213. Dr. Tera Giroux on Low Back Pain, Diagnostic Imaging, and Manual Therapy

at our Florida facility, outstanding manual therapist who has made my neck feel a lot better on top of bringing a lot of great uh ideas to the table to challenge the ways that we do things and reaffirm other ways that we do certain things as well. She brings some experience from different sports. To what we do with our baseball athletes. And it's led to some awesome discussions, many of which I think we'll highlight today in this conversation. So enjoy today's chat.

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Today's guest serves as our sports chiropractic and performance therapist at Cressy Sports Performance Florida. She's a board certified chiropractic physician who specializes in soft tissue injuries, rehabilitation and injury prevention, and return to play programs. She also holds a board certification as a certified chiropractic sports physician.

Originally from Michigan, she graduated a Bachelor of Science in Kinesiology from Michigan State University and went on to obtain her doctorate of chiropractic degree from Palmer College of Chiropractic in Port Orange, Florida.

She then spent five years working in various outpatient sports medicine clinics where she treated a wide variety of athletes. In twenty nineteen, she moved to Las Vegas, Nevada, where she spent the next four years on the sports medicine staff at the UFC Performance Institute. There, she supported athletes both at the institute and on the road during their fight weeks, helping them overcome injuries and get back to their journey of fighting for a belt as quickly as possible.

She then went on to join the staff of the WNBA Las Vegas ACES as their assistant medical director, helping the team in their journey to win a world championship in twenty twenty three. She holds certifications in active release technique, facial manipulation, grastin technique, rock tape, cupping therapy, dry needling, and is currently studying to become certified in chiropractic acupuncture.

She's also certified Selective Functional Movement Assessment, McKenzie, Dynamic Neuromuscular Stabilization, and Blood Flow Restriction Training, which she utilizes as part of her assessment and treatments to figure out the cause of dysfunction and pain and get her athletes back to performing optimally.

Please welcome to the show, Dr. Tara Giroux. Tara, I know we hang out all day at the facility, but so it seems like a formality, but welcome to the show.

you know, the combination of it all, but ended up majoring in kinesiology and really enjoyed it and working with athletes and being more hands-on um and kind of just like seeing that success and the progress from it all. So I ended up going to Cairo School over PT um just by getting some exposure to uh you know, both kind of aspects and realms of the world and thought, well, Cairo's pretty cool. It's a little it's a little different. I think I can um You know, do a little bit more with it.

still kind of like something that only happened in like the hospitals or um I just didn't have the biggest the biggest scope. So I went the Cairo route and as I was, you know, going through school, kind of realized really quickly Like there's so much more that can be added to this, I think, to make this even more successful. So

Uh, we obviously learn a lot of anatomy, a lot of hands-on, a lot of palpation skills, chiropractic skills in school. Um, but as I kind of went through clinicals and whatnot, I realized. how important it was to bring in like a manual therapy aspect to it and a rehab and exercise aspect to it and how just when you really combine those three, they really took off and you got great results. So it's kinda with that route.

in a female population. And now you come to the baseball world where you see a ton of upper extremity stuff in a male population. Like I'm I'm not sure what the next step would be if you were gonna find a fourth discipline to treat, but What what's the biggest contrast that you're seeing? Obviously I outlined some of them, but what do you see in terms of the athletes you deal with, not just in terms of injury issues, but even mentalities and things like that in front of you?

Um, most of the injuries are trauma. You know, there's there's some chronic stuff in there too, of course. Um, but you know, the thing with those athletes is. They have to fight in order to get paid. And they're also independent contractors, which a lot of people don't really realize. So at the end of the day, whatever they decide and whatever they want to do is up to them. So if they say they're fighting

even though they've got a broken hand, they're gonna fight. And there's not really much that anybody else can do about it. Um And so I mean that was just that was so interesting and it was just such a wide variety of different injuries and you're managing concussions all the time with that. Um really close to the weight cut aspect of that. So learned a lot of cool things from like the dietitian and and that whole dietitians there and that whole world of weight cutting and

Um that's just a whole different topic. Um, but yeah, then went into the WMBA, which was completely different. Now I'm in a little bit more of a sports Um, or just sorry, like a team environment. So I'm dealing with front office, I'm dealing with, you know, management, I'm dealing with agents, things like that. Um, and

the say of kind of what's happening in their progressions isn't just specifically with that athlete anymore. I got a lot more people to deal with. Um and so just completely different. And and for the WMBA, like our seasons, it's fast and furious. It's six months. It's super short. It's condensed.

