Three clinical case studies: a toe fracture, a neck flare-up and safe loading

If it duplicates your problem or if it becomes really uncomfortable, just tell me and we'll stop. And so I'd see her face kind of wince and stuff and I said, does it hurt? And she's like, hmm, yeah, I didn't want to say anything though. You know, and so I'm like, please, please say something. And so she came back and she was feeling worse. And so we did this a couple of times and then she would feel worse after doing it. And so finally she said that I, she's like, I don't want to do that. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery.

And now your host, Dr. Sebastian Gonzales. Hey everyone, it's Dr. Sebastian Gonzales, your host with the Restoring Human Movement podcast. Thanks for joining the movement movement. This is your first time. Welcome. This is about a 45 minutes to an hour long format where I'm trying to become a better clinician and hopefully improve my communication between myself and my patients. And hopefully my patients will meet me halfway on this. So if this is your first time, just know that you need to go back in the archives. There's a ton of great ones back there where this is number one. I think we've got to be in the 170s right now.

So this has been going on for a couple of years now. I'm hoping that my presentation has gotten better over the years as well as some of the information I'm dragging out of some guests. Now, as you heard in the preview, we're going to discuss today some case studies. I've been asked by some of the listeners to have some case studies because it just helps them understand maybe how it would work through a case flow, in particular, without really having to shadow me. Now, in the beginning of this podcast, I guess I should relay that it was mainly intended for only patients. I was trying to improve, I guess, record some of the conversations I would typically have so they would understand.

And I started realizing all the listeners are students, ATCs, trainers, and so on. So it's becoming a little bit more migrated to that. So I want you guys to understand this is still patient-friendly. You can still share it with some of your clients and hopefully give them some empowerment as well as some understanding of maybe the way you're working with them, hopefully if you're working with them the same way that I am. You might or might not. Either way, no offense taken. Now, a couple house-cleaning things. Number one is, I think I mentioned it in the beginning of December, Cody D-Mac and Marianne Harrington asked me to talk about the R2P workshop that might happen prior to the symposium.

In particular, what I'm kind of thinking is that we haven't pinned down a date as of this podcast yet, but me and Cody D-Mac have been talking a little bit about they wanted to have a R2P student-based and doctor-based workshop in Southern California. So they talked about having it at my clinic, but my clinic holds about probably 15 to 20 people. If it gets much bigger than that, we might have to move it somewhere else. So the details of that are a little bit sticky. However, they're thinking, I think, around March 7th or 14th, it's still a deal. Cody's going to come down and teach a bunch of stuff, basically all the things that you want to know about how to incorporate rehab exercise and loading into your programming.

So I think for R2P students, don't quote me wrong on this. I think it's $40, and I think for doctors, I think it's like $90 or something like that. Either way, contact, you can contact them. I'll put them in the show notes here, but go to R2P, what is it? R2P Performance, I think is their website. Rehab. Just go rehab to performance and ask about the Southern California workshop, and then you'll get into that. Now, before I get into the case studies, let me share a little short story about myself so you understand where I'm coming from as a human. And hopefully you guys like shadowing me through this podcast, Adventures, that is the Restoring Human Movement podcast.

And thanks for spending the time with me. So we'll get into that short story really quickly, and then we will get right into the case studies. So recently I was talking to somebody over dinner about, we're talking about these robocalls, and just the problem with them, how many do you get a day? And they're like, I get about five. I'm like, dude, I get like five to ten of these things. It's crazy how many there are, right? And so she actually, I didn't realize there was something like this. So she says, when I have the time, I actually sit there and gather information from them. And what you're supposed to do is you take that, and you're supposed to report them to a certain website, which will help, like the FBI or whoever, track them down and stop them.

And so I said, what do you collect? And she's like, well, you're supposed to get their phone number, the company name, what they're looking for, what time do they call, and so on. And so I don't know all the details of it because I haven't done it yet, but I said, how long does it take? She's like, it takes about five minutes or so. You just kind of just let them bait you. And I was like, ooh, that sounds good. I kind of like that. And we started talking about reality TV shows of how cool would it be to actually see on the other side what actually happens, like if your information got one of those things to stop calling you, right?

And so I was like, you know how they have like all these like NCMICs or whatever the heck they call it, like all these shows with all these cops and stuff? We should do one, but call it RoboCallCop, where all we do is track down and see what these call locations are like, and you shut them down. I would watch that shit all the time. So if you guys know the details of that, I'd love you to share it with me so I can start ending those things too. Let's get back into the show. Okay, so the first case I'm going to share, and all these names are going to be changed to protect patient privacy, obviously, and I might change a couple of those small facts just to make sure that people aren't identifiable as well.

So over the last couple months, I've had a few interesting cases come in. I'm hoping to cover three of them today. One of them is going to be a foot or a toe with a soccer player, a high school soccer player. Another one is going to be where basically I went wrong, I think with a upper trap shoulder case. And another one is where I think I did it right. And I'm hoping that I get through all three. If not, I'll carry on to a different podcast, but we'll certainly start with a foot here. So the foot case was an interesting one. He came to me a few months back, and so he'd been in for some other things before, but very active young kid, nothing really visibly wrong with him.

He was, he's athletic, you know, he's a good kid, he likes to play soccer. And so he came in with an injury mainly from being stepped on. And I know that I've gotten these in baseball where you get cleated or stepped on or hit a base and you jam something. And for the most part, I, I mean, I should have been cleated. I got my elbow cleated one time, diving into a base. It freaked me out. After that, I had to go to the ER and everything. Had to, actually, there was no skin left. It was just a flap that had gone away. And so we just let it heal up. And so I still have a scar from it today. So soccer cleats, though, I think they're, they're nubs.

They're not metal. So he was stepped on and it was right around the base of his big toe. I'm sure with ball handling, I'd have to, have to check the details. But for the most part, he got stepped on right there. And so he was having some pain at kind of the base of his foot or base of his toe while kicking. And so I, I'll start off with this, is I don't see a lot of, I guess, trauma cases like this. I consider this trauma where there was an injury, incident, a contact. I tend to see a lot more, I guess, what we call a quote-unquote overuse type of model because there's no actual definitive time.

