“Some patients think I just need to rest. I need to take some time off. And actually we know that that makes patients worse. Exactly. And you know, going back to a little bit of research too, now we know when a tendon gets deloaded, even like two to three weeks of not loading, not exercising, that that muscle tendon unit gets into the really mood conditional tendon, which is really hard to come back again and unload it appropriately so the person can run.”
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. Rogers: Welcome everybody to our podcast. And here we are with Gina Fick, an amazing physical therapist out of Colorado. Gina owns Fick PT and Sports Performance and. My name is Zuzana Rogers. I own Runners Edge, Alaska in Anchorage, Alaska, and we really welcome any opportunity to sit down and talk about topics that are close to our heart and that we’re really passionate about. And today we’re gonna talk about all these changes that are happening in physical therapy in general and mainly in sports physical therapy. You know, when I see patients, many times they come to me and they say, well, my doctor told me something different. Well, my chiropractor told me something different. I don’t know what to do. Oh, you as a physical therapist, can you please show me some exercises and give me some stretches? Right. But what we’ve seen in physical therapy are these tremendous changes in the last five to 10 years. From my perspective, a physical therapist should be the primary care provider for any musculoskeletal conditions. What do you think, Gina?
Dr. Fick: Absolutely. We’re well trained and skilled and have the expertise to be able to really guide patients through that musculoskeletal diagnosis and treatment process. And I think we are the ones that should be on the front lines of that care. So let’s talk about maybe a patient example. Let’s say I come to your clinic, I’m 50 and I have hip pain and I don’t really wanna wait three weeks to see my primary care physician. I don’t even know where to go. Sure. So, if I come to you, what would you, how would you approach me even before your first appointment?
Dr. Rogers: We’re gonna spend time talking with you on the phone and just trying to find out who you are, what your goals are, maybe what your experience has been with physical therapy in the past. Your success story or maybe where the traditional medical model has perhaps failed you. We’re gonna get your story and we’re gonna try to connect with you early on, even before you come in. And then when you come in, really again, just connecting, listening to your story, finding out what you really value, finding out what’s really important to you. As a 50-year-old perhaps runner, we’re gonna find out, do you have an event coming up that you’re training for? How long have you been hurting? Have you had injections? Have you had, you know, costly or painful surgeries that you’ve had to work through? We’re just gonna really try to dive in and find out where you’re at and where you wanna go, and then go into a functional examination process to see where your deficits are, and really day one to start treatment and trying to focus on getting you back as quickly as safely as possible to your sport.
Dr. Fick: That’s actually really cool. Do I need to bring any kind of imaging or doctor’s notes to my appointment?
Dr. Rogers: You know, that’s up to you. It’s not required. If you have a long history and you’d have physician notes, the imaging report, we really welcome that because we want as much information as possible to be able to know your story and to know your journey as far as that pain and that dysfunction is concerned and so that we can really have the full history and story, and then do our own examination and do our own findings and be able to correlate maybe what you found in the past. In Colorado. We don’t need a physician referral, so we can evaluate you so we can start treatment day one. There’s not a long process of waiting. We get you in and help you find answers right away.
Dr. Fick: It’s the same in Alaska. You know, we don’t need prescription from doctor or even imaging to come to physical therapy practice. And usually in our practice, people can get in pretty quickly, maybe within 24 to 48 hours. So it eliminates that waiting period, you know, long. You finally figure out as a patient, you know which direction you wanna go, and then you have to wait right? So if I, if I understand it right, a physical therapist should be able to diagnose absolutely. And to give a diagnosis to help our patients. Correct. Can you give us a little bit of a background on how do you come into diagnosis, and what is your thought process? Then how do you treat this person?
Dr. Rogers: You know, our education in particular is very intense and specific on differential diagnosis and treatment of musculoskeletal conditions. We spent a lot of time learning and helping to find answers and ways to help our patients diagnose their pain and their pain generator. I think sometimes we can get a little too focused on that ’cause we wanna focus also on function, but we are able to tease out and find the root cause of your dysfunction based on your functional movement patterns, specific range of motion or special testing or strength testing. We’re able to identify those deficits right away. If you’re a runner, we’re able to put you on the treadmill, do a gait analysis or running analysis, shoe analysis, orthotics analysis, we’re able to be really comprehensive. We wanna be really thorough at your initial appointment just to be able to say, alright, let’s put the pieces of the puzzle together. Because a lot of times patients come to us, maybe they’ve seen a few different providers, don’t have a really clear answer what’s going on, and we want you to be really clear about what’s going on and say, alright. You have this specific condition, this specific tendonitis, we think this is what’s causing that. Here’s how we’re gonna get you better and really give you hope and a plan moving forward so that you feel confident that we know how to help you and that you have a good plan moving forward.