Um, they have really long off seasons, which maybe isn't a great thing for them. A lot of these girls are going to play overseas in the off season, which are, you know, a whole different beast to deal with and they're not getting good care over there.

So you're kind of coming back and you have like a month of a window of time to kind of get them ready for this season and then it's go. And it's a lot of lower extremity injuries and the impact of the hard floors and the shoe wear and just like so many different factors. And then obviously

working with the female population, those nutritional factors are coming into play. The hormonal factors are coming into play. So um couple that with just the league in itself was growing at the time. So there just wasn't a lot of great access. A lot of the teams didn't even have their own gyms at that time. A lot of the teams didn't have their own performance facilities. They've got, you know, a team of two handling like strength and conditioning, nutrition, sports medicine and equipment. Like

So it was just it was a lot and I had to wear a lot of hats there. Um, and in settings like that, you're not really able to like do what you know how to do best and like use your whole manual therapy skill set. You're putting out so many fires and I was in a medical director role. So I was just overseeing a lot more things, not being able to be as hands on as I would have liked to.

Um, and then kind of moving out of the that, you know, professional sector and into the private sector where I do have the time again to kind of treat how I want to treat. Um, and I also have a fantastic team that supports me. We've got, you know, a lot of good equipment, data diagnostics in the house as well, great minds to pick from. And it's a little bit, in my opinion, kind of the best of both worlds. So

Obviously, like you're seeing 13 year old kids that are massively broken. Like it's it's eye-opening in that regard. But I'm curious what's like, what's jumped out at you the most? What's been the most surprising?

school, then they're going to school, then they're doing workouts after, and then they maybe even doing working out with a different sport. And it's like this whole day thing. They're even doing more than the pros are doing. So that's a crazy thing for like our youth athletes that I was seeing. But I think just baseball, um, just coming into it again and just really wrapping my mind about the longevity of the sport and like

I can get them to Saturday, but like are we gonna be able to get through the next month, the next two months, the next six months, nine months? So yeah, it you know, I went from a sport that was all year round to a six month sport to now like a nine month sport. So I think just kind of managing those.

the loads of, you know, their activ the activity, the rehab and making sure that they're getting everything that they need so that they can recover as quickly as they need to while also, you know, just

We got to the point where we were able to, you know, really educate them on, hey, you're a 24-7, 365 athlete. Like you can take a few days here and there, but like let's let's style it back or let's, you know, manage this. to a way where you can still have a little fun, but then, you know, time to time to get in gear again. Um and the same thing with WMBA was like there was such a long off season that it was hard to reel it back in with the overseat stuff. Um, but yeah, I mean it's

I I think one of the biggest conversations that we continue to have is is load management for sure.

techniques and and tools in that sense. Like ideally if you can be good at a couple of them and some people will just say one, but I'm gonna argue a couple'cause it's just you know, not one size fits all with every every one of these athletes. So hopefully you have a few of those in your toolbox as far as manual therapy. But then I mean there's just so many other things that

you really need to have a good understanding about if you wanna be successful in working with professional athletes or really any patients. I mean, you have to have a good understanding of exercise prescription, rehabilitation techniques, load management techniques, being able to speak to a patient, educate them on whatever, you know, whatever it may be, getting that buy-in from them. You're a psychologist all in one day as well. I mean people are

You know, hanging on the ledge all the time. You gotta talk'em off of it. Um, you gotta know when to refer too. You have to know when to reach out to your referral system. I think that's a big one that you know, a lot of practitioners, you know, might not dip into enough. But I think, you know, you have a great network. I feel like I've got a really good network. And I think that's a big reason of why, you know, we are so successful is because

A lot of the times our athletes don't live near us or we're doing remote programming and we need to send them somewhere else or they're over, you know, it's over our head. We need a second opinion. And I think having like the humbleness of knowing that is really important as a practitioner or a coach. And yeah, just having all of those tools and an understanding of a little bit of all of those things I think is gonna make

like what the best practitioner is. And that's what I look for as well when I am referring out or if I'm looking for a provider for some athlete in a different city or something. I I want them to have all of those kind of at their disposal and being able to communicate with those.