It's just people are like, well, it just started to happen slowly over time. And I, I prefer these because I don't want to say I don't have to think as much, but I don't have to think as much. I can still screen, I screen out all the red flags and I screen out all of the other drivers to it. But for the most part, I don't have to check quite as much with shear testing or load testing into the joints because a lot of times these things are referred. However, this guy in particular, he, he had it right into the joint area. And so after I had this case and the foot was coming in or a, or a foot or a toe was coming in, a couple of my interns jumped in like, I want to see this one, you know, because usually we see a lot of hips, backs, groins, and it's just kind of like, like we've already seen that before or they've already seen that before.

So they want to see me examine a foot and ankle. And so with the foot and ankle, I tend to use a handful of tests that are obviously screening out your ATFL. They'll screen out talar dome. They'll, they'll screen out a high ankle sprain, as well as we'll do some resisted range of motion of the foot, check passive active range, active range of motion too. And then we'll make sure that there's, there's not referred. By the way, we do check hip and back prior to these cases. Checking for swelling, temperature change, and things of that nature. I do like to, after doing the diplomate test, it was a, it was a, it was a risk that I had in my examination.

And so in that case, when it gets into like all the little, little tiny bones, I tend to go into a little bit more shear testing and just trying to identify all of the little joints right there and just figure out if that's driving a symptom or not. Because if I do that passively and just kind of take the, take the joint through different ranges of motion with a little bit of overload, then I feel a little bit more comfortable that that's the, that it's actually a joint-based problem, a capsular problem. And it's not some type of tendon or muscle. I mean, sure, it could be ligamentous, but it, I'm, I think I'm better at identifying what the exact area is rather than just referred because things cross.

In this guy's case in particular, I think if I only did range of motion testing or resisted, I would have been misled. And so resisted range of motion testing showed that it tested positive on the tibialis anterior, which is with dorsiflexion without the toes, and also isolated down into just the big toe extensor. So the extensor holosus longus. All the other resisted range of motion testing, like the, like the, all the little toe muscles and flexors or extensors and flexors didn't tend to bother him. He could basically walk around with no problem, and it was positive and shear testing. Interestingly, he was, he had already been managed by somebody, and so they already did some x-rays just to check out stuff.

And they did see a little bit of a calcific area into the, into the foot or into that location of pain, but they thought it was really just an old injury because he's an act, just an active kid. And so they ended up using some lidocaine right over the spot, which I think it helped for a little bit because they thought it was maybe some compressive, a compressive effect of the nerve on top of the joint. And, and it was just very short lived, the relief. So I think they were on the right track, honestly. I think that's a good thought process with, with having some compression of the superficial structures of the joint, because I think a lot of people just jumped to joint with that too.

But I think that was a good idea, especially since, uh, preliminary x-rays were, were negative. Also too, if you guys are thinking about x-rays, there's, I think the, from the way I understand it is if you x-ray too soon, you will miss the little fractures, but you wouldn't have caught the big, and if you x-ray too late, then, or I don't want to say too late, but later, about three, four days later, then you'll catch the little ones. I like to think of it kind of like we're at the beach and we're at the boardwalk and there's sand all over the boardwalk. And so I can't see where the cracks in this, when, in the boardwalk are because the wind hasn't started blowing yet and all the stuff hasn't cleared out.

So with this, I kind of think the body cleared out the spot from the fracture. And so you can see the little tiny ones after a couple days. Either way, um, the initial fracture was, was negative. He was still having pain and the initial intervention really wasn't helping. So he was there with me, not to treat, but just for guidance. I actually kind of like cases like this where someone comes in for guidance because there's not a big rush to treat. They're just asking, what do I do next? And I feel pretty good. I mean, I feel good about myself knowing that they trust me enough to actually come in just for, Hey, what do I do?

Where do I go? You know, if I go to you, I'll go to you. If not, I'll go to someone else. But where do I go? So after the initial part of the exam, I, I didn't know what it was, you know, like thinking, well, the fracture is still on the board because we don't know for sure. But I think an MRI would know for sure in this case or a CT. CT is probably a little bit more, um, indicative of finding that fracture there. But do I really want to subject this still growing kid, possibly still growing kid to, um, that much radiation in a CT? So I opted to tell them to do an MRI on it and they didn't really have, I guess, great insurance for it.

It was going to be challenging to get it. And I just gave them the conversation of, look, money talks. You know, I know that when I was, I don't try to make the parents feel bad with this at all, but I tell them, look, when I got hurt in high school, my mom literally drove me 30 minutes, two times a week to have me, um, inspected as well as is treated because I, she felt it could possibly get me better and it did. So she was willing to make that call. She was willing to make that time happen. Obviously it wasn't money, but she would have paid probably any amount of money to make me feel better.

So sometimes I struggle with understanding why some parents just, they're like, you know what, this is what my insurance pays for. This is what we're going to do. And this is, this is how it's going to go. And I just tell him, look, if he was my son, I'd just pay the money because I want to know that he can play again with no problem. Okay. If I clear him today and we, he still could have a fracture in there. So I would say just, just go get it. Go pay cash. All right. It's only cash. It's not a big deal. Right. You pay more money probably than other things. So let's just, let's just see if, let's just see what it is definitively, because I want to be able to clear him and it's going to help give me information about whether it's going to be safe for him to return or not.

Some parents are open to doing this. Some aren't. Um, and some, I guess some people are open to doing this. Some aren't. I always let them know that, look, I, I, I did an MRI on my back last year because I wanted to know. And I was, I let them know ahead of time that I actually felt 95% better, but there is still a little bit there. And I was like, Hmm, I wonder if, and you know, it was that thought of, Hmm, maybe I wonder if, you know, and if I wonder, I might as well just know, you know, I'm not looking to see if there's any really big relationship with degeneration and, you know, all those DDD and, um, all those things, they kind of tell you the big, bad, scary things or the gray hair of the spine.

