuff. It's that tingling and that weird thing like that.

01:17:33.420 But the real number one that you look at is, do they have weakness or do they have loss of some sort

01:17:38.320 of foundational control? That's when you got to get integrated with neuro and orthos right away.

01:17:43.240 If we don't have that, now you're in the like decision-making domain.

01:17:47.240 So this means you're going to do the rectal exam, make sure sphincter tone is there.

01:17:50.700 Yeah, exactly right. That's definitely on the long list of things I refer out for, for sure.

01:17:55.300 So if you're in that kind of mechanical low back pain or even some disc nerve issues, but no weakness,

01:18:00.340 now there's a ton of strategies we can do almost as a first diagnostic step to see how your body

01:18:06.180 responds. Now, what I mean by that is we're not going to do some crazy aggressive therapy or

01:18:10.420 treatment or manipulation of the spine, but we're going to do some sort of intervention like muscle

01:18:14.580 work or McKenzie exercises for discs, which are highly researched and really effective to see how

01:18:20.400 the body responds to those things. If your body responds in a positive way, even for two hours,

01:18:25.380 that's a great indicator. Like let's keep going down this road because even the best surgeons that

01:18:29.940 you and I have both talked with about mutual clients, they'll say, let's give this a little time and

01:18:33.720 see what your body does. Things can heal. The natural processes of the body can take care of

01:18:37.440 themselves. So one of my favorite examples actually is a disc herniation. She confirmed

01:18:42.180 on MRI. She was doing McKenzie protocol, which again, is fantastic.

01:18:45.720 Describe for people what that is.

01:18:46.940 So McKenzie protocol is a really great system that you essentially put the patient in various

01:18:51.340 positions and you do this gentle arching or pumping. And you're basically trying to take

01:18:56.680 pressure off that disc to where slowly over time that bulge can recenter and balance out.

01:19:01.840 Can people do these by themselves or do they need to be? Yeah.

01:19:04.320 Very easy.

01:19:04.960 We can link to where people can go and look at these.

01:19:06.940 Oh yeah. McKenzie protocol is fantastic. Their website has a database where people can find

01:19:10.340 people in their town. So if they have nerve pain, it's a great place to start because

01:19:13.900 all those McKenzie practitioners know what I just outlined too. It's like, this is a McKenzie thing.

01:19:18.540 This is not. But what's fascinating about McKenzie, sometimes even in the room,

01:19:22.200 they'll get a reduction of nerve symptoms while they're in that position. Nerves provide very

01:19:26.880 productive information. You can trust symptoms of a nerve really well. So if I get what they

01:19:32.020 call a centralization, meaning I had sciatic pain all the way down the leg, and then you put me in

01:19:36.000 this one McKenzie position, and now it centralizes to the hamstring.

01:19:39.120 That's a great diagnostic indicator.

01:19:40.660 Exactly. And so just because that individual might have an MRI with a disc herniation,

01:19:45.200 that doesn't mean it's an injection or surgery right away. Obviously, part of the decision making

01:19:49.440 is what are they having to deal with in their life? What is their timeline? All those other factors.

01:19:53.020 But if you can encourage a hot disc patient to wait and make sure that they're actually

01:19:58.640 letting things heal and run their course, they could be much better off in four to 10 weeks.

01:20:03.760 It's almost always the sign of a great spine surgeon, which is once you rule out the

01:20:07.720 acute weakness, the thing that is a surgical necessity, the ones that want to wait are generally

01:20:15.580 the better surgeons. Yeah, we've chosen the better side for sure. But this case I was going to talk

01:20:18.960 about earlier, she was a fascinating one. So confirmed disc herniation, and then she had

01:20:23.260 an annular tear, which basically the annulus is a part of the disc. Best analogy to describe it is

01:20:27.960 she had like a little thing that was equivalent of like a cuticle that was just kind of peeling off.