Dr. Fick: Absolutely. That that’s great. And that’s actually one of the things I wanted to talk about. As, say I’ve been a PT for 20 years and Gina, you’ve been PT a little bit longer than that. We’ve seen this evolution of physical therapy care where, a clinician might be very careful with maybe lifting weights, having the patients lifting weight or being very gentle with our treatment. And if what we know now, we can actually load the patient a lot heavier and make a much bigger and bigger impact in their strength and how to address certain tendinopathies, for example. So, we should not be afraid loading patient. And now we know what happens when we actually load the tendon very heavy. And maybe I feel it’s not because we didn’t know, but I think it’s because the technology is much better now. Technology is much better. So we can talk about tendons, you know, kind of leading into my 50-year-old hip. Maybe I have some gluteus medius tendinopathy. What would you do for me?
Dr. Rogers: I think first I would look at again, your functional movement patterns. Assess your range of motion, assess your strength. Once we get the diagnosis of gluteus medius tendinopathy, here’s how we’re gonna treat that and we’re gonna start loading you as appropriately as we can right away. What does it mean? Loading? Yeah, loading is just putting, applying tension or force through that tendon so that we can start to develop some adaptation of that tendon. So we wanna increase blood flow of that tendon. We wanna improve the tensile strength. We wanna challenge the collagen in that tissue so that it can adapt and heal stronger than it was before. I think we also have tools that we can use modality wise that can help with that, but I think one of the most important tools that we can teach our patients is how to appropriately strength train and load that tendon safely and give them confidence to do so. Because in the past we didn’t do that. And so some patients think I just need to rest. I need to take some time off. And actually we know that that makes patients worse.
Dr. Fick: Exactly. And you know, going back to a little bit of research too. Now we know when a tendon gets deloaded, even like two to three weeks of not loading, not exercising, that that muscle tendon unit gets into the really poor conditional tendon, which is really hard to come back again and load it appropriately so the person can run. And I really, really love the research of Jill Cook and the Ebonie Rio, the Australian university in LA Trobe. And they really are really big into tendon loading heavy, right where you go, isometrically. And because now we know with UTC, the ultrasound tissue characterization, we know that with loading the vascularization, the tendon actually produces and the tenocytes and gets stronger. If you imagine tendon is as strong as the tensile strength, the strength of the tendon is as strong as steel. So imagine that we can’t be gentle with that. We have to load it heavy. And like we said before, patients were not buying into the loading heavy because they were afraid. They did not know. So I think that’s one of the big advantages of continuing education and knowing what’s happening with the tendon. Now we know how to load it, progressing through the stages, like you said, you know, figure out what’s going on. And loading and loading towards the functional. Running for examples and whatever people wanna do.
Dr. Rogers: Exactly. I think that it just gives patients a lot of confidence that they can go through their functional activities and they can go through strength training without risk of damaging that further, but actually it’s going to be helpful for them. And so I’ve seen it give our patients a lot of confidence and actually hope. Versus saying go put a boot on and be non-weight bearing, or be partial weight bearing, or, you know, rest for six weeks. I think our patients wanna be active, they like to be active and they have permission now to load that tendon appropriately. And we just see much better results in the clinic and I’m sure you do too.
Dr. Fick: Yeah, absolutely. So here’s a question. Before in my clinical practice, we always were taught to respect pain. We should decrease the pain. We should worry about pain. If it’s painful, don’t do it. Has your approach changed in the past few years?
Dr. Rogers: Yeah, absolutely. Especially if we’re talking about tendon, I think there is a certain amount of pain that the patients should expect if we’re doing the right thing and loading that tendon. I tell patients, you know, if you’re having up to three or four out of 10 discomfort. That’s okay. If you’re having more sharp pain or pain beyond that, then I’m gonna become a little bit more concerned and maybe back off a bit. But when you initially start to load those tendons heavier, you will have a pain response. And that’s just kind of the neurology of what’s going on in the tendon as it’s healing. But for sure, I think used to be, oh, it’s painful. We shouldn’t do that. And again, we were probably unknowingly just doing a disservice to our patients.