I'm just looking to see if there's anything, um, just odd, you know, like I'm looking to see if there's red flag indications in there. So I just kind of wanted to know, I wanted to know I had a clean bill of health, right? That's why you do what you do. I paid cash for it. So I'm a perfect example of leading by example on this type of thing. I wouldn't lead by example on everything, but I tell him, look, I did this. I think you should do it too. So, um, at that point, the only one extra test that I did was I asked him to show me what hurt because I didn't fully understand the mechanics of kicking because I don't play soccer and so he kind of showed me what that was like and so I didn't have a ball in the office, the soccer ball, but I did have a med ball and I said, this thing's a little heavier.

Can you just show me like where you contact this thing, um, to kick it that hurts and so he showed me and so it looked like a stress test that I hadn't really done yet and so I did the stress test and isolated it down and it looked like there's some irritation, um, right around the base of the first, um, metatarsal into where it's inserted into the tarsals and so I, I, I told him, look, this thing looks like a joint to me. I think we need to investigate it. I think we need to look at an MRI and we'll just see what we find from there. We find it's positive. I might send you to a podiatrist because I don't feel comfortable managing these cases and so, uh, what I did that day was I just taped him up.

We taped him into a, um, I guess a movement check type of, uh, a tape job where that movement that bothered his kicking was a little bit more of a, gosh, I'm forgetting, I forget my foot, a foot in hand relative to abduction, adduction anatomy, but either way it would push, uh, he was kicking from the inner part of his toe and so it would push it towards midline and so I basically taped it so it would resist a little bit more of midline. He was able to play with the ball a little bit, it decreases symptoms significantly and so that's why I left it at that point. I did get word later that actually had, he had, uh, an MRI done which I'm very happy with because there's a lot of, there's a lot of parents that just don't do it simply.

I've had people who, uh, looked like their kid could have had slipped femoral capital epiphysis and it's very suspicious findings and I said, look, you need to get this done and they just don't do it. So I'm very happy and I always, every time that happens, I, I tell the parent, I'm gonna say, you're a very good parent. Like, I'm very, I'm very happy you did the image because X, Y, and Z. And so I try to make sure that they know that, that their, their, uh, ability and willingness to shoot the image and follow the recommendations that I give are what's going to make their, their kid, the, give their kid the best possibility of recovery because the kid doesn't really have any power in this.

So I just let them know ahead of time about that or I let them know after the fact, after they do it. So he actually ended up having a fracture still. He had a growth plate fracture. And so it just happened to be like the perfect storm. He got stepped on the area where the growth plate still was open and he had a little fracture there. And so luckily he did go to the podiatrist that I suggested and he did a really good job managing. I read the notes and I think it was really creative about what he did because he also empowered the patient, which I love. And so he basically said, look, for about four to six weeks, you're, you're going to be off kicking this ball with that foot, but you can actually increase the time ball handling on the other.

And so I want you to get really good at cooking with the other foot and handling the ball over there. So then you can become a better soccer player in the end. When I read that and I talked to the parent about it, I was like, man, this is great. I love that. I love that, you know, because he could have easily just stuck him in a boot and then just told him, told him to don't move because it would have been easier. But this is what I'm talking about with, uh, uh, we had the, we had the workshop or sorry, we had a meeting where all the meeting of the movement came and just like-minded professionals that like to empower their patients.

This is exactly what I'm talking about. I'm talking about having a like-minded podiatrist who is open to getting a little bit more creative about their suggestions to make the, make it so the patient can make the, uh, make this a favorable, um, time, time in their life. I know some people that broke, I broke my right arm when I was playing a basketball or sorry, when I was, uh, during basketball league, but I broke it snowboarding. And so I broke my right hand and I'm right-handed. So I couldn't, I couldn't shoot with it, but I did a bunch of left-handed scoop shots. So I was never a great basketball player, but this helped me use the other hand.

And so I think this is a great opportunity to use the injury as a way to, to improve the athlete. So overall general physical preparedness in this case is important. And this is just side notes is we don't decondition the athlete to improve the quality of that one area unless need be. There's no reason this kid can't do pushups and pull-ups and single arm pulling, um, do light drill work where he's not kicking with that foot as long as he doesn't increase the amount of irritation to that section. And as long as he's under the compliance of, uh, what his podiatrist gave him at this point, I didn't give him extra recommendations because I think he was really good with what, what he was doing.

Um, but we shouldn't decondition the athlete because the problem is when you bring someone back into their sport after taking say four to six weeks of not doing anything, then you have a deconditioned human. We already have a deconditioned foot. We got to mess with, but we don't want to have a deconditioned human. And so getting a little bit creative and stress testing your people, whether they be athletes or just, just regular Joe's is, um, important because you can give them better recommendations about what they can and can't do throughout their life and just give them a good solid, uh, answer about yes or no.

Hey doc, will this hurt if I actually, um, cycle while I'm on their firm bottom shoes and you're really not pushing off too much of the toes? No, it'll probably be okay. Pull with the heel, right? Hey doc, can I go jump with this? I'm going to do repeated jumps. Well, there's a lot of toe movement there. And like, does it hurt to jump right now? Yeah, kind of. Then no, let's not do that right now. But instead, you know what you can do? We can probably do some, uh, goblet squats. We're going to drive to the heel a little more, a little bit more predominantly than, than drifting the toes. Cause I don't want to irritate that one joint that's in question.

Or, you know, maybe we just shy that whole thing back and we just do a little bit more of, um, uh, we'll, we'll keep off the toes completely and just do hip thrusters. I know it's a different movement, but either way, there's the, just the example there. So I think getting a little bit creative is probably the takeaway from this case study. And also too, make sure that if you feel that you are looking at a possible fracture, make sure that you roll out the fracture. And I remember, um, there's, there's one doc, I won't mention names. I don't know if he wants to mention it here. He mentioned that he had to shoot three MRIs before he found something positive, but he thought it was positive.