01:20:32.160 So traditional protocol, we started her on McKenzie's. Great lady, we're actually still

01:20:36.420 friends, but she was really hurting. So we worked with her for like two, three weeks. And every time we

01:20:41.800 put her in that McKenzie position, it hurt her worse. And it was local pain, but the ridiculous

01:20:46.000 symptoms reduced. So long story short, what we learned over time, she went back over to another

01:20:51.240 place, tried that for a while, it didn't work. The disc herniation was actually taking care of

01:20:55.340 itself, but that annular tear was still sticking out, creating extension-based pain. So after about

01:21:00.400 a year of rehab, her body was able to scar up and that healed and it was fine. But what was really

01:21:05.700 interesting to me was she needed McKenzie's early, but then we actually had to cease the McKenzie's

01:21:10.120 because we were jamming that annular tear. And so then we restored just more pillar strengthening,

01:21:14.360 dynamic neuromuscular stabilization, all those other things. So it's like different things at

01:21:18.340 different times played a big role. It must be amazing how often we all encounter,

01:21:23.520 hopefully not personally, but professionally, people with lower back pain. The statistics are,

01:21:28.220 can't imagine there's too many people listening to us who don't have personal or indirect experience

01:21:32.640 with it, either obviously through themselves or through somebody they know closely. There is

01:21:36.720 something about it that I can really relate to being nerve wracking. It can be terrifying and also

01:21:42.540 demoralizing, I think is how I would describe it. Just demoralizing when your lower back hurts in a

01:21:47.480 way that's not the same as if your shoulder, elbow, knee, or hip hurt. No, it's different. I mean,

01:21:51.700 the best analogy is I sprain my wrist, might have to wear a brace or something, but I can generally

01:21:55.800 function. I can go to a movie, but when your ribs or your back is hurting, not only are those muscles

01:22:01.180 much more big and powerful. So when they react in spasm, they're really good at it. These small

01:22:05.880 muscles in my wrist, when they react in spasm, you're like, oh, that's kind of sore. But the low back,

01:22:09.460 I mean, that group of muscles is really good at freaking out. The type one fibers, postural stuff,

01:22:13.580 a lot of detail. The other thing is you can't do anything without affecting you. Sitting in a movie

01:22:18.080 hurts, walking hurts, affects them constantly. And that's a big part of the rehab story is finding

01:22:24.620 these little wins where they can actually do something and it either does get worse or heaven

01:22:29.120 forbid, makes them feel a little bit better. Do you think this is scalable? I feel fortunate that

01:22:33.620 we're able to take care of people where we have the luxury of doing this very bespoke approach.

01:22:38.180 You can integrate your strength and conditioning with your cardio, with your PT rehab and all that

01:22:43.320 stuff. And it's all great. But do you see a day when this could all be app and AI driven where any

01:22:49.260 person out there with any set of lower back symptoms could be provided with the feedback that they would

01:22:56.060 need to take care of themselves? If they execute, absolutely. How would you get the feedback? If you

01:23:01.080 have good enough image recognition software, would that be a necessary step that if you were using such a

01:23:06.040 device, like an app, you would have to be able to set up your phone on a tripod to be at least able

01:23:10.880 to capture you doing it? Because the advantage of being able to do this the first few times with

01:23:16.480 an actual person like you is the cueing is so important. A lot of these exercises are not natural.

01:23:25.280 Yeah. Well, especially if you're that person who's suffering from that injury, then odds are you didn't

01:23:29.560 perform these exercises well subconsciously. So that's what set you up for it. What is interesting is the

01:23:33.960 video recognition software is getting fantastic. I've demoed a few now where the AI is actually

01:23:39.060 watching someone do movements and saying, Hey, you know, this was too far out that way or whatever.

01:23:43.100 But that also goes in the bucket of everyone moves differently. My femur length is different than

01:23:47.860 yours. So the angles with which I'm going to lunge are going to be a little different. This idea that

01:23:52.100 if you take principles and you know the symptoms, and then most importantly, you know how people react to

01:23:58.140 really conservative loads, that almost tells you more than did their tibia rotate three degrees or not.

01:24:03.500 I could care way less about three degrees of tibial rotation based on AI software and care way more

01:24:08.900 about, you know what, I did these lunges in this setup and we activated some neuromuscular reaction

01:24:14.280 to where my glute fired a little bit better. My knee felt way better. And then when people give us that

01:24:19.320 good qualitative feedback, now you know how to trim up that program. So I think the AI part of it's going

01:24:24.920 to be more that it's going to be less about, Oh, what degree did it move? But more about how did you

01:24:29.880 respond to each drill? That's safe. And then we go from there.

