“One of the things that I like to focus on when I’m talking to my clients and people that come ask me about shoes is more around what kind of foot you have, like what the engine looks like, rather than putting on the tires and figuring out what kind of tires you need to put on there. If the engine is built well, then the shoes or the tires will work very well. I’ve seen a lot of people who come in, they have the next percents, the vapor flies, the alphas, whatever it is, as far as the carbon plate shoes. I look at their engine and the engine’s not good, so the shoes really aren’t doing much for ’em.”
Welcome to the PT Rebels Podcast. This is the place to learn how you can become a PT rebel and take charge of your own health and wellness. We will help you find answers to your questions about pain, injury, and the path towards healing in the most efficient and effective way possible. I’m your host, Dr. Gina Fick.
Dr. Fick: Dr. Rob Berghorn from Ascent Physical Therapy in North Massapequa on Long Island, New York. Ascent Physical Therapy is a health and wellness clinic that specializes in endurance athletes and active adults to help this community understand, learn, and take their own health into their hands to be their best, both in life and sport. Rob, welcome to the podcast and thanks for joining us today.
Dr. Berghorn: Thank you for having me, Gina. It’s a great honor to be here.
Dr. Fick: Rob and I met through a mutual business coaching program, and it’s just been an honor to find out more about Rob and the great things he’s doing there in New York as a physical therapist. I wanna have Rob on today to talk with you all about our practices and how we best serve the running community. Rob, can you tell me about your clinic and the type of clients that you serve there?
Dr. Berghorn: Yeah, so we’re in a rapidly growing portion of our business. Really trying to get as much of the running community involved in what we’re doing because we’re really trying to hit you on all different points so that we’re able to create an environment where you can not only come when you are feeling like you’re not your best, but also keep you in, push you forward into the goals that you have for as long as you potentially want to continue either running or competing, or even if you’re just trying to stay training with your friends. We just like to make sure that you stay happy doing what you love.
Dr. Fick: That’s interesting. So if you’re an athlete in the New York area and you’re a triathlete or endurance athlete, you’re really not experiencing pain. How can you help someone like that be able to be at their best in the upcoming competitions?
Dr. Berghorn: Yeah, so we work a lot with our people. So when we first, when you first come in and see us, we sit down and we really get to the nitty gritty of what you’re involved in. So what sport, what distances, what your goals are, what injuries have you had in the past. We really take the time to listen to you and to figure out where you are right now, meet you at where you want to be, and then take you wherever you want to go. So basically we have a variety of different things. So we have our wellness programs where we help train you and keep you accountable on whether that’s your actual training components. We fill in the gaps and the pieces of the puzzle that may be missing in your training plan, whether that’s strengthening mobility work, any running assessments. So we improve your efficiency of your running mechanics, but we also work on your overall strength and performance so that we can prevent injury and also improve your resiliency through your training.
Dr. Fick: Thank you. Rob. What are some of the biggest deficits that you see in healthy runners who perceive themselves to be healthy? Not really in an active injury process?
Dr. Berghorn: Yeah, so I can even talk about some of my teammates and even myself sometimes as a business owner. We’re doing a lot. I’m sure you can relate a lot to that. With everything I do, it’s sometimes we miss the sleep. We don’t sleep the number of hours we’re supposed to sleep. We don’t eat the right things at certain times. We don’t eat enough, we don’t recover as well. So the right foods while we’re trying to recover. So getting enough protein and getting enough carbs, getting enough of the hydration back after we’re done working out. So all those things, those are one of the big things that people don’t consider in their training, but it is one of the big things that people miss. Additionally, it’s the strength training on my side too. I don’t see a lot of endurance athletes strength training, and they’re not really focusing on the things that are gonna keep them solid and keep them able to tolerate the forces that they’re experiencing while they are performing in their sport.