And so the person did have to pay for one image, I believe. And the other ones he had to argue with an insurance to get repeated MRIs done. So it's sometimes money talks. Okay. Actually money always talks in this case is if you want to, if you want to have control of your healthcare, pay the money. All right. Simple. I had to do some insurance, insurance calls for people to get, uh, an image covered, uh, last week. It was, it was, it was hard on me as a, as a provider. I'm, I'm not saying I won't do it for my patients, but it took literally hours to try to get all, both these ones cleared for these people.

And luckily, uh, they did get cleared, but I told them in the middle of those conversations, I said, look, this might not get cleared. If it doesn't get cleared, just pay the money. I did it. I paid it for my back. And I can honestly say that. And I'm sure you guys have heard me before in the podcast when I hurt my back, when I was trying to rehab, but I was afraid of lifting weights again. And so I literally paid a strength coach to come in two days a week to work with me, lead by example, be okay with paying somebody else to, to guide your care. And that way you can honestly say to some of your patients that that's what they should do because you did that.

You're not just making the suggestion. You literally wanted the best care for yourself. So that's what you did. So I hope that case was enlightening to everybody. Um, I, I don't know the outcome of the case yet. I'm sure it's going to go very well, um, or else I would report a little bit more on that, but I think he's on a good track. And I, I really liked the treatment plan on this, although I was not the main treating clinician on this or the one that made the solid recommendation. Um, I feel very, I feel happy that I was able to, to guide them the right direction because they just felt like they had no direction whatsoever.

So let's get on to the next case, which is going to be where I think I did something, uh, I don't want to say wrong. I just could have done it better from the beginning. All right. Case number two is about a right upper trap, which I believe was neck related. And, um, it was a, a lady who was about mid fifties or so, and she just fell, um, into the water really. So I mean, the water's not air, so it's a little bit more of a, we can consider this maybe like a little whiplash or from the side, you know? And so that's kind of the way I read it, but I also took a pretty long history in examination in this process.

So here's some of the highlights, at least with the examination. Number one, that she had had, uh, quite a bit of past history with some neck issues, not really a history of shoulder issues in the past. She didn't really fall or hit anything other than just the water. And it was just from, I mean, it wasn't from a cliff or anything, it was just from, you know, something of, of just above the water. And so, uh, she was having some issues mainly into the shoulder, as she would call it, into the, kind of like the upper trap area. Um, sorry guys, I think if I'm, I'm trying to clear out, don't eat oatmeal when you're doing a podcast because oatmeal dries you out and I keep having a swig water in the middle just to try to get the, uh, it's got flaxseed in there.

So the flaxseed, you can't get them, they're tiny, you can't get them down. So they're kind of stuck in there. I'm trying to get them out. Either way, I'll try to pause that and just chill it down. The, uh, so she was having me major, uh, majorly upper, upper traps. That was a major complaint, uh, or the chief complaint rather. She was also having some other stuff correlated to, which she, um, it took a little bit of digging to get it out, but I think it was really related in this case. She was having some periscapular pain or, or pain into the shoulder blade region, which is really common for people who have, uh, upper trap tightness.

And I believe it's mainly from, uh, um, radicular. If you look at C5, 6, 7, 8 on a referred pain pattern, that periscapular mid-back pain is going to be very common. And if you heard the podcast I did the very beginning of the year, I did a whole audio kind of on this that, uh, if someone's not ready to come in and see me, I, I give them that audio so they can get an idea of what's going on. So they keep, don't keep chasing that, um, that scar tissue maybe they think is in there. So the, there was all, there's some mid-back pain and tenderness. There was also some into the right medial aspect of the forearm, um, kind of into the area of the, I guess, flexor carpial neris.

If we were going to make a, um, location based upon a muscle underneath, uh, she wasn't able to turn her neck to the right. She had pain, pain with raising and shoulder, uh, raising and lowering her shoulder. She also had numbness in the part of her fingers too. And so that was all uncommon stuff for her. And she felt like she couldn't really open jars. And so there was some, uh, there was some other stuff going on. Um, and so she was really concerned about that top area right there, but she, uh, obviously it had more stuff to this. And I think it was, it's not that it's a large complex problem, but I think if we, um, bring all the data points together already is there's going to be some nerve aspect to it because there's, uh, there's a little bit loss of hand strength.

There's also two, there's, there's the, uh, numbness in the fingers and also the periscapular presentation. She also had some headaches too, which is kind of new for her, which would make sense if you kind of hit your head on the water. But, um, she was having stuff that was a little bit more beyond just the shoulder. So, um, there wasn't anything else really big with the case. I screened out everything else, but those are the major takeaway points right now. So she, she did reduce her symptoms in about a week significantly. I'll start with that. What I did mainly for that treatment aspect was that I did some, uh, a neurodynamic approach.

Uh, she was into the age range where I don't think really a disc was going to be the major driver in this, but I think there was some minor nerve impingement, especially since there was stuff going on, uh, into the arm. Um, now I guess, can I say impingement versus tension injury? I don't know. All I know is that there, I think there's a nerve aspect to it. And so I usually go with a shack lock opener, at least in the beginning on those cases to just, just to see what unmuddies a little bit rather than going into too much of the nuances just yet. And luckily that, that tended to help. But one thing that was kind of happening was that she was, I mean, she's, I saw, I saw she was just having neck things on and off over years.

And so I was like, something's driving this, you know, and, uh, based upon, uh, the Guido van Reis again, the tractor state model, I think the upper traps are probably not helping in this case. They're just dominating, right? There's ponds. And so she was, she's overall, she, she doesn't spend a lot of time doing physical activity. I mean, she's active with getting around, uh, but she's never really spent any time doing weight training or exercise of that nature or so on. So I took the liberty of saying, you know what? I think, I think a little of this might help. And so I didn't push her right into weights right away, but I, I told her, look, we should do just some corrective exercises.