01:24:33.320 And that's where training the AI is much more nuanced and complicated.

01:24:37.500 100%. 100%.

01:24:38.340 Yeah. Image recognition is one thing, but it's knowing what to do with that information.

01:24:41.840 Yeah. Knowing, am I going to do an overhead dumbbell on a DNS three month and all these other nuances

01:24:45.680 versus the legs? There's certain cases that I'll do that one for one and the other for another. And it's really a matter

01:24:51.540 of knowing what you got to start with. And then we test it a little bit and then we test a little bit

01:24:56.040 more. And then the outcomes are dictated by how do they respond to that exercise?

01:25:00.740 And why did you gravitate towards this? I mean, we didn't really get into telling people your story,

01:25:04.520 but you went to chiro school, but then you immediately went out and did a sports medicine

01:25:09.720 thing. You worked with the New York Giants. Why did you just opt into the role you're doing now,

01:25:15.320 which is much more in the PT rehab space than it is what people I think assume of traditional

01:25:20.960 chiropractic, which is here's a 40 adjustment schedule. I don't have a point of view on that,

01:25:26.200 but what drew you more towards the side of things you're on now?

01:25:29.240 It speaks to a bigger thing, which I'm really degree agnostic in the sense that I hope someday

01:25:33.840 in the future, there's like a more clear certification or degree where there are chiros and

01:25:39.260 PTs and frankly, strength coaches. All three of those people, I would trust way more to do a rehab and get

01:25:44.920 someone better. Who would I send my mom to? I would send my mom to all three of those people

01:25:49.020 if they have certain skillsets and like approaches. Independent of degree or credential.

01:25:53.740 Totally. Because the chiro degree was my baseline training. That's where my license is and all that.

01:25:57.740 But the traditional view of a chiro is with the manipulations and the adjustments,

01:26:01.420 that's 5% of our week at my practice. Our practice, we have chiros, amputees, but you can't

01:26:05.640 really tell who's who because everybody's doing what we call is active rehab. So one of the things I

01:26:10.340 always tell people, I don't care what their degree is, but if you're going to a rehab clinic and it's

01:26:14.420 one-to-one relationships, so it's not group, but it's one-to-one and they've got a bunch of weights

01:26:18.720 in there as well as their traditional bands and stuff, now that's an indicator, okay, these guys

01:26:23.420 are going to build me back up to something actually strong, not just make me come in here forever and

01:26:27.380 do rehab purgatory where I do the same micro drill over and over. We got to build over time. So I'm

01:26:33.320 really agnostic to a degree, but that said, my story, I basically tried to create a residency for

01:26:37.580 myself right out of chiro school. And back then it was really manual therapy based. I learned a ton.

01:26:42.180 And I was by far the lowest guy in the totem pole, which we all know how that works. A lot of time,

01:26:46.320 a lot of learning, but I was there to soak it up. Everyone always thinks pro sports is the top

01:26:49.960 and it is in a lot of ways, but it wasn't really for me in terms of an official team relationship

01:26:54.300 because I just didn't like that personal schedule. And it was pure chaos. You'd spend a week fixing

01:26:58.620 somebody up and then they'd go out there and get blasted again. You're like, oh, that's a bummer.

01:27:02.080 It's kind of like when my son builds his tower of magnet tiles and then his sister knocks it over.

01:27:05.680 The look on his face was me every Sunday. So I really enjoy the off season side. I really enjoy

01:27:11.980 more of the project. And I realized early on that when you're only doing pain relief manual therapy

01:27:16.860 work, there's a lot missing. We're not building people up. We're not strengthening them. Yeah.