Dr. Fick: I totally agree. It’s the biggest thing that we see in our practice. Not being really prepared to handle the training loads and volume that you’re putting your body through, especially for an endurance athlete, a triathlete, to put your body through those types of loads, forces, volume-based training. When you go through that, if you’re not strong and if you don’t have tissue resilience, that’s when we see things break down and injuries occur. Rob, can you speak to some of the most common types of injuries that you see in your endurance athletes?
Dr. Berghorn: Yeah, nine times outta 10 it’s more of a chronic overuse kind of issue. Something where it’s either they are not tolerating the forces like we were just talking about. They’re increasing their load or their intensity or their volume too quickly. They are not taking the appropriate amount of rest or not recovering appropriately. So I generally see a lot of tendonitis cases. We see a lot of joint irritation, inflammation, we see a lot of bursitis. Mechanical issues, plantar fasciitis, low back pain, you name it. In the chronic pain realm, we get it. Or at least when I say chronic pain, I’m more of the overuse kind of things. You name it, it’s there.
Dr. Fick: Yeah. And that’s what we really see too. And so I think education in this community is so important. I know you do outreach yourself. Can you speak to some of the outreach that you do in your area and some of the types of clients that you’re looking to help in your area?
Dr. Berghorn: We do a lot of in-office seminars just ’cause we have so much space in the clinic. So we host our own events where we bring people in. We speak about different topics. Some of the topics we spoke about this past year. We had our first sanctioned Half Iron Man this past year that I competed along with a lot of my teammates. So I hosted a clinic on that for everybody to make sure that they had all the building blocks before they started training for the race to make sure that they were all set up to go. We did something on staying fit and active after 40 to make sure that people are staying in one piece, not aging like their parents were. We are doing community outreach stuff with places like Orange Theory, meeting up with different CrossFit gyms as well to make sure that they’re and their people healthy and staying in the gym.
Dr. Fick: I love that. It’s really smart and it’s a great way to get connections and get people connected in our running community. Speaking of community, one of the biggest things I hear out in the community or questions related to shoes, what shoes should they be wearing as trainers? Should they alternate shoes? What are the best shoes for them? How often should they replace their shoes? How much emphasis do you place on shoes and what does that conversation look like with your clients?
Dr. Berghorn: Yes. One of the things that I like to focus on when I’m talking to my clients and people that come ask me about shoes is more around what kind of foot you have, like what the engine looks like, rather than putting on the tires and figuring out what kind of tires you need to put on there. If the engine is built well, then the shoes or the tires will work very well. I’ve seen a lot of people who come in, they have the next percents, the vapor flies, the alphas, whatever it is, as far as the carbon plate shoes. And I look at their engine and the engine’s not good. So the shoes really aren’t doing much for ’em. But then I take a deeper dive on it and I really assess them. I take a look at not only what their running shoes are that they have, I take a look at the treads, I take a look at their feet. I take a look at the rest of their body, and I give them a description of what their shoes should look like and what it should perform for them in order to create the kind of fit that they need.
The biggest things I do see that are, that people don’t really recognize, and one thing that is something that people should be able to understand is that when you buy shoes, ’cause I have a lot of clients that buy like multiple pairs of shoes, especially at the end of a season when it’s all on sale, you have to think that whenever it’s sitting on the shelf, it still has an expiration date, sort of. It’s like the milk, it still goes bad regardless of whether you’re using it or not. So if you have a shoe, try to use it. Don’t let it sit for a year or two when you go through another two or three pairs. When you do have your shoes, if you are someone who runs multiple times, sequential days, back to back, make sure there’s either 24 hours between, or make sure that you have a second pair of shoes that you can rotate out on because that foam in the shoe doesn’t recover until about 24 hours afterwards. And then also you want to have enough stability and also support. So the cushion and the support in the shoes really depends on what the engine looks like. Like I was talking before. So if you have the appropriate mechanics even if you’re flat footed, you may not need a support shoe. You could probably do well with a neutral shoe.
Dr. Fick: So Rob, one question that I get a lot from athletes is, should I wear orthotics? What orthotics are right for me? Can you talk to us a little bit about what your orthotic recommendations are for patients and how you determine that?