And, and, uh, you've heard me over the recent podcast that I, I make things challenging for people sometimes, you know, because I want to get it done quicker and I want to make sure that they get the response that, that, um, that they need and validation that that's actually a good exercise for it. I don't want to just give them busy work to do. I don't want to give them a sheet of paper with 10 things to do and have them walk away and then just do that for the rest of their life. I'm trying to scale them. And, and usually I tell them that some of the corrective exercise I give them is a, it's a long test.

I'm just looking to see if the couple minutes we're doing this decreases their symptoms or it increases it. Uh, either way is fine. That's, that's the way it is, but I need the information if I'm going to help guide you to decrease potential of this coming back. So keep in mind, she was already 50% better. So she was already happy with things. And so she, um, she came back the next time after doing this stuff. And, and so it was, it was increased. And so, um, I've had people over the years that I think I could communicate better with. I know that there was, there was a lady way back in the day that, uh, we joke about it now.

And she, so she's a good friend. She, I'm like, I'm like, you know how hard it was to get information out of you? And she's like, yeah. She's like, laugh about it. And I'm like, I'm like, I, at these, in these tests, I'm looking just to see if it creates pain, don't be strong and don't say anything. I can see it on your face. Just tell me better, worse, the same. And so with her, we had to come up with a number system. I'm like, what is it now? She's a five. She's like a five. And I was like, how about now? And she's like a four. How about now? Oh, it's a seven. And so I knew it was moving, but she didn't have to really say, she didn't have to be a pleaser and say, oh, it's good.

You're doing a good job. So she just, that lady in particular was just, you know, she just accommodating. She's trying to make probably me feel good about what I'm doing when I'm not really helping her because I don't, I'm not gathering the information. And so with this lady as well, I think I should have used that number system a little bit because I'd say, look, these, these exercises should not hurt whatsoever. It should feel effortful. And I kind of indicate the regions where she should feel the effort, but I'm like, it shouldn't be painful. If it duplicates your problem or if it becomes really uncomfortable, just tell me and we'll stop.

And so I'd see her face kind of wince and stuff. And I said, does it hurt? And she's like, yeah, I didn't want to say anything though. You know? And so I'm like, please, please say something. And so, um, she came back and she was feeling worse. And so we did this a couple of times and then she would feel worse after doing it. And so finally she, she said that I, she's like, I don't want to do that. You know, I had her, I had her do something like, oh, we were doing carries. Um, and it wasn't with a lot of weight. Um, it was doing carries and I was trying to do the whole, um, explain, you know, that these weights are about the size of a bag of groceries that are just really heavy and you're just walking home with these groceries, you know, and, um, kind of using the weights as, as an activity, a daily living type of approach.

And so, um, she, she, she had some concerns about that, um, because the weights were obviously the weights and the exercises were not making her better. They were making her worse. Um, and she had concerns about why we using these weights at all, you know, because she had not come from, um, a weight training background. She didn't come from a sporting background and it's just, she succeeded pretty well throughout her life with not doing those things. And she'd been feeling good minus the, you know, aches and pains that would go along with quote unquote old age, which is what a lot of people chalk those things up to.

So it's like expected, they're happy, like they don't need to add more. They don't want to add more. And so I think the problem with what I was doing was, although I was trying really, I was trying to actually add in the information that was needed to understand why these things might be useful in her long-term care. Um, she, she didn't really see it, you know, and it wasn't important. And so I think she felt like she was being forced into it. And so we sat down and had about a 30 minute conversation after that. And so I just told her, look, I'm not going to force you into doing anything you don't want to do.

Here's the rationale why. And so I laid the thing out a little bit and I just explained that, you know, the things that we're doing here, I know that we're doing a couple different things each time, but, um, there's a plan in place is why I'm doing it. And I wrote it all out, like kind of in a nice flow chart a little bit. Here's where we're at. Here's where I, uh, well, I took you a lot where you were at last week. Here's where I think you should be. And I think that that's end of care right there. Then just do that. And so she, she, she told me what she wanted was not that. And I said, okay, you know, like I, I understand, I understand your, your concerns and we won't do that again unless you tell me for some reason that you want to, I'm like, I might still explain how these things might work.

Cause I think it's in my, it's in your best interest to, um, just hear me out, but also to, I'm not, I'm not here to force you to do something you don't want to do. And I want you to feel better. Like clearly after leaving the last couple of times, you didn't feel good. So I want you to feel good. That's why you're coming. You want to feel good. However, I just want to make sure that, that, you know, that I, I have your back. Okay. You're not, you're not, uh, I'm not going to force you to do anything you don't want to do. What would you like to do today? And so, um, she showed me the one she was comfortable with.

And so we went on the floor, we did some floor-based exercises. We did some push-up planks, some side bridges, some bridges and things of that nature, some general, general mobility exercises. And she walked out feeling happy, very like she felt walked out feeling better. Feeling happy. And since, since that time, she's been doing much better. Um, and we were able to, uh, incorporate, um, one thing which I did discuss with her after things got flared up. I said, when things get flared up, I think you just, we just got to cool it down. Um, and so I'd given her, um, a home exercise to reset it just to cool it down.

And it was working in office, but I think, uh, when I see that people are a little bit more out of, um, it's not comfortable and they don't have control over it, they, they're typically not using those exercises or the exercises aren't working anymore. Um, and so I call it the Smokey Bear approach to say, look, if you leave here and the fire's up, like, I don't want that. But if it's like that or during an exercise that we're doing, that might be a little bit new, um, just, just say something and I'll show you how to put the fire out. Okay. Smokey Bear says, put the fire out. It's fire season.

Put the fire out. Smokey Bear also too. He looks around and he sees that what else is a fire potential here? And so he sees kids gathering wood and so they're gathering wood. He said, Hey, what are you going to do with that wood? And they're like, we're just going to build a teepee. Great. Cool. I'm going to watch you. Right. He watches them. Now, if they put the, if they put it in a teepee and they start lighting it, he's over there really quickly. He's going to put that fire out, but he takes note of things that are potential and he's patrolling and making it so that it's, um, that fire season does not have an accident.