01:27:20.960 So that's when I just started doing this deep dive as much as I could and learning from as many people

01:27:24.520 as I could about the foot and balance and neuromuscular training and all these other things to

01:27:29.160 where it's a compliment at my private clinic when people are like, what are you? We actually have

01:27:33.160 people coming to our office now. We're like, I need to go see my chiropractor later. And one of

01:27:36.320 my other docs will be like, well, I'm a chiropractor. Like what? I had no idea. And they've

01:27:39.200 seen us for years. So we're probably supposed to identify ourselves better, but regardless,

01:27:42.860 we're solving problems. What is the role for what most people think of when they hear

01:27:47.060 chiropractic, the adjustments? What does it do? I don't want to ask you to sort of be

01:27:51.400 critical if that's the word of a profession that you're a member of it, but the fact that you

01:27:56.360 aren't out there doing it 24 seven suggests either you think it's really, really valuable,

01:28:02.420 but it's just not something you want to do, or you don't think that it's valuable enough.

01:28:06.280 How would you advise somebody that came to you and said, hey, Kyler, I have injury X,

01:28:10.820 my neck, my back, whatever. I got this awesome package of 40 visits for X number of dollars

01:28:16.260 with my local chiropractor. I see him for eight minutes a week, twice a week, actually. It's

01:28:20.700 really special. Do you think that's a great plan?

01:28:23.000 No. The way I would describe it is I've benefited from getting adjusted myself. Things get out

01:28:29.040 of whack. Things get stiff. You sleep on a plane where you're like, that's a real thing,

01:28:33.060 but it's a tool in the tool belt. And the really good practitioners have a bunch of tools. I could

01:28:38.400 say the same thing about chiro adjustments as I could dry needling or active release or McConnell

01:28:43.040 taping, like a million tools out there. The really good practitioners have a huge tool belt and they

01:28:48.380 know when to use which one at what time. So just throwing cupping at somebody and hoping their muscles

01:28:53.260 get better, it's insufficient. In the same way, I would say just adjusting someone over and over,

01:28:57.740 it's not enough. There's more that could be done. And so what I get asked a lot, especially now that

01:29:02.940 I'm older, like all my friends I've accumulated over the years, I didn't account for as I got older,

01:29:07.100 there'd be more questions exponentially because they're all getting sore and hurting. But what I

01:29:11.240 always tell them is I need someone who's got a bunch of tools in their tool belt. I need someone

01:29:15.320 who's going to literally treat your case as something unique every time. It's not just like everybody

01:29:20.480 here signs up for twice a month. That's a big red flag for me. And I really want everyone always

01:29:25.280 building towards more strength. You have to be adding strength. That's what makes things stick.

01:29:30.380 That's what optimizes movement. That's what makes people feel empowered and less frail.

01:29:34.600 And it frankly builds more of like a moat around themselves to where if they do step off a curb

01:29:39.200 weird or they sleep weird on a plane, they're less of a triage patient. They're more of just like,

01:29:43.680 oh, I'm a little sore today, but they still work out and the workout helps it.

01:29:46.360 So is it safe to say then that whatever the suite of underlying modalities are from adjustments to

01:29:52.740 taping, to cupping, to needling, to active release, to manual, you name it, the goal of all of these,

01:29:59.880 and the more of them you can utilize, the better is to create a window in which the individual is

01:30:06.680 safe and out of pain so that they may do the work to retrain a movement pattern and increase strength.

01:30:14.420 The most simple terms. Absolutely. We say that sometimes about even cortisone injection. Like

01:30:18.680 I don't like people racing to get a cortisone injection, but if you tell someone to strengthen

01:30:22.320 a knee that really hurts when they do a lunge, they're going to look at you like you're a jerk.

01:30:25.880 So at some point we need to do something to get that pain down. So then we can open that door and

01:30:30.420 run through it and running through it with strengthening and making them stronger.

01:30:34.080 Okay. So let's kind of put this now all back together, right? We've kind of gone really deep down

01:30:38.380 one of the three pillars. You now have basically two things you're trying to do. You're trying to

01:30:44.000 do everything you're doing in concert with a broader agenda of creating a precision training

01:30:53.460 program, not an exercise program, not a workout program, a training program for an athlete whose

01:30:59.460 sport happens to be life. And you have to be able to do it with the strength and conditioning coaches,

01:31:04.300 the cardio coaches. And then the other thing you have to be able to do is you have to be able to do

01:31:07.800 this remote because most of the 10 squared clients are remote. They come to Austin for two days.