Dr. Fick: So I feel exactly the same way. What about strength training? How much do you load? How much weight do you guys lift in a clinic?
Dr. Rogers: Initially, if we’re starting out with someone, we do try to control that pain though, so it’s very acute, very swollen. We’ll start out with isometric training up to their tolerance level, but we do like a general tendon loading program as proposed by Jill Cook, where we’re doing isometric holds up to 50 seconds. A minute rest in between sets up to 80% of their maximum effort. Yeah. And that’s heavy and it’s hard. And generally if the patient does have discomfort, like I said, up to three or four outta 10, I educate them that that is okay. And the more they do those repetitions, we start to see their pain response decrease.
Dr. Fick: Yeah, I see exactly the same in my clinic. And another thing to add, you know, if like people, like patients say it’s painful during the exercise, but the pain resolves within 24 hours we’re great. Great. Yeah. I tell them this is exactly what we need to be. To make a difference. Exactly. To change the tissue. Exactly. Yeah. What else do you see in your clinic? You have some technology as well.
Dr. Rogers: You know, I think assessment wise, we really like to, especially if we have the higher level athletes that are really just wondering how much activity they should resume. Part of that, say it’s Achilles tendinitis. And say they’ve been doing a tendon loading program, they’re getting stronger. We want to test their asymmetries. How much force can you produce out of your right leg versus your left leg in a single leg hop? A squat jump, a counter movement jump. And how much does that, how much does the fatigue affect those results? So for instance, we may put you through a workout and then test you. We may have you run a few miles or go through a training, and then we test you. So we’ve introduced some fatigue. What does that look like during those tests? And then, you know, if we see, sometimes we see 30, 40, 50% asymmetry side to side. So we’re able to get more buy-in when we educate the patient and show them the numbers. And we actually have that projected onto a screen in the clinic, so where they can directly see those numbers as they’re testing. And some patients actually get pretty competitive ’cause they. They wanna improve that right away, but we educate them on how to improve that, how to get that better. And sometimes just putting them through certain type of manual therapy or workout routines in the clinic, we are able to see an immediate effect and change just by helping to change the way that they’re moving or loading in the clinic.
Dr. Fick: Absolutely. And you’re giving your patients the power of knowledge too, right? As we know, most injuries happen in the second half of a game or the very last few minutes of the game when all the body is fatigued, so we have to assess that somehow objectively so people know. Yeah, it’s really cool. A kind of a example from a recent patient. We have a middle aged female who was told that she needed a hip labral repair. She’s a pickleball player and she loves hiking and being very active with her husband, and so she went in to see the orthopedic surgeon and the orthopedic surgeon said, I think the only really way to fix this is to do a surgical repair of that labrum. And she also had a tendinopathy of the gluteus medius and gluteus minimus tendon, and reported that the majority of her pain was on the outside or lateral part of her hip. So I started digging a little deeper and a little further, and that was her pain generator. It wasn’t the labrum. And I said, I think you can hold off on that surgery, but here’s what we’re gonna do moving forward. And we actually took her through an educational session. At first, before we got onto the force plates, we taught her just how to load appropriately through her hip, and gave her more confidence. We did a little before and after we tested, did the education, put her back on her asymmetry decreased by about 18%, just in about 15 minutes.
Dr. Rogers: Fantastic. So it was just that input and that education and then. She was of course very excited and it was still a lot of buy-in from patients that way because they see a direct link in how we’re able to help them and how by doing those exercises they’re gonna get better. So it’s really cool. It’s really, really cool. Yeah. And having the technology to actually be able to measure things, it’s so big. And we both see a lot of ACL patients. Yeah. You know, in the past. The ACL patient would go back to the doctor at three to four months postop, and the doctor would do Lachman or they would test the ACL graft and say next week you’re in the game. But we know now for ACL especially, you have to keep them out of the game for at least 12 months, and the real rehab really happens six months out when you regain your agility, your strength, your power, your cutting ability. Gina, how do you test that when you have somebody come back to you?
