“Richard Feynman’s father, Melville, taught his son, the difference between knowing the name of something and knowing what goes on:
See that bird? It’s a brown-throated thrush, but in Germany it’s called a halzenfugel, and in Chinese they call it a chung ling and even if you know all those names for it, you still know nothing about the bird. You only know something about the people; what they call the bird.
Now the thrush sings, and teaches its young to fly, and flies so many miles away during the summer across the country, and nobody knows how it finds its way.
Doesn’t this tell us something in the sense of learning? Words or names don’t constitute knowledge. Knowing the name of something doesn’t help us understand it.”
Anatomy is overrated for physical therapists and movement professionals. To preempt the strawman responses, anatomy is not unimportant. Anatomy is just not typically taught in a manner that contextualizes its real utility. Traditionally, the study of anatomy is akin to memorizing the instruction manual (including all the parts and unique nomenclature- effectively learning a new language) for a car in hopes of becoming a better driver. During my first semester of physical therapy school I was responsible for identifying every muscle, bony landmark, blood vessel and nerve in the body. Almost eight years later, I would most certainly fail any of the written or practical exams from that course. I can no longer draw the brachial plexus from memory. My current inability to do so does not diminish my appreciation for how the brachial plexus is important conceptually. If clinical practice alone does not reinforce the information tested in an entry level course, however, then said course is a means of initiation or selection, not a precondition for clinical competence.
There are too many abstract discussions in the performance space these days about how to train and rehabilitate athletes. These circular arguments usually yield nothing substantive or actionable because providers spend too much time defending their ideology and trying to articulate why they are in the right instead of just being transparent and “showing their portfolio”. As an example, investors should demand that financial advisers share their own portfolios instead of pontificating about macroeconomic theory. Words matter but what people do when they have skin in the game reveals more about them than their explanatory justifications for said actions.
The point of these case studies is not to suggest that what we did in any of these situations is particularly good. If we’re being honest, we don’t always have robust outcome measures to suggest that what we do really “works”. More often than not, we default to the eye test. We coach and own our decisions. The intent here, therefore, is to be completely transparent about what we did when an athlete’s time, money, and readiness was at stake in hopes that other providers share their experiences and contribute to a more genuine collective conversation.
Russell Roberts is interested in how the essential insights of economics can help us understand the world around us and lead better lives. He is a research Fellow at Stanford University’s Hoover Institution and host of the weekly podcast EconTalk–hour-long conversations with authors, economists, and business leaders. His latest book is How Adam Smith Can Change Your Life: An Unexpected Guide to Human Nature and Happiness (Portfolio/Penguin 2014). It takes the lessons from Adam Smith’s little-known masterpiece, The Theory of Moral Sentiments and applies them to modern life. He is also the author of three economic novels teaching economic lessons and ideas through fiction. A three-time teacher of the year, Roberts has taught at George Mason University, Washington University in St. Louis (where he was the founding director of what is now the Center for Experiential Learning), the University of Rochester, Stanford University, and the University of California, Los Angeles. He earned his PhD from the University of Chicago and his undergraduate degree in economics from the University of North Carolina at Chapel Hill.
One of the most effective ways to potentially create lifelong patients who remain dependent on the medical system is advising them to completely avoid the things they enjoy doing until they are totally “ready”. The problem with this advice is that seldom do sports medicine professionals ever actually define what constitutes readiness. To be fair, readiness can be a difficult concept to satisfactorily operationalize. Often though, avoidance as a blanket treatment strategy is risk aversion and evasion of professional responsibility masquerading as patient advocacy and safety. The idea here is that nothing can go wrong if people who like running, as an example, are told to no longer run. This line of reasoning can backfire, however, because the longer people put off their preferred activities the more elusive and seemingly unimaginable these tasks become. Since eighties action movies provide profound insights into how to confront timeless problems, we need look no further than to Viper, Commander of the Navy Fighter Weapons School from the movie “Top Gun”. After Goose dies in a training accident, Viper recommends that Maverick, the pilot at the controls during the incident, immediately return to the cockpit upon the completion of the investigative proceedings. Viper knew that the longer Maverick abstained from flying, the harder it would be for Maverick to “get back in the saddle”.
To be clear, I’m not suggesting that athletes sprint at full speed the day after a surgery or a major trauma. There are instances in which a patient’s preferred activities do pose the risk of further injury. These instances are probably less common than we think. I’m talking about telling the recreational weightlifter with minor, atraumatic knee pain to just “stop squatting”. I’m talking about an asymptomatic high school sprinter who two months after suffering a grade 2 hamstring strain in a meet still hasn’t done anything resembling running at the suggestion of medical professionals. I’m talking about the finance executive with occasional back “tightness” upon waking who has refrained from Muay Thai classes for two years despite an unremarkable MRI because somebody told him that his pelvis is asymmetrical and his glutes “don’t fire”. I encountered each of these patient scenarios in a single day and these stories are far too familiar.
There are a variety of reasons why somebody might experience knee pain during something like a barbell back squat. While the whole isn’t always the sum of the parts, it seems reasonable to look for low hanging movement fruit via orthopedic testing at the relevant individual joints and to screen gross, multi-joint patterns. Lacking passive knee flexion, for example, might yield some clues as to why the knee hurts while squatting under load. Regardless of a patient’s goal, restoring normal knee flexion is generally desirable and should be achieved as quickly as possible assuming the anatomy will allow it. Nevertheless, patients need not always be completely “ready” to do the things they enjoy or things that closely resemble said activities. In fact, it’s likely patients weren’t “ready”, via arbitrary constructs like “glute firing” and “pelvic symmetry”, to do those activities when they were asymptomatic.