I think being in the game and being humble and asking good questions and and getting that network because at the end of the day, we just want what's best for the athletes. Right. So If I know a guy who can do something better or, you know, read a better MRI report than me, I'm gonna send them their way and get that input because I trust, you know, I trust that provider and um and I think the athlete trusts that as well if they're like

Hey, like if you're just honest with them about that kind of thing. So

skin rolling, no, no anything above and below the joint, just hasn't been even touched. Um, but what are some of the things that that maybe jump out at you? Like when you see people who haven't had good results and you know you you kind of jump in later and you have the benefit of hindsight.

a soccer player and, you know, 18 year old who was gonna go play in college and had was at her was in her four months of physical therapy and had not gotten any manual therapy and didn't have full extension in her knee. And it's still happening out there to this day. And that's just a really sad thing.

to see. Um, I mean, so yeah, that's a that's a big one, knowing, you know, making sure you're getting that. Hopefully it's it's good or you know what is good and you're looking for it, you're seeking that out. Um You know, I think a big one too is just the lack of you know, integration with

rehab or or, you know, progressions and on the strength conditioning floor. Um, and that probably targets more of the chiropractors that I see in their realms, right? So they're doing a lot of manual therapy, but maybe they're not getting you know, the right rehabilitation program, the right strength pro program to follow up with the manual therapy as well. So I mean, it has to be both. That's how it works.

the best. I mean, there's cases where one is enough, but you know, it's I think it's rarer and rarer rarer and you can always argue that having them both is going to be kind of the best.

It's really always so interesting like what that athlete has to say and where they're coming from and what's and I think also what's important to them. Like what are their what are their goals? What are they feeling? What do they want to get back to? I think those are really important questions to ask, but

I mean, a lot of the time that history is gonna tell me like 80, 90% of what I need. And it's very if you take a really good history and you really are actively listening, a lot of the times you have a really good idea of where to start or you already know where you're gonna go with it. Um and then, you know, going on from there, obviously like for me

Yeah, tell me what hurts. Tell me what movements. Let's let's check it. Let's go through movement screens. Let's go through, of course, our neuro and ortho testing. Um, let's go through provocate. uh provocation and relief testing like what hurts? Can I make it better if I manipulate here or there? So it's a lot of like testing and retesting in my evail as well as in my treatment.

Um, imaging's great, but it rarely tells me the full picture, as you know. Um, for me, structure does not always equal function. So I'm gonna take that and put it in my back pocket consideration of imaging, of course, but It's just gonna tell such a different picture when you get that person in front of you moving around. Um, so it's it's a good adjunct, but it's not everything to me.

than we thought he was. And he wound up having a bilateral spongy that needed some screws put in it. And so it was a, you know, I think a good eye opener and we did right by the kid. And So we've had these good discussions about both acute and chronic low back pain. So let's talk about how we're we're attacking those, right? So let's say you get acute low back. It's a guy who throws out his back deadlifting. How are you approaching? You know, he hobbles into your office.

both the evaluation and the treatment. Is there is there like a roadmap that you have in your brain for something like that? As a friendly reminder, this episode is brought to you by Mark Pro. It's a cutting-edge recovery tool that provides all the benefits of active recovery, but without the extra effort, muscular fatigue, or stress to the joint.

This is something that's a huge hit with our athletes at Cressy Sports Performance, and I use it absolutely every day. If you're looking for the same results that these athletes get, visit markpro.com backslash baseball and use coupon code Cressy at checkout for an exclusive discount.

That's a whole nother thing. Cause I feel like a lot of practitioners, they go through their orthos and they go through like their little flow chart and their textbook and then they they skip on neuro a like big time and they miss stuff. And Um, that even went into like our assessment with that, like uh that initial athlete we were just talking about that came in, right? Is

Something just wasn't right. The way that he should be moving did not up to the test. And once I dove in a neural a little bit more, I kind of realized it was like a different kind of disc instability thing that we were we were talking about, right? So roll out those red flags, make sure you're doing a good neuroscreen. And then obviously figure out what happened. Clarify the mechanism of injury.

um assess the movement tolerance tolerances after that, like what can they do? What can they not do? See where you're at there. Um and then I mean from there I I obviously think manual therapy is like a great way to like put the fire out, so to speak. Um, and I think it's really great in the beginning of those acute low back cases because they really can't do a much on the gym floor, right? You you gotta put that fire out first. Um, and then, you know, really just progressing, um

were you know, what was he doing? What would they were what were they doing? Um how how do they overload in a way that got them hurt? Um I think there's after we kind of figure that out, there's a space for like a deload process of that and then reload, right? And just kind of figuring out and getting them exposure to those correct movement patterns and re-educating the patient for that like long-term success.