Dr. Fick: It depends on where they’re at in the stage. I mean, we’ve had ACLs this past year who’ve had up to 60% asymmetries and most the surgery was it far away?
Dr. Rogers: Oh, no one was 10 months out.
Dr. Fick: My goodness. Yeah, 10 months out. She had been to one of the bigger outpatient orthopedic practices, had surgery there, had physical therapy there. She came to us and wasn’t able to return to play soccer. Still had pain, didn’t trust her leg. Let’s do some testing and we started diving into it. Way off. We took her through functional testing, hop testing way off, I mean more than 50 to 60 or more percent asymmetries. She was very fearful of loading that leg. We started doing testing with the force plates. We did testing with the handheld dynamometer with knee flexion and knee extension. She had over 60% asymmetry. So no way is that patient appropriate to return. So we put her through another six months of rehab. Yeah, yeah. And then she was good. It was unfortunate that she came to us with that much asymmetry, but you know, to safely return her to sport, we had to really educate and spend a lot of time because at that point her parents had spent a lot of money. She was sick of physical therapy, didn’t understand what went wrong. Of course, you know, that’s, it’s a very discouraging, but we gave her hope. We took her through the right program and the right testing and she was able to get better, but without being able to objectify.
Dr. Rogers: Yeah. I mean you go back to the orthopedic surgeon. Oh, ACL’s nice and tight. Yeah. You wear that brace, you’re good to go. And that’s exactly the role good clinical sports physical therapist is looking at the whole person, top to bottom, look at their training load, looking at their sport specific demands, talking with the coaches and figure out plan how to return them to a hundred percent because you don’t just say, yeah, you’re good to go and start playing soccer because that’s a recipe for disaster.
Dr. Fick: Totally. Yeah. So, you know, I think you honed in on the communication piece. That’s so important because coaches, they just need to know if their athlete’s good to go or not. And you know, most of them would think after 10 months of rehab or more, 12, 14, whatever it may be, that they should be good. But you know, if no one’s really communicating with the athlete generally isn’t able to really communicate adequately, especially a high school athlete. And they’re gonna wanna play. So they’re gonna say, I’m good coach, I think I’m good. Let’s get going. There’s providers that do release those athletes return to sport. But I think if we’re doing a good job, we’re doing our due diligence as sports physical therapist, I think we have to be really determined to do the right thing with that patient and objectively test them.
Dr. Rogers: Yeah, I absolutely agree. So one of the things I wanted to bring up is just the concept of the ACL bridge bracing. Have you heard of that? What do you know about that?
Dr. Fick: You know, I really think there’s some huge breakthrough in physical therapy. So bridge bracing protocol is a protocol developed by, I think it was Dr. Bridge, who the background is. We thought that ACL, when it’s ruptured, it cannot heal by itself, but now we know there’s vascularization in the ACL and if we add stem cell and perfusion in the joint, the ACL has a potential to heal. So the bridge brace protocol is kind of banking on the idea of yes, let’s give the ACL a chance to heal. So pretty much you screen your patient really well. It has to be a fresh ACL injury. There should not be a meniscus damage as well. The patient should be a good healer, non-smoker. The general environment is good and they should be able to be in the brace. And the 90, 90, 90 degree flexion brace for about, well, two weeks without movement and then you start opening the brace. So just, you know, side note, I had a patient before I knew exactly what this bridge bracing protocol was, he was a physician and he ruptured his ACL and broke his tibial plateau in a ski accident. And, you know, the knee was hugely swollen and there was just so much stuff going on there. So, and he wanted to go non-operative. So I told him, let’s, let’s try to rehab this. You know, you have all these great stem cells in your knee because of the fracture. Don’t push it and don’t push your range of motion because you have the fracture. So he was pretty careful about the first stages of rehab and we took care of the swelling. We got him strong. We used BFR. He actually ended up getting stem cell injection into his knee, and he was super diligent about his strengthening within the range that he had. So long story short, about three months after his injury and after starting rehab, he MRI’d himself again and the ACL healed wonderful, which is amazing.