Dr. Berghorn: Yeah. As for us, we do our own 3D printed orthotics, and we really try to go through a process of analyzing the foot. The way it not only sits, but also the way it moves. A lot of times when you go to other facilities, I noticed both as a client myself going to them, but also as a practitioner, shadowing some practitioners that they always take a static approach and they don’t really assess what else is going on with the person to be able to create the best recommendation for people. So I will say a lot of the times orthotics are good, but I never use them as a permanent fix. I see them as a tool to assist in what else we are doing to make you as the person slash the engine better. A lot of times orthotics acts as a crutch and can make things weaker over time, especially the smaller muscles in the foot, which are your important parts, especially if you’re a runner trying to create a stable base for you to stabilize, push off on, and propel yourself while you’re doing your sport. If we don’t have that stable base, if we don’t have a strong rigid lever for you to create force, you’re not gonna be doing very well. So when we work with our clients, we really try to make sure that they have the tools in their toolbox. We try to make sure that best for ’em ’cause it’s not the best for everybody. I know some people who have flat feet, like I have flat feet myself. I don’t use orthotics, I don’t use any kind of assistance in that way. ’cause over the years of my training and my experience, I’ve used strengthening the engine, improving the different components of my performance to eliminate any kind of issues I would have. But just like any other runner, I’ve had almost every injury under the sun as far as overuse stuff over the course of my training career. So I’ve been through it all. I’ve experienced most of it. I feel like orthotics is more of a tool than anything else. I don’t necessarily, but it also has to be done in the right way to make sure that it’s the best fit for that person.
Dr. Fick: Love the focus on the engine, because I think that’s where as physical therapists, we can help patients make the best long lasting changes in terms of tissue resilience and overall longevity in the sport. So if you’re looking at the engine and you’re doing a running assessment for that client, what does that look like in your clinic?
Dr. Berghorn: Yeah, so the assessment that I created comes from a combination of a number of different assessments I’ve seen over the years. A large component of it comes from actually an ACL return to play protocol where we’re really focusing on whether the limb is balanced at least 90% compared to the other side, so that you’re able to see if there’s any missing pieces to the puzzle. And that assessment goes through everything from mobility and flexibility, strength, power, explosiveness, and your ability to withstand all the forces that are involved in that. And it goes on an ascending level of difficulty. So if either the patient doesn’t feel safe or I don’t feel like they’re going to be safe doing an activity, we stop the test right there. We go over what you missed, what kind of components you’re missing in your toolbox, what things that you could be doing in your training to make that better. And then we do the running assessment and the assessment from there is basically the assessment that I usually do is about an hour and a half. We sit down, we have a detailed history. We go through the functional assessment of the mobility, the strength, the flexibility, power and everything. And we go on the treadmill and we record the front side, the back. We take a look at it, slow motion, full body, and we go from there and break down the different components and figure out whether we need to go for physical therapy in order to help alleviate any kind of pains or restrictions that we have, or we go into a more wellness thing to improve your performance from that standpoint. So there’s different ways that we can go once a person goes through that running assessment.
Dr. Fick: I think that’s one of the key things that you can do is identify any asymmetries or weaknesses that you potentially have because it’s gonna make your training much more efficient. Potentially help to reduce injury risk and create better overall long-term longevity in your sport. That’s what we’ve seen. We use biomechanical assessments as well. We do a running analysis on the treadmill when athletes can really start to look objectively at those deficits, make sense to them why they should really focus on health and wellness to help the efficiency in the sport. Let’s talk about strength training. What are some of the most common deficits in terms of strength that you see in your endurance athletes?