And so it's preventative as well as, um, as palliative. So with this being said, I tell her, look, I want you to do those exercises frequently, even though things aren't bad, but when things are bad, I want you to put it out. Okay. And so tell me, talk to me during these exercises today and just let me know what's going on. And so I think I was missing two parts there in this case is number one, I was trying to put her into a little bit more of a model, which I thought she would fit into, but I was wrong and I didn't ask her. Second was that I don't think she had control over her symptoms. Although, um, I was in the impression that she was because she was feeling better and she was clearly doing the homework at that point, but she didn't understand.

I don't think she understood that she can still use those. And I just needed to be a little bit more clear. And so since then we've, we've, uh, had good discussions over doing floor rehab together. Um, she's open to doing a little bit more challenging things, but we're still not getting, we're not getting into those things with the big, bad, and scary. And I, I've been a little bit more mindful over the course of her case that what is the implement that I'll bring out of, out of the weight room? Am I going to bring a kettlebell or am I going to bring a backpack with some, with some sand in it?

So there might be other things that I'll give her, um, sticks, bats. I have other implements throughout the office that are less scary and they have less of a stereotype of building, building muscle and, um, you know, kind of like the macho type of thing. And so that is my, the approach I'm going to take a little bit more with her and I think it'll go very well. And I'm going to do a better job of just communicating what the intention of each exercise might be and if what she feels in that number system to make sure that I'm communicating to her and she's communicating to me. And I think we'll all be happy right there.

Now, really quick break from the show. I want to propose a educational series to you guys, for you clinicians out there, this is not intended for patients. Uh, I recorded a webinar series, um, a little while back. I recorded it. It's over 15 hours easily when you put all six parts together, but I broke them up into two, three hour bits. We cover what I call the five-step patient care, uh, system. And I've developed this because I've been training interns and this is a good way to organize thoughts for them and also easy way for me to teach too. And so step one is history taking, working diagnosis, physical examination, dynamic testing and good exam flows.

Just really good, solid exam flows, knowing when to use them for hips and shoulders and backs and cervical and so on. Also, we do cover first aids, how to get people out of pain without having to use medications and really without even having to put our hands too much on them either. That's very empowering shit for people to be able to do stuff on their own. We also cover corrective exercises, which is number three and when to use them, how to use them, which ones to use, how to cue, how to cue them, how to coach them. Then we cover loading. DMACC, Dr. DMACC also covers a little bit into the other products we have on the page too.

Um, that one is, if you want to go a little bit more into depth on number four, which is loading, uh, Dr. DMACC covers that again in 12 hours of the low back one or sorry, no, it's two hours, two hours of the low back one and another two hours of upper quarter and cervical spine. So as you can see, I could not fit it completely within the five step series because it takes more detail than that. So he covers a little bit more thoroughly in there, but I do make introductions into it and I do do some of my coaching and cueing style too, which is a little bit different than his. However, uh, I want you guys to go through this and really take the heart of the, what I'm going to say is, uh, and taking the light that is intended.

If you don't get this, shame on you. Shame on you because it is one of the most educational, useful, cheapest, um, series that you can possibly get to improve your clinical knowledge. Um, uh, again, I don't say that lightly, but I, I feel like a dick when I say it is, um, if you don't get it, I don't, I don't know what you're spending your money on. I don't know why you're going to all these other workshops that show only little tiny parts of things. And so this is an organizational series. I know a lot of you already know how to do tissue work. You already know how to do some stretching techniques.

You already know some exercise techniques. Why do more? You might as well just figure out where you're missing things and learn that one. Learn how to plug in those things you already know. Many of you are very, very good at tissue work already, and you don't need to go to more. I know that I spend a lot of time doing a lot of tissue work. I don't need to learn a lot more. I probably need a little bit more, but not a lot more. I need to figure out where my, where my competencies are lacking. And for many years, my competency was lacking in corrective exercise, QN, and loading strategies. And so after plugging those things in, man, fricking game changer, fricking game changer.

Anyways, we cover hip, shoulder, low back, cervical spine, and referred symptoms. I'm going to share with you a review that we have on the low back one, uh, taken by one of the people who went through the course as I taught at live. I highly recommend this guide to any chiropractor and physical therapist looking to up their game in treatment of the low back. The guide is a great supplement to anyone who likes crisp book protocols by Don Murphy. If you read those books and agree with the patient's needs to have better control of their own health, then you will love this. Sebastian Gonzales gives you a step-by-step guideline of what to look for in examples of exercises for treatments that will be useful the next day, not just theories and concepts.

Great. Well written. I like that. So please go through there. Again, take my comments in the light that it was intended. I want everyone to improve. I want our profession to improve. I continue to learn people who have been around longer than me as well. Um, and there's no need for everyone to struggle and try to reinvent the wheel. I know our, we get frustrated when our patients try to struggle through some of the easy stuff that you could teach them. Um, don't make the same mistake. They do. Don't let them go around on YouTube videos, looking for solutions when you have an easy solution for them.

So, p2sportscare.com slash products. You won't be disappointed. We'll see you on the other side. Back to the show. Now, into the third case, I think this is where I did things right, and I didn't realize how right, uh, until the patient actually started talking to me about her, more of her past history. Now, I had someone referred in to me who was, um, she had, she had lots of different things going on at the time. She's had lots of issues in her body. Um, she's about 45 years old. She's had headaches, she's had shoulder pain, she's had knee pain, she's had back pain, she's had a lot of things.

And so, she, what she really struggled with was that she did not, she has not developed, she wants to get stronger. She wants to exercise. She feels good exercising. But, the problem is that whenever she exercises or she's been put on a program, she tends to have a flare-up and then she has to stop. And so, she said she's been to multiple trainers and boot camps and so on that she goes like one or two times and then all of a sudden she hurts for so long that she just stops. And so, it's frustrating to her. And so, the reason she was referred in to me was because one of her friends does some weight training, um, here.