hear and my feedback from those patients, it's like, wow, like my other doctors never have done this before. Like The more like a lot of the times if you do a really thorough process and you're just kind of like reassuring them, talking them through, like, you know, really letting them understand what you're doing, building that trust that that's what that first visit's all about, especially with those.

chronic back pain patients that have probably seen a million doctors. They've got a lot of psychosocial layers and and, you know, fear around their injury and and their movements and what they can do. Um, so you know, the manual therapy aspect, the the rehab aspect is is important in that and it's going to help them, but it n never probably going to be the full answer. I mean, what one there's one off, of course. There's one offs all the time. But I mean

There's just so many layers to chronic pain. I mean, it can be tied to like an emotional episode. It can be coming from organ system issues that have been overlooked for um, systemic inflammation issues. There's the whole female aspect or hormonal issues and um, you know, things like um

sister and and omitriosis things like that. Like it's just it's so big and what you know, the best as a provider, as a most consultant provider, like you can again add that, you know, bring in your expertise, help them however you can, but like don't forget to get the other things involved and look at all of these different aspects and make referrals and things like that when you think it's important.

Um these these things are just rampant. Everybody's got discogenic stuff on imaging. But not everybody has stuff that lines up their symptoms. So do you have an algorithm in your brain on what you will send out or is it is it totally case by case and it's just when things don't line up and you need more information?

Two treatments, one treatment, three treatment, five. I don't like it totally depends, right? And until I really stop seeing progress or I see regression, obviously, if I see any neurological regressions, of course, um, we're gonna keep going.

And it's, you know, if there's 1% progress or something, I'm gonna keep go I'm gonna keep going. Um it's slow it might be slower than normal for some people, but it as long as I'm seeing that, like I'm okay with it. The other situation that comes into mind is just

If for some reason that athlete isn't like buying in or they're continuing to ask a lot of like fearful questions, like, you want to get this for a peace of mind, let's do it. No problem. Like, you know, there's there's that factor too. Yeah.

You know, to stress test it and the thing gaps way too much. It's a ligament that's overstretched. So, like, I think I've done that way more. It's just referred out just to like. It's kind of peace of mind for the practitioner as much as it is for the the actual athlete just to know that the diagnosis is actually accurate. So you're you're working from the same the correct starting point.

our gut, uh, you know, our with our experience looking at what they're coming in with. Maybe we need to maybe we do need to get an image or an updated image on something. Maybe it's been a while. Maybe they've had the image, gone through PT, nothing changed. And then it's like, okay, well were they yeah, were they really working on the wrong thing? And in that case like

For me, it's like, well, let me do one or two treatments and like see where I can get. And then at that point, if really nothing's changing, then like, okay, well yeah, we're definitely gonna get another image, see what's going on and cover basis.

And then the second one is I think the misdiagnosis of nerve entrapments as like strains or strains. Like I just I'm finding it on almost all of these guys. Um, and it's, you know, with the combination of some annual therapy and some neurodynamic um, you know, interventions like these these things that were quote unquote sprains and strains.

are clearing up in a session or two. So I think those are like the two big things I'm seeing so far. And I'm getting pretty good results going down those routes. It's been fun.

You know, you can call it kinetic chain, you can call it nerve trap. It's probably a little bit of both, but I know for me personally, treat my neck and my shoulder magically feels better. So I I do think the neck has been overlooked so much in this this population. So it's it's good to see it getting some love.

You know, and it's not that I've gotten away with it, but it's just it's something that's interesting as like my full like background in everything that I've started with, like everything comes from the spine, right? Like as a chiropractor, that's kind of what we're taught. Um, so it's just interesting to see like how much I can really affect that the upper extremity or lower extra extremity when I hit that as well.