Dr. Berghorn: I would say overall it’s either one or two things, and it always affects the knee. Whenever somebody comes in and they have knee pain, I always describe it to them as, you know, if you think of your hip as the older child and you think of your foot and ankle as like the youngest child, they’re always beating up the middle child. So usually one or two things are going on where there’s breakdown in the strength, the stability, or the ability to withstand the force at either one of those. And it creates different manifestations depending on what’s going on. And it’s always different depending on the person as well, based off of their own specific mechanics when they’re training or competing. We really try to be as functional as possible with any kind of strength training that we’re doing. We always start with body weight first. Make sure that their ability to sense their body in space is appropriate. And then we start adding load and we gotta think of, you know, forces that are being exposed at any point in time during a run. If, for example, we’re experiencing five to seven times your body weight at your knee. And if you think about how many steps that you’re taking, for me, every 5K might take about 5,000 steps. So you’re experiencing a lot of force, a lot of stress on your body, and if it’s not in the right place at the right time, you’re putting undue stress on different structures that don’t need that stress. So adding load gradually and making it as specific and functional to the activity that your athlete is performing is what’s really going to assist in creating that higher level of performance for that athlete.
Dr. Fick: I agree. I think one of the things that’s been missed in the past in traditional physical therapy is just the physical therapists haven’t really been encouraging patients to load those tissues as much as they should. We progressively load our patients as well, and we encourage heavy loading and adaptation to those tissues because, like you just described, the amount of steps or the amount of forces and loading that you’re going to undergo in a 5, 10 K. Think about, then you’re moving into half marathon and triathlons. That’s significant load. And some of the strength deficits that we see are just astounding. I have a patient who just completed an Ironman and he was unable to do a single leg calf raise on one side because of an Achilles injury. And it’s amazing to me that he could compete and do pretty well, honestly, without being able to do a single leg calf raise. Now he’s very lucky he doesn’t tear an Achilles or have a more significant injury, but that’s what we see all the time right now.
Dr. Berghorn: One client that’s sticking out in my head, he started seeing me almost this time last year. He had a herniated disc issue in his low back and did it swimming, and he was competing in more like sprint and Olympic distance races for triathlon, and he started seeing me within three months. He was back to training. We worked together and got him competing in his first marathon, his first half marathon, his first half Ironman together, and he is doing it much better. He had multiple PRs during this time. It’s loading that athlete specifically to what their engine needs in order to create a system and create the efficiency that needed in order to perform at their best. I know I keep harping back on the same components and they’re very basic components, but it is a lot of things that do get missed in other kind of healthcare facilities, which is tragic in some cases.
Dr. Fick: Rob, can you talk about the uniqueness of your clinic and how you operate and function and how you best serve clients based on that type of care?
Dr. Berghorn: Yeah, we are an out of network, cash based facility, so we really pride ourselves on getting results for you first, rather than what insurance or doctors try to push on you. We really try to listen to everything you have to say about your experience. ’cause your own unique story is very unique to you. No one else can tell that story. So we really try to listen to the entire story so that we have the tools that we need in order to create an experience that is exceptional compared to anything else you’ve experienced. We get a lot of people that come in here and they tell me, I’ve been in back pain for 12 years and I’ve been to PT for almost 12 years, and it helps, but I never feel like I’m out of it. And the woman that I’m speaking about right now, she’s five sessions in and she doesn’t feel like she has any back pain anymore. And she said that she moved around her whole living room without dealing with any after effects. So it can happen very quickly if you have the right tools and you have the right things and the right sequences, and if you listen to the person, sometimes that’s just enough to create that experience that will make them as best as they can be.
Dr. Fick: I agree. Listening is one of the top things that’s missing in current healthcare. So one of the things that we really value in our practices, both you and I, is the ability to sit down and listen to someone start to finish their whole story. And sometimes you don’t even get the whole story maybe until 45, 50 minutes in, or maybe the next visit or a few visits down the road. You hear the real value in what they’re trying to accomplish because that’s the way that they handle stress or that’s the way they’ve overcome addiction, or that’s the way they cope with a loss of someone significant in their lives. Once I think listening to the whole story and being able to provide from top to bottom just an exceptional experience that’s based on exactly what the client needs and wants. Their goals versus the goals of doctors or insurance companies or someone else. I think that’s the key and the value that we can provide. We start that on the initial phone calls and when someone calls in, we make sure we take time to listen. I know our operations manager was on the phone with someone the other day for 45 minutes and she listened to the entire story. So I place as a business owner value in that, and I give our staff the opportunity to do that because I know that’s gonna transition into a much different and better patient experience.