And one of her friends had, had an issue as well. And then so, I've put him on to a little bit more of the model of the sustainability training. Just keeping training sustainable. And just doing it so that it's just a little bit every couple days and just making sure that you feel good. A little bit based upon the, like, easy strength model. Um, and compound lifts, um, and just stuff that's not going to bother them. You know, at least in my opinion. At least after we teach a little bit of form. So, using this program, if you're wondering, I'll just use the standard, um, basic, um, don't go over 25 reps.

Um, you can, you can cycle through five different movements if you want or just make three. Uh, and then put something overhead. Um, carry something and pick something up from the floor. Just standard Dan John, uh, simplified terms. And so, I'll give them options of exercise to do. But, uh, I'll tell, I told her, I said, look, I want you to come once a week or once every two weeks for a little bit of time. After we, uh, implement some, some tension cues as well as some form. Uh, because a little bit of the, a little bit of your issue is probably the form, number one. But also, two, the, the tension was probably poor.

Uh, at least after watching her do some lifts. I, I believe that was the case. And, and third is that I think the program was just maybe too much for you. And so, maybe we just take a little bit more of a long-term approach with this one. And we just make something so you don't feel trashed afterwards. You just feel like, huh, that was kind of easy. I think I'll do it again, you know, the next day. And just think of the long, inclining slope, which is going to be the rest of your life. And just make something that you can sustainably do over time. And it'll produce the results you want. And it's not going to be a race.

And so, she was down with that. She came a handful of times. So, we did some tension cues. Um, I, by the way, I did do some physical exam with her just to stress test and see what was, what was safe. But she was very clear about she didn't want to really do treatment. She wanted to learn how to lift and how to exercise so she can do it for the rest of her life. So, that's the, that's the route that we took. And I did prescribe some exercises I thought that were going to be useful for her things. And I did see that her, her things that she had been bothered by had a partially mechanical aspect to them.

Like the, the back was flexion intolerant. The neck had protraction with it, uh, which created some headaches. And so, I was mindful with that when I was creating the cues with her. And so, when she was protracted a little bit, I'd, I'd put a little sticker on the ground and tell her to look curiously at the sticker. And so, she'd pull the chin back a little bit. But also, too, she had a visual cue where she was looking at the sticker. Uh, I have this sticker called Francis Frog. Francis Frog is a, uh, it's a character made by one of my friends. And so, yeah, he's got big old eyes. So, it makes work for, makes, makes, uh, good for a staring contest.

Anyways, she, she has done really well with this. She is extremely coachable. She does her homework. She's really excited and motivated. She's in the office for no, no more than 30 minutes at a time. We do a really quick warm up, warm up. We're getting the cylinder, the front side back wall, uh, accomplished. And she's doing some glute priming. And then we go through the pattern of the movement. And we just go through those movements in, in, in regards to what the program is for that day. To this date, she has not had any pain while lifting. It's been six months. So, I think that was a really good win.

And she was super excited. And she said, you're the only, I guess, trainer. I will say, she's a trainer. So, I was going to say, quote, because there, because I'm doing the training certification. Um, that I've been to, who's been able to, to help me through this. Now, I think I should retract a little bit just to make sure that everybody understands that. Um, I did read an article recently that it was, I think, written by Ben Stevens. We're talking about, we're not coaches and we're, we're doctors. And so, I do agree with that. However, the, the, the prescription for this person is, is, I think it works very well.

If we know mechanically what's going on with that person, we can coach it very well. However, um, I do agree with the fact that we're not coaches and we don't program especially well. Um, and so, this is not to another case study, but I'll just, um, give you some enlightenment. Is, I had a, I had a baseball player come in. It was a high school baseball player. I took him through tension cues. I cleaned up some of his lifting. And then, I actually told him, I, I can do no more for you in regards to lifting. And, you need to go to a strength coach. And, I referred him to a strength coach. He's doing very well now.

And so, I usually tell people I can take him through, um, the basic five lifts or so. Or, the basic five movements, rather. Teach them tension. Make sure that it's not going to aggravate any problem that they have. Build up a little bit of weight in there. And, then, all of a sudden, my, my ability to give them more productive things to get them to their goals is lower. And, this is where, the reason why I don't really work with professional athletes. Or, or anybody who has, uh, aspiring Olympic potential. Or, high school athletes who are looking to strength train in that manner. Like, uh, I, it's just not my job.

Okay. I'm good at diagnostics. Uh, building of programming, corrective exercise, first aids. And, then, uh, some loading and tension cues. That's where I make my bread and butter. Now, for general population people, I can have them do the basics. Kind of like with this person, um, that was successful six months, for six months. Because, that's all she needed, at the time, in my opinion. She's felt very good. She's not asking for anything fancy. And, she just wants some basic things she could do at home. Some easy movements that make her strong. And, that's what we did. So, I've implemented a push, a pull, a carry, a squat, a hinge, in various fashions.

By the way, if you guys have not watched Dan John's intervention already, you, you should watch it, or read the book. It's great. So, that's the basics of those case studies there. I think I did a, I, I'm going to give myself a nice pat on the back for that last one there. Because, um, I was surprised, actually, when she finally, she, she told me that, um, in due, it was this, recently she told me this. She said, I'm so excited. I, I've not been able to do this anywhere. And, I've been doing it for six, with six months with you. But, more so, I've been doing a lot of it on my own. It just takes, your program is just working for me.

And, I said, perfect, great. I didn't know it was working that well for you. I just, I thought you're getting a little bit of a sweat on and a little bit of a challenge. So, um, I was very excited to see that. Because, she's been able to be, become more empowered. And, pretty soon, she's going to be released on that. And, so, as long as she has the programming that she feels comfortable making on her own, I have no problem with people doing that stuff on their own. I, I love it. I dig it. I think people should. Sometimes, they just don't know how yet. So, um, I, probably on that note, too, before we start closing up, is that, um, I've been experimenting a little bit with creating sustainable strength, um, training programs for people, more for my wellness model here.