01:31:12.580 They do a whole bunch of assessments. They go away for six months. Then they come back.

01:31:17.320 Some of them go away for less, but a lot of them, they go away for a year. It's because they're out

01:31:21.180 of the country and it's just not easy for them to be here. So how are you able to do this remotely?

01:31:26.620 What are the challenges and what enables it to make sense? What do they need when they're back home?

01:31:31.660 We get that question a lot because before 10 squared, some of the athletes I would manage who travel a

01:31:35.780 lot, like a couple of my golfers, they would call me and say my back hurts from the hotel room.

01:31:39.940 And I had the luxury of knowing so much about them and how they moved and what their body looked like.

01:31:44.720 I could take all that and then be like, well, what are the symptoms? We rule out the scary medical

01:31:48.600 stuff and then we try some exercise. And we were able to get a lot of results for these athletes

01:31:52.620 and they were about to tee off in two hours and compete. So we've taken that model. And when we

01:31:56.700 were designing the assessments at 10 squared, one of the biggest themes was we need enough time to know

01:32:00.960 as much as we can. A lot of people want it to be faster, but we're like that initial step needs to be

01:32:05.480 so in-depth that we are certain about all the factors of how you move and where you're strong

01:32:09.860 and things like that. When I have that certainty and I'm not flying blind and someone calls me and

01:32:14.580 says, you know what? My knee's really sore after doing these exercises. We either hop on a Zoom and

01:32:18.840 just talk real quick and I can actually test them on Zoom because the exercise is the test. So many

01:32:24.380 people think they need a doctor to do like a Lockman's test and pull on their leg. The story,

01:32:28.840 their profile, and then how they respond to the exercise, that is the test.

01:32:32.120 And so we can program exercises really effectively in a remote way to probe the fence or test it.

01:32:38.060 And if it responds the right way, we definitely can fix it quickly. I had a client this week,

01:32:42.820 his shoulder was bugging him. We did a Zoom call, took about 20 minutes. We have our library at 10

01:32:46.960 squared. I fired him off a few exercises. He messaged me. He's like, it feels a lot better.

01:32:50.400 He didn't have to go to the doctor. He didn't have to go anywhere. Now, obviously if the story was

01:32:54.120 different and I was worried medically, I'd concierge that in the sense of I'd find him someone local and

01:32:58.520 refer out. But if I'm not worried medically and we think it can respond to load, we're going to load

01:33:03.480 it. And a lot of times people are shocked that we can make their neck tension go away with an

01:33:08.080 exercise in the same way that if they traditionally got a massage or something, they'd get that relief.

01:33:12.720 It has to do with what your body does when things are off. And if you load it, it'll actually respond

01:33:17.540 more because your nervous system's involved as well. I want to tell a story on that vein that is one of

01:33:23.280 the most incredible experiences I ever had. This would have been in 2018 or 2019. And I had the

01:33:31.580 first flare up I'd ever had of my lower back since 2000 when I had my botched surgery and all that

01:33:39.800 nonsense. So I'd gone 18, maybe 19 years, maybe it was early 2019 without a single flare up. And then it

01:33:47.380 happened. I get the flare up. At the time I was working with this guy, it was my first person I'd ever

01:33:52.840 met who did DNS. I had already learned about intra-abdominal pressure. We were doing all

01:33:57.400 stuff. In fact, when I went to see him, my back was totally fine. I had tennis elbow. So I had this

01:34:02.600 tennis elbow and he figured out pretty quickly that my tennis elbow was completely due to my

01:34:07.280 scapular instability. And my chief complaint was when I do a lot of pull-ups, my elbow hurts.

01:34:12.660 I don't even play tennis. So we had fixed all that, but I kind of was like, this is amazing.

01:34:17.300 I want to know what else is going on. And then independent of that, I get this lower back flare up.