The point here is that there is a middle ground between the “just load it” camp and the movement optimization camp. The former undervalues skill/technique and the relative merit of competing movement “solutions” while the latter demands a perfect hip hinge and specific abdominal bracing sequence to perform even the most routine activities. With regards to loaded squatting, there are ways to modify the task (alter loading pattern-goblet/zercher/safety bar, alter stance width, alter depth, incorporate external constraints- eg squat to a box, modify intensity, modify volume, modify tempo, modify positional emphasis- concentric, eccentric, isometric, etc) to potentially reduce symptoms even without addressing more micro level evaluation findings. Rather than telling somebody “don’t squat” we can provide alternatives that closely resemble the provocative activity, back squatting with a barbell in this case. The treatment plan can simultaneously address local or more joint-centric influences on the global pattern of barbell back squatting. The part vs. whole training debate is social media clickbait. It’s not a debate for which practicing clinicians need to pick a side.
In the past, I was guilty of emphasizing the things physios value internally (“movement quality”, individual joint function) too much early on at the expense of what patients actually care about. I undervalued the most important question (“Why are you here?”), the answer to which is generally to confidently perform an activity of daily living or movement that occurs in athletic and/or occupational endeavor without substantial pain. Now, I still care about the former but I make it a point to perform the latter in as contextually similar a matter as possible without symptom exacerbation on the first visit.
The high school runner referenced above performed Mach drills (A walk, A skip, A run) and tempo runs on a non-motorized treadmill on his first visit. Remember he hadn’t run at all in the previous two months because it was deemed to be “too dangerous”. If two months post grade 2 strain isn’t safe to do skipping drills and tempo runs, when is it the “right” time? To the extent possible, most physio treatment sessions should incorporate both part and whole training as skill development and reconditioning, even in the presence of pain, require a blend of both. The finance executive above performed rotational medicine ball throws and light striking on pads soon after his initial evaluation. I told him not to wait any longer to start taking Muay Thai classes because the moment when his glutes start optimally “firing” from a perfectly symmetrical pelvis will never come.
There’s no way to definitely validate many of the constructs that are de facto reasons not to do things so we might consider shifting the clinical burden of proof from demonstrating that something is safe to demonstrating that something is dangerous. I did advise the finance executive to do various exercises at home to address range of motion and strength in his hips because I thought it would help his performance, not in pursuit of some ideal that pathologizes normal human variation and creates dependency on volume based treatment models (e.g. 3x/week for 8 weeks or you won’t get “better”). To be clear, I’m not suggesting that these people were “cured” because I had them mimic their preferred activities early on in treatment or that I achieve superior clinical outcomes to providers who utilize a different approach. I am trying to make a more concerted effort to consider what patients value instead of just telling them what I think they “need”.
Avoidance is not a sound risk management strategy in sports medicine. Risk aversion is not risk mitigation. Outside of post-operative situations and legitimate orthopedic trauma, complete avoidance of the desired activity is seldom helpful. Avoidance without an immediately actionable progression scheme is more likely to perpetuate fear and doubt. Risk mitigation demands that risk be applied responsibly and avoid large downsides or fat tails. Without some risk, however, there is no adaptation or confidence. Too little risk can be just as dangerous as too much risk, unless patients remain in their cocoons forever. Without risk, the patient relies on nothing but hope and time. Something physical therapists and sports medicine professionals often forget is that most of our patients functioned just fine before they met us. A minor injury, sensation of pain, or temporary setback need not justify months of physical therapy, orthopedic consults, home exercise programs, or bodywork. More is not better. Better is better. A health care system that minimizes competition among providers and stifles market forces incentivizes more treatment, not better treatment.
There’s a huge difference between helping somebody to help him/herself and trying to be the reason somebody gets better. Well intentioned medical providers often try too hard to be the latter without appreciating that more information, intervention, etc. can confound clinical outcomes. For this reason, it can be very difficult for patients to dip their feet in the medical pool without getting sucked into the deep end. Additionally, there are systemic political and economic incentives that promote interventionism and the medicalization of normal fluctuations in health and wellness. The goal of rehabilitation is to help people return to the things that are meaningful to them, not to maximize EMG activity in a special muscle (a list that continues to grow with more research) or receive a perfect score on a standardized movement assessment. The latter should serve the former, not the other way around. In the information age, strategic insight is neglected in pursuit of tactical endeavors from which it is easier to generate data points and quantifiable metrics. Maverick enjoys being awesome at aerial combat and if he’d waited for the perfect time to start flying again he might have missed out on what proved to be his finest moment. To be awesome, you have to be a little dangerous.
Courtney Reardon recently became the 68th American woman to summit Mount Everest and survive. An unlikely person to find herself at the highest point on earth, she has worked in Finance in New York City for the past 12 years and is currently a Senior Vice President in Business Development at an asset management firm. After graduating from Columbia University, she began working on Wall Street at Bear Stearns and subsequently BofA Merrill Lynch and BMO Capital Markets. Courtney developed her love of the outdoors later in life, during the depths of the Financial Crisis. Swapping out her usual dresses and high heels, she uses her vacation time from work to climb some of the world’s highest peaks, such as Mount Everest, Denali, Kilimanjaro, and Vinson Massif in Antarctica among other peaks.