Um, I had a handful of friends take advantage of it, and I think it's going well. It was interesting, though, that, that, um, one of them, he's like, hmm, for the price that I paid, I don't think it's worth it. And, I said, you're probably right. Like, there's no bells and whistles or so. It's about 30 minutes, but it looks pretty darn challenging for you when you do it. Just do it at home. And, so, I'm hoping that the results are going to be what I expect. And, it was for 12 weeks, and they do one session in my office just to understand what the program is for the week and cleaning up any, any movements and cues that I might have to do.

Uh, they don't have any problems, really. And, so, that's why I wanted to implement this, is because I see that, as I'm 38, I have friends who are, you know, getting a little bit older and out of shape. And, you know, life's kind of getting carried away. And, it's, uh, I mean, it's kind of now or never, I think. I mean, I've, I've met people who, in their 40s, they feel and look like crap. And, there's people in their 40s who feel great. And, I think Tom Brady's probably out of this. It's like, well, how do you do what you do at 40? How do you feel good at 40? Well, he probably does a lot. It just doesn't, it's not genetic, you know.

So, I'm, I'm hoping to share some of the sustainability, uh, training with, that I do with just some of my friends and family and, um, and hopefully to grow this into a more, uh, a more patient-based model. Like, something they can get, they can get into and do after their problem is actually more resolved. Um, within that, I tend to, I was thinking about making it more complicated or not because my friend's like, hmm, well, it's not worth it. I'm like, do I need to add more? I'm like, hmm, I don't want to add more because it's, if I add more, it's more complicated. I'm not trying to make it complicated.

I don't want it to run your life. I just want you to do it. And so, I thought about even adding like, okay, what are some easy things you can do for nutrition? Well, drink water. Something like that. But I'm like, hmm, I don't want to do that. I'm like, why don't I just take the approach of they, they have to come in and do those sessions and hopefully during which we might talk about water at that point or, hey, what'd you eat for lunch? You know, things like that. Just kind of drop things onto them. Not like force good habits upon them, but make it a, make it a time where they might get some new ideas and hopefully that'll carry over later into the rest parts of their life.

Because, I mean, I'm telling you, if you guys are 40 or 50 or so, you see some friends that are, they're like, how'd you do that? You know, and other friends, it's like, oh my God, like, like you go to a classroom and then some of your, some of your classmates have already died from heart attacks and things of that nature, knee replacements. So I don't see any major reason for that to happen, at least not to people that I know. And so that was the, it was reason for the development of that model. I'm hoping to, I'll probably collect some testimonials later to see what their thought was and how I can improve on that.

Either way though, I, the goal was to create something like I did with this last case study where things just work. I want it to fall into place, but I don't want to force it upon them like that second case study because that was where I probably did a bad job. You know, actually, before we actually close on that note, I should probably address the point. I'll probably do a whole nother podcast on this later is that I think as a society, I think we've, or at least in maybe America, I think we've gone too far into loading people. Okay. Loading people is for a certain time and place. As with case two, I didn't need to necessarily load her to make her feel better.

She felt better already and she was okay with just normal activities, daily living movements, going for walks and things of that nature. By the way, in that second case study, reaching overhead made her shoulder feel better and neck and shoulder blade. Hmm. So it's more of a nerve root one, right? But Cody sign probably. So I think it's important to realize too, that there's different implements that we can use in, in loading if you do choose to load, but how much is too much? Everyone's really, a lot of people are concerned about being strong. How do I stay strong when I get older and so on? And it's like, well, how strong do you need to be?

Because if you look around at like, say your grandfather and grandmother and so on, ask them if they, anything hurts. And I bet a lot of them say not really. But when you look around all these fit people, ask them what hurts and they say a lot, you know, like they're probably the reason why people like me are in business. All right, athletics is, is not always easy on the body. It's more demanding. I'm not saying don't play sports and don't lift weights and don't do fun stuff, but sometimes just doing the basics in life is not a bad thing. And so I think we've gone a little bit far on that end in trying to push the envelope into getting people strong.

When I think we need to question, do they need to get stronger period or how strong is strong enough for this person's life? So I think that's an important spot to hit and just don't overlook the importance of general daily movements, going for walks, swimming, big arm movements. I mean, people with Parkinson's, they go to those classes with the big, big old arm movements, they, uh, leg movements. They feel, they feel better from that. Just as general, like movement as medicine. It's not always a load. Movement can be medicine. Now, thanks everybody for listening to this podcast. Um, I know that you can listen to many other podcasts and spend 45 minutes to an hour with them, but you're spending it with me.

So thank you. If you're a dedicated listener, you've heard a couple episodes and you like it, please tell me what you like and don't like. I'm always open to criticism. Just message me at, um, performance HB on Instagram. Uh, by the way, all the information on Instagram is a little bit more patient friendly. So, um, it's, it's, I don't want to say simpler terms, but I'm not getting into the nitty gritty on things. So just understand that's what it's for. Uh, and, or you can email me that is Seb, S-E-B at P2 sportscare.com. I'm open to hearing what you have to say and what you want to hear about next.

Um, please suggest, suggest this to another chiropractic student, another DC, another PT, another ATC, another trainer. I'd love to keep growing this podcast and, uh, I'd love to get it into the tens of thousands per episode. That'd be awesome. I, I've had a lot of people, um, reach out and say they're, they're, they, they say I'm doing good things for the profession and I'm like, really? God, I feel great. I love it. Um, I'm honored that if you guys think that. So thanks again for being part of the movement. If you're a listener, dedicated listener, you are part of the movement and I'm looking forward to meeting all of you at the next movement meeting, which no date is set, but I'm sure we'll do another one at some point, uh, in time very soon here.

So, uh, have a good day. See you next week.