01:34:21.200 And so I'm in there seeing him on one day when I'm in, honestly, about the worst pain I'd been in

01:34:26.560 in years. His training, by the way, is also a chiro. So he's chiro by training who probably

01:34:31.460 hasn't done an adjustment in 20 years, just doing DNS. And I'll never forget the exercise he had me

01:34:38.000 do because I was like, I don't know how this is going to work, dude. So he laid me on my back

01:34:43.120 and he had me get into an imaginary leg press position. You know those old school leg press

01:34:48.960 machines where you're pressing up? Yeah, yeah. Not the one where it's on a slope,

01:34:51.880 but the rack moves vertically. Yeah, super old school. Yep. So I'm on my back, I'm in that position

01:34:56.420 and he is now laying on top of me. So he's got his pecs basically on my feet and he's cuing me

01:35:05.200 through really good intra-abdominal pressure and isometric contraction, pushing. And lo and behold,

01:35:13.280 my back is getting better and better. And we're doing sets, 10 second, 20 second, 30 second.

01:35:19.560 At some point I'm getting so strong, we need more resistance. So now we go and build a makeshift

01:35:24.900 thing under the squat rack where I forget if I was on a Smith machine or on a squat rack,

01:35:29.280 where basically now I have infinite resistance, kind of like how you described it with the partial

01:35:33.800 deadlift. I am getting to the point where when I walked in there, I wouldn't have been able to push

01:35:37.800 10 pounds away from me. That's how much pain I was in. And now I'm convinced I was pushing 600

01:35:44.240 pounds of force against that immovable bar. And I've never felt better. And I couldn't understand

01:35:50.500 how that could happen. How is it that I could not walk, but limp into that guy's gym in so much pain

01:35:59.080 and spasm. And an hour later, I feel like a million bucks. How could that happen?

01:36:05.500 Two things. One thing in your story, it really speaks to how pain is inhibitory.

01:36:09.460 When your brain is perceiving that threat and that pain, it goes into preservation mode where

01:36:13.480 it's like, look, I'm not going to have you run the fastest forward of your life because I don't

01:36:16.960 trust all these movements. I'm trying to figure this out. My analogy is like that hand on the

01:36:20.660 buzzer with family feud where the brain, like whenever it feels threat, it's like, I'm going to

01:36:24.360 hit this buzzer and I'm going to send you a pain signal. It doesn't mean you're damaged. It's just

01:36:27.500 like I'm hovering. And if you're really stressed or it's a really high level pain, it's like,

01:36:31.020 I'm going to do it at first sign of trouble. So number one, it just really explains

01:36:34.340 your story is that effect. But then it's like, okay, how do we get the brain to take the hand

01:36:39.620 off the buzzer? What loads can we introduce to make these muscles, one term in the musculoskeletal

01:36:46.060 world, reciprocal inhibition. So if I'm going to contract my bicep like crazy, my tricep almost

01:36:51.480 has to eventually get enough signals where it can't fire. Your brain might be trying to fire it

01:36:55.400 and it's got this co-contraction going on and there's that protection going on. But the more

01:36:59.100 stimulus you give to that bicep, eventually that tricep has to let go. So what he was doing is

01:37:03.880 he was putting you in very specific positions to where you had to load something where neurologically

01:37:08.140 your brain says, I'm going to turn this other thing off. And I got to actually meet the demand

01:37:11.480 of this force because force is how your nervous system responds. And so he was loading one direction

01:37:15.940 so much that eventually that QL or whatever else could have been spasming with you had to eventually

01:37:20.680 kind of melt and let go. Not only were you now activated and stable and feeling stronger,

01:37:24.960 but that muscle was in this inhibitory contracted state. And then I let go. One of the things I say

01:37:30.160 in my private practice all the time, my first five years out of school, I was working on the QL.

01:37:34.180 My thumb has got scars from it. I don't touch the QL anymore. 10 years ago, I realized you don't even

01:37:39.180 have to beat someone up so much. In a weird way, these kinds of exercises are more gentle.

01:37:43.520 They're more therapeutic and they're more long-term.

01:37:46.300 They're active. So it's long-term. You're tapping into that nervous system,

01:37:49.360 demoing an exercise or having someone do a very specific exercise based on their profile and their

01:37:54.420 symptoms is actually a great way to make someone feel better. And you just got to give them the

01:37:58.740 right stuff. Yeah. I consider that one of the most profound experiences of my life from a physical

01:38:04.300 perspective and also in how much it changed my point of view about what back pain is and isn't.