Dr. Rogers: Wow. So I feel really. We just didn’t know what the potential of a ligament like that right. Is to heal. Now we know. So I think what we’ll see in physical therapy practice is developing more and more of this bracing regimens and protocol and how to load the patient appropriately to stimulate the healing. And then we can maybe think about the orthobiologics, right? And think about more BFR because we know what BFR is. And think about how the patient and doctor communicate together and help this patient get well. So, you know, I think that’s a really, really big advance in physical therapy and I think we need to watch that.
Dr. Fick: Absolutely. I’ve had the opportunity for the past eight years to work with a regenerative medicine company in the Denver metro area called RegenX. I’ve been blessed to be able to work with those physicians and I’ve learned so much and they’re very skilled in diagnostic ultrasound and they use MRI images and technology to be able to identify what structures are injured. They take them through a really thorough examination and I’ve seen fantastic results from the doctors being able to specifically identify the injured tissue such as the ACL, MCL, sometimes meniscal tissue, even with osteoarthritis, and they have all these really cool techniques that are emerging with regenerative medicine and orthobiologics, and when they’re used appropriately and partnered with really good PT who has a good understanding of how to rehabilitate that patient. We have seen fantastic results. We use a lot of BFR with those patients. In fact, I did some research early on to try to figure out how we could potentially use BFR to help improve their overall stem cell count before the procedure.
Dr. Rogers: Yes. We’re seeing that too. Yeah, absolutely. So let’s talk more about that. It’s actually a very fascinating topic. Yeah. And I don’t think too many physical therapists or surgeons know about it. So what is BFR?
Dr. Fick: So, BFR is blood flow restriction training, and it’s use of a modified surgical tourniquet cuff that either goes up as high as we can on the thigh or the upper arm. It’s to partially and temporarily restrict blood flow, either to the brachial artery or the femoral artery in order to affect arterial blood flow in that limb during exercise. Or it could also be done passively. So we are able to use that technology to take patients through a series of exercises so that they’re exercising at a much lower load, maybe 20%, 30% of their one repetition max, and get the same result as if they were exercising at 70 or 80% of the one repetition max. And we actually see the same strength gains. Yeah. Over a six week period.
Dr. Rogers: Yeah. We do the same thing in the clinic, and it’s almost like a form of biohacking. You know, imagine you’re exercising with five pound weight and you’re gaining all this muscle. But even more fascinating is what happens before surgery. We use BFR two different ways before surgery. The first one within 24 hours before surgery to upregulate the stem cells, right? And then downregulate the hormone myostatin that actually produces fatty infiltrations and muscle tissues. So we see patients coming out of surgery and they have minimal atrophy. They’re able to maintain muscle mass right after surgery, which is so cool. Then, you know, prehabilitation, even with ruptured ACL or an injury, we can exercise, workout, like you said, in the very minimal load, but get the benefit of your patients working very hard, which preserves muscle, preserves everything.
Dr. Fick: Exactly. And there’s actually a decreased pain response. You can feel an immediate effect as a patient, which I think is really good because patients, a lot of our patients want to feel like they’re doing something with exercise. With BFR, you definitely feel that muscle pump and muscle activation, which is very encouraging and you feel like you’re getting going right away with your rehab process.
Dr. Rogers: Yeah. And you can, we also use BFR to induce a cross education effect, you know, when you exercise your non-involved side, maybe because the surgical side is so fresh from the surgery. So you see, I think our last study showed 15, 16% of muscle transfer to the operated side. So we have all these biohacking tricks now that we can use to help our patients just get their strength back really quickly and recover.
Dr. Fick: Yeah, and I think, you know, you and I have been at this a long time and it’s been a lifelong quest to be able to try to stay at the top of our game and research, and I think we both gain a lot of enjoyment of being able to do that and stay at the top of our game in terms of latest testing strategies, latest rehab strategy, latest hacks. ’cause truly we really love our profession and we want the best for our patients. And I think you and I are similar in that we don’t settle for anything less for our patients. And I think that’s how we model our clinics and our practices as well. And it’s probably what kind of keeps us going and keeps us doing this and keeps us really excited about what we do.
Dr. Rogers: Yeah, absolutely. Yeah. That was a great discussion.
Dr. Fick: Yes. That was amazing. I think we should do it again.
Dr. Rogers: Yeah. There’s so many cool advances that are happening in PT and like Gina said, we have to stay on top of the research because basically if we don’t stay on top, we are falling behind.