Dr. Berghorn: Exactly. A hundred percent agree with that.
Dr. Fick: Let’s talk about recovery. So for your endurance athletes, what do you recommend for recovery, whether that’s rest days, nutrition supplements, what does an ideal recovery routine look like for an endurance athlete?
Dr. Berghorn: Yeah, so when we get a new client, one of the questions is always, what does your training schedule look like? You want to stick to your schedule, especially if you have a coach, as they have the knowledge and the experience to keep you doing what you wanna do as well, at least in your best interest in that sense, we really try to pick apart the different pieces of that puzzle. Then we start talking about sleep. We talk about their work environment. What’s the stress level look like? We take a look at your nutrition, what were you eating during the day, and then also your sleep regimen. What does that look like? How restful do you feel? A lot of the wearable technology that we have now, fortunately, has the ability for us to track sleep. We really tried to take advantage of that as well to see the quality of the sleep is, give recommendations based off that. If the person is doing those basics and getting that in, that’s usually as much recovery as they need. Some people do need an assist where they can come in to see us, they can do sports medical massages. We have recovery boots where they get compression to help with that. We’re starting to incorporate more stretching and mobility work into our wellness packages as well, so that they’re able to help cover that way as well, and also move better at the same time. So that is definitely something that we do. But as far as nutritional stuff, getting in some protein afterwards to help with some of the nutrients that you need in order to help heal that muscle backup after you put some stress through it, getting the right amount of carbohydrates and supplementation for all the electrolytes that you lost during your workouts and whatnot, that’s all very important as well.
Dr. Fick: Fantastic. Speaking of overall nutritional health, one question I have for you is what types of bone stress injuries are you seeing in these endurance athletes? What are some of the things you do to recognize those types of injuries?
Dr. Berghorn: Yeah, so bone stress, especially in the female athlete. I do see it in the younger high school, and I do see it in the peri postmenopausal area, especially for women. A lot of times that happens either because of the hormonal changes that happen around those times and or because of the nutritional components. And usually it’s either they’re postmenopausal, not getting the right things to supplement what they’re losing due to the hormonal changes. Or it’s around the teen range where they’re just not eating enough ’cause they feel like they need to fit a stereotypical kind of body shape and they need to, that they are very skinny. And that’s it. Unfortunately, in this day and age, it was very common during my high school career, but it still is prevalent at this period of time. Despite some of the other educational kind of components I’ve seen in the community going around, it is getting better, but I do see it. We see metatarsal fractures, so fractures in the foot. We see tibial fractures, we see sacral fractures, so rarely do we see pelvis, but it does pop up as well. Where they get just too much stress through that bone because of either the load or the load in combination with the lack of nutrition leading to that fracture.
Dr. Fick: If there’s a young female athlete who’s in high school and she’s experiencing shin splints that don’t really seem to be getting better, that lower leg pain becomes difficult to even walk without pain. It’s waking her up at night, or maybe she wakes up in the morning with just that deep aching pain. What do you recommend that athlete do?
Dr. Berghorn: Yeah, so if you’re a female teenage athlete at home right now, and you’re listening to this and you find that you’re dealing with some shin splints and you have been dealing with it for longer than a couple weeks and it has not gone away despite you stopping or reducing your volume of your training, go get it checked out. As far as in New York state, you’re allowed to come see someone like me for 10 visits, 30 days, whichever comes first, and we can definitely check you out. Make sure that we’re not dealing with a stress fracture, that it is actually still shin splints. We don’t want it to progress to a stress fracture in that sense. But if we feel like there’s something going on that’s in that stress fracture realm, we’ll send you out to one of our doctors who is very fantastic in being able to listen to you and figure out whether it gets you to the right imaging to see if this is a stress fracture going on, and then we manage it as best we can. So whether that’s being put in a boot for a short period of time, or if it’s just stopping your training and then we just do some guided therapy to allow for the tissues to heal, apply the right stresses at the right periods of time, while also working on the other components of the engine that you may need work on as well that caused this issue so that once you’re healed up you can hit the road running and be better than when you were before injury.