01:38:10.480 I don't want to suggest for a moment that if you're sitting here listening and you have back pain,

01:38:13.100 that's the answer. Go and find a guy to do that. But I'm saying that there's so much more going on

01:38:18.280 than we realize. And so much of back pain is not surgical. And so much of back pain can be healed

01:38:24.160 with retraining a movement pattern and getting our nervous system to kind of get out of the way.

01:38:28.980 I mean, one of the exercises I think we're going to cover in the gym, I have a lot of clients that

01:38:32.120 come in and they're like, look, I'm nervous about the chiro thing, or they have some fear around it.

01:38:35.920 They heard stories, whatever. They're like, can you help my neck though? Absolutely. Because

01:38:39.240 there's a million other ways to cook this recipe to where we normalize the motion of your joints.

01:38:43.460 We make the muscles strong again. We reestablish the relationships of your shoulders and your

01:38:47.580 scapula and your neck. There's a million ways to make someone feel better with exercise where you don't

01:38:50.980 have to do aggressive therapies. I don't care if it's stem cell or PRP or prolo or dry needling or

01:38:56.120 chiro. It doesn't really matter. Exercise needs to always be the answer. And you can do therapeutic

01:39:00.580 exercise that actually does a lot for people that drops the pain too. So speaking of that,

01:39:04.760 I think what we'll do is we'll now pivot over to the gym and kind of work on a few issues. So we

01:39:09.060 identified four areas that we want to highlight for folks. We're going to do neck, lower back,

01:39:14.760 knee, and shoulder. I guess you picked those because that's 80% of what people complain about.

01:39:21.180 Yeah. It's really common for one. I tend to see that one of the things we want to highlight in

01:39:25.720 this next session is really highlight to people, oh, wow, this doesn't look like a knee exercise,

01:39:29.560 but it could help my knee. This idea of working around a structure that has pain to help that

01:39:34.300 structure feel better. I think that's what we're going to go for. And I think the regions we selected

01:39:38.120 are just really common, really debilitating. And frankly, generally people whiff on these a lot.

01:39:43.260 We get so many of these cases in our practice that it's like, what were they doing? They didn't do

01:39:47.260 this. They should have done. So we're going to try to go that way.

01:39:49.980 So walk us through the framework. I love your framework for how you approach these. So

01:39:53.560 what's the framework? First off, that bifurcation we talked about earlier, where

01:39:57.600 do we need to consult an orthopedic or neurosurgeon? That's number one.

01:40:00.880 How do you make the decision? The story, the incident, what it looks like. If we're talking knee,

01:40:05.840 if they're a soccer player, they twisted it really weird yesterday. It's all swollen on the joint

01:40:10.640 line. I'm more worried about the joint. Conversely, if it's a runner where it's been kind of off and

01:40:15.560 on for a long time, no acute incident, no joint line swelling, the pain is kind of vague. Those

01:40:20.760 are two very different presentations. So one's going to be more like ortho consult. One's going

01:40:24.660 to be like, let's tinker around as a rehab pro and see what we can do. So that's the first

01:40:28.420 bifurcation is basically playing doctor and being like, what's the right path? The other thing I really

01:40:33.080 want to encourage is that the best orthopedic surgeons in the world, like you spoke to earlier,

01:40:37.080 they don't want to do surgery or inject everyone right away. They're referring out all the time.

01:40:41.600 And a lot of clinics nowadays have like a physical therapy clinic in-house and there's all kinds of

01:40:46.240 constraints with that. The best orthos don't just give someone a list of every PT clinic in town.

01:40:51.840 They're actually referring to different clinics based on that clinic's strengths and experience.