5,000 years. Like they wouldn't have painted about it in ancient times if massage didn't feel good and work. But what would your response be to people that, you know, they say, hey, there isn't a clear, clear mechanism of action? Um, you know, what is it that you think is actually happening when you treat somebody?

rehab and we're adding it in to with adjustments or with with the different things with different all of these different factors, right? So I mean you at the end of the day, like Someone can't argue with me if you like if I'm seeing less pain, if I'm seeing better range of motion, I mean if I'm seeing improved tolerance to activity, there's something that's happening there. And is manual therapy like the end all be all no? But I think it does like

open the path and open a window to let us go down to start like rehab sooner, for tissue healing to happen, um, for neurophysiological mechanisms to happen in the body. I mean It's incre it it does show, I mean, studies that have said is increased mechanical receptor and it you know, things like descending inhibition. Um

And I think also just there is something about just like putting your hands on someone. Like there's a trust that happens. There's a relationship that gets built. It's psychosocial. Like it's, it's just how really about the technique. how you integrate it into like the bigger plan.

So they don't really know if they feel better, but then three or four days later it's magically improved. And I think there is something to be said about it's almost like letting the lymphatic system do its job. Like we're we're getting flashyolares to glide, we're we're changing fluid balance on the tissue and Just uh just reallocating things. So I I I think it's hard because it's it's not an easy transient study that you can do beyond just range of motion.

And they don't really realize actually like how many other systems we're affecting. Like we're affecting the parasympathetic system, we're affecting the systemic system, the lymph system, the vascular system, neurosystem, organ system with manual therapy. And then I think also just if you get a practitioner that can like understand all of that um and like take into the location of those things.

making sure they're all working together, nothing's, you know, there's no clog, they're all aligning. I think that's something I do and I take all of it in consideration and I see that big picture. And I think that's, you know, why I get pretty good results in my treatment.

You have to take these continuing education courses. Like they're expensive, they're time consuming, but like you have to take them in order to figure out what's gonna work best for you, what you jive with. Um, you have to have a few of them in your toolbox. Like I don't care what you want to pick if it's like active release versus fashion manipulation versus copying scraping. Like you have to have a few different tools, right? Um it it needs to be

It needs to be there. It's non negotiable, especially if you want to work with the highly um or elite athletes because they're expecting it because those guys are already getting it. So I think it's really important to figure out like what the people you aspire to be like, and that was something I always did, is what are the what are they what have they taken? What are they, what are their techniques? What are they into? What's the new thing? What's the most evidence-based?

And I think go from there and like just start taking these courses, start learning, start investing in yourself. And that goes across I think any profession. Like investing in yourself, you're never gonna go wrong. Just like finding, yeah, and just like being open minded, being hopefully evidence-based, um, getting, you know, being able to take feedback and and and grow from that too.

They might be able to help by the education that they're putting out, some of the exercises they're doing. I mean, you can kind of go look at their website, see what courses they've taken, techniques they've taken, and you can maybe find and research. those techniques in your area to try to find someone. Also like look around you. If you're in a big city.

If you've got you're in Detroit and you've got four four professional sports teams, there's probably providers that are seeing those athletes. Where are they? Like that's a good place to start. Um, you know, kind of just trying to find, I think. people that you would want to treat, treat you and and be okay with that and not just kind of settle for someone who's close to you. Um, like, you know, really try to find the best of the best for yourself because everyone deserves that.

And it says nothing about credentials, like what, you know, clinical skill set he has. I understand it's like very patient focused, but when you're actually trying to make a referral, I always tell people make expertise easy to perceive, like across a bunch of different mediums. Some people want to talk to you. Some people want to come visit your office. Some people want to read an article you wrote. Some people want to look at your credentials. You have to make it easy for them to see. So

Um, you know, because it's because I I'm dealing with just like such this like long term of a sport now that I have to look even more ahead than I ever have to. So it's really about I've been able to kind of slow down, question myself and being able to find the right recipe to like push it'cause I think there's times for that for sure. But also know when to kind of like, okay, you're right, we have to dial it back. We have to go slow. We've got still four more months kind of thing. Like

And and respect now me working with athletes that also have an organization versus me being in private versus me being right next to the in the front office kind of thing. So yeah.

Other people like need to see what's going on. And I think I'm at a point in my career, like over a decade in that it's time for me to, you know, like start teaching and start like getting out there and like telling people what I'm doing and and like how I'm helping in figuring these things out. And um whether that's the chiropractic world or or just all sports medicine world, I I think there's a future of

being able to like give back and and teach and to just kind of help other practitioners if if you know, with with some of the stuff that I'm seeing. So

Well, this was fantastic. You've been an absolute difference maker at the facility. We love having you. So it's cool to to be able to share your wisdom with a a larger, you know, uh group out there. So thank you for taking the time.