Dr. Fick: Excellent advice. One thing I’ll add to that in Colorado, if you come in and see us, we can also write a referral for imaging. So if you feel like you need an MRI, for example, to help identify or rule out a bone stress injury such as a stress reaction or stress fracture, that’s something that we can do for you as well. So I think that’s also valuable, but I think it’s just having that team, the right team in place to know who to call upon if you do start to have an injury. So even if you’re not injured, come in on a wellness basis, come in and identify any biomechanical abnormalities that you may have get involved in a wellness program. So that you get to know us, you get to know helpful hints on how to deal with training loads, training volume, how to communicate with your coaches, how to best recover. So if something does come up, you know who to call, and we’re just a phone call, a text, a message away, and we can stay on top of these types of things so that they don’t progress into something more significant or serious. Rob, another question I had. Say you are a collegiate runner and you are a freshman in college and you’re training at higher intensities, maybe higher volumes. You’re lifting heavier than you have before, so you just have a lot of, in a big increase in loading overall, and you start to develop, say, an Achilles tendonitis and you’ve got this nagging pain in the back of your heel into your foot, you’re not really sure should you continue to run? Should you take time off? Should you tell your coach you’re not, if you’re a collegiate runner in that case right now who’s just getting into indoor season, what would you tell that runner? How would you advise that runner to proceed with that type of injury?
Dr. Berghorn: Yeah, so I can definitely speak on that, especially since that was a big transition for me. ’cause I went from high school track and field to college track and field, that’s when I really started lifting. Within a year and a half, I gained 30 pounds of muscle. So there was a lot of heavy lifting and there was a little bit of injuries along the way too. So I could definitely speak to that kind of section. So basically, if you’re in that situation where you do have some kind of injury at that point, mention it to your coach. When I was a college athlete, it did take its toll on me. So if you are that athlete who has that little bit of ache, has that pain. Talk to your coach, your coach shouldn’t get upset with you. They’re part of a bigger team for you, and that team is going to help support you. Your coach is connected to the athletic training facility that’s located within the school. Athletic training facility is connected to the right doctor that’s gonna help you out, and that doctor is gonna be hooked up with potentially any physical therapy you may have to do in addition to the training rehab that you’re gonna have to do with your athletic trainer that’s at the school for your specific sport. So you have the network in place and that’s the biggest difference between high school and college. It’s getting better at the high school level, but at the same time, communication is key. So if you do the right things to communicate with the right staff, you will get supported. You will get better faster than if you just let it sit and brew and continue to let it get worse.
Dr. Fick: Absolutely. That’s an experience that I had in college as well. I wasn’t a runner and played basketball, but same experience, and I think communication is key. Being your own advocate, really communicating with your coaches, athletic trainers, and feeling confident that you can go to them and you can communicate those things so that you can help address those early on before they can become a bigger thing. Thank you so much for being on the podcast today. It’s really fun to talk about all of these things with you because we share such similar clinics and clients. And just so proud to watch all that you’re doing there and the expert that you are in your community. And I think this is just part of a bigger mission in terms of just helping people continue to have health and wellness throughout the course of their lives to stay healthy and fit and happy and active. I think that you’re doing a great job promoting that and I look forward to seeing you again soon.
Dr. Berghorn: Yes, thank you. It’s been an honor being on the podcast with you, and I look forward to all the growth that you have as well. I know that new facility’s ramping up and it’s doing great so far. We will open up January 2nd. We’re super excited. We’re going from a thousand square foot facility to a 4,300 square foot facility, so we’ll be able to serve more clients and serve them better.
Dr. Fick: Thank you so much again for your time, and we’ll talk soon.
Dr. Berghorn: Yes, definitely. All right. Take care.
Dr. Fick: Thank you so much everyone.