01:40:55.440 Some clinics specialize in running, some specialize in strength training. If your ortho is specifically

01:41:00.000 searching out different PT clinics, that's a huge win. It's a great sign they know what they're

01:41:04.000 doing. If they just give you a handout and they're like, go call somebody, that means they think all

01:41:07.600 PT is the same and all rehab is the same and it's not. So that's number one. Once we've got past that

01:41:12.060 bifurcation of knowing that it's a rehab case, then the protocol really turns into what is the safest

01:41:17.320 and smartest way to create a change? Maybe it's a manual therapy. Maybe it's dry needling. Maybe it's

01:41:23.340 one of those treatments we spoke to earlier, or maybe it's a strategic load. That decision is a lot

01:41:28.100 of times based on the patient's comfort. Read the room. Are they cattle rancher dude who wants to push

01:41:32.420 through pain and they're going to go back to work tomorrow? Or are they someone who's really scared

01:41:35.740 because the pain is high? We got to build trust. We got to get them some sort of pain relief to show

01:41:40.320 that we're medically being responsible and making sure we're going the right direction. But then once

01:41:44.140 we've created that change, then we start to load it. A lot of times, if I have a joint that I know is

01:41:49.000 permanently compromised, let's say someone with total knee replacement, I'm not going to actually beat

01:41:53.600 up the knee a lot. Traditional insurance-based rehab is going to go after that joint because that's the

01:41:59.140 code that's associated with it. And they know they're going to do that really well.

01:42:02.840 What I'm going to go for first is the foot, the ankle, the hip, and their pelvis in general.

01:42:07.840 Because if there's a lot of low fruit there, I can enhance the pelvis strength or the foot strength,

01:42:13.160 and I can actually buffer that knee to where it doesn't have to work nearly as hard.

01:42:16.400 And those people get a reduction in symptoms overnight.

01:42:19.040 Yeah. So that makes sense. That's basically the thought algorithm on how we do this.

01:42:22.640 What can we show people? We're going to go to the gym and we'll give people a few examples. I'd love

01:42:26.620 people to have some takeaways on, hey, what can we do here? How could I put this into practice on my own?

01:42:31.080 Yeah. Well, I really want to focus on what people could do themselves right away. They

01:42:34.180 don't have to make an appointment somewhere. And so if you're looking at the three things

01:42:37.360 that can go wrong in musculoskeletal, it's the tissues, it's the joints, and then it's

01:42:41.060 that motor control or exercise window. So we're going to dive into some of these exercises

01:42:45.360 that might not be expected to be helpful for your neck or your shoulder, but actually indirectly

01:42:51.520 can load those structures to try to get that relief, just like you experienced with your low back.

01:42:55.300 I see. So we're going to just show people a set of exercises around each of those three

01:42:59.080 pillars per joint.

01:43:00.980 Yeah. Per joint. We're going to dive in and show like, this is what you can do for the tissue.

01:43:04.180 This is what you can do for the joint. And then most importantly, these are some loads you could do

01:43:07.760 that actually help reprogram that software to where you actually stop overloading the area that hurts

01:43:12.020 and get everybody else back on track.

01:43:14.060 Okay. Excellent. Kyler, this was really a ton of fun. Enjoyed sitting down with you. It's not

01:43:18.960 normal that I sit this far from you, but at a distance, you look just as great as ever.

01:43:22.920 Devastating as always. Thanks a lot.

01:43:26.060 Thank you for listening to this week's episode of The Drive. Head over to peteratiamd.com

01:43:32.420 forward slash show notes. If you want to dig deeper into this episode, you can also find me

01:43:38.440 on YouTube, Instagram, and Twitter, all with the handle peteratiamd. You can also leave us

01:43:44.040 review on Apple podcasts or whatever podcast player you use. This podcast is for general

01:43:50.060 informational purposes only and does not constitute the practice of medicine, nursing,

01:43:53.940 or other professional healthcare services, including the giving of medical advice. No

01:43:58.900 doctor patient relationship is formed. The use of this information and the materials linked to this

01:44:04.580 podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for

01:44:10.520 professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining

01:44:16.140 medical advice from any medical condition they have, and they should seek the assistance of their

01:44:21.100 healthcare professionals for any such conditions. Finally, I take all conflicts of interest very

01:44:26.460 seriously. For all of my disclosures and the companies I invest in or advise, please visit

01:44:32.060 peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures.

The Peter Attia Drive - May 26, 2025

#350 ‒ Injury prevention, recovery, and performance optimization for every decade ｜ Kyler Brown, D.C.

Episode Stats

Length

Words per Minute

Word Count

Sentence Count

Misogynist Sentences

Hate Speech Sentences

Summary

Transcript