Back Pain Masterclass: Exactly How I Treat Athletes

I think more or less like my version of a masterclass podcast on treating low back pain .

I gave an in-service to the doctoral students at champion who are rotating through before they may be going to do like a sports residency or something else , and essentially just sat down for an hour and a half with them and said , like this is my framework for how I treat athletes for back pain , from a gymnast with back pain from like back walkovers and back

handsprings to , you know , an everyday baseball athlete or softball athlete who is , you know , having pain with throwing or hitting or deadlifting in the gym and just talk about some adult fitness people to just active , healthy people who want to work out and be active . You know how we help them for back pain .

So at this point in my career I've unfortunately treated like 1000 people for back pain and I feel like I have a pretty good understanding of like the systems in which we use the research around it , what things seem to be helpful and kind of how to apply that really dorky stuff to an everyday .

What do I do right now to feel better , which I think is the most important for patients or gymnasts or athletes that we're working with in general ?

So during this part of the year I always try to share more medical stuff as we go closer into season because unfortunately , as season comes closer for gymnastics and many other sports , you know , back pain , injuries as long as , like hip and knee , shin splints , shoulder issues , that kind of stuff starts to kind of creep up a bit .

So I wanted to get information out there to help the ATS , the PTs , the chiros out there . And if anybody wants some of the medical resources from shift , they're all on sale this week for 25% off using the code season 25 .

Because I want to try to help people get access to information on , you know , injuries that are going to happen in the next kind of six to nine months as the season progresses .

So yeah , you can learn everything from how I treat gymnast for back pain or hip injuries non-op operative rehab , acl stuff , slap repairs , rotator cuff stuff pretty much all I've learned .

I put into courses and or PDF guides , which are online , you can check out in the show notes below , just to hopefully get a big chunk of that money saved for you and learn a lot of stuff if you're going into season , working with teams or working with anybody else .

So this is kind of my approach to spondylitis , back pain , sciatica , stuff like that , summarized in a little bit of a quick masterclass version for podcast . If you want the full thing all the exercises , all the worksheets , all my hands on techniques , check out the resources from Schiff's online medical library .

So hope you all enjoy this conversation about back pain . All righty , I think we're good for this , okay , so in the hope of giving people more exposure to a wide variety of things that you probably don't see , so Maddie is with Lisa and I , so she sees like 11 spines a day . You guys are with Lenny . You see more ACLs and stuff .

So as part of our staff meeting , we're trying to get more exposure to everything . But I also feel like the time at Champion . You want to spend an hour with someone who's done a lot of the thing , right ? So like to ask Lenny about questions about the ACL , or Mike about the shoulder , dan about like knee pain , kevin about running .

It's probably good to have like a long session to try to share my framework for how I think about things and then answer any questions that you guys have , because you only obviously are here for a limited amount of time and or we'll see so many people , so you want to have all the things you're prepared for . So we're going to the goal of this .

We have an hour and a half . The goal is like 30 ish minutes of a vow and then maybe like a little bit 40 minutes ish of treatment stuff . I think that's the most important is like knowing what to actually do with somebody when they're really , really in a ton of pain .

And then the last two , uh , the last chunk of it maybe 20 minutes , 30 minutes is a case studies , um , to kind of use two examples of the stuff that we talk about . Um to again hopefully have you guys leave here and feel moderately confident with the information .

Obviously you need reps to be in the trenches more , but I would say lumbar spine is probably the thing I've treated the most like not being facetious or hyperbolic , but I probably treated a thousand people for back pain since grad school to now , just because of the nature of how gymnastics .

And then I got baseball , then I got softball and everyone just started coming to me for whatever back injuries . And so the reason I say that is not to flex on people , but to say is that when I first started out , it was the thing that I needed to read about the most .

Like I felt moderately prepared for spine stuff when I came out Like I knew how to treat people .

The clinical prediction guideline had just come out 2015 or so , so I had that , but I did not feel as though I really had a good handle on what to do with somebody who was in the trenches painful at the moment , and so I actually think the spine course at my at my college was really good and uh , we had a guest lecturer come in and talk about like

McKenzie stuff , which was awesome , but yeah , I just didn't feel really prepared . So when I got out , I was treating in my first job was pretty much all insurance based clinic stuff was sorry , maddie , I'll move this . You don't see ? My coffee um was , uh , a lot of chronic pain and a lot of workman's comp and a lot of gen pop .

It was not the people we see now which are like the pro baseball players , the gymnast , the , whatever it was , very much like the everyday person . So good and bad . Because good that it forced me to be a master of the back right first , so learn the anatomy really well and learn all the courses that were available .

Bad because that's a tough population to apply things to , because it's a mixed bag of how much they want to work and who they . You know what they're doing there . Car crashes are sometimes awkward with insurance and stuff , and so , yeah , I didn't feel like I had a full timeline to help them and really prove to myself that what I was doing was working .

But in the course of that happening , that was when , um , pain science was like all the rage , right .

So pain science had just become really popular , but , like Laura Mosley and uh Butler and some other people , so there was a ton of books , courses , stuff and I like , um , just got thrown into that because the population I was treating definitely had a mixture of , like , chronic pain and or chronic re-injury .

I guess is a way , chronic pain is not chronic re-injury , right . So I did have some of those truly sensitized people who were like legitimately fearful of their back and the whole MRI thing .

So there was a time in my life for two years where , like , really a lot of that was super important and I think I helped a lot of people because I leaned into pain science quite a bit right , and then I started seeing more athletic people so gymnasts , dancers , ballet in particular so spondy started to come about more and that I didn't really feel like the

pain science stuff explanation wise for education , which we'll talk about actually was really helpful , but in terms of treating people and helping people it didn't really do it , because sports are really high force right Throwing a baseball , doing gymnastics multiple times body weight , you're having a fracture right Like you truly have something that would cause a

significant amount of pain if you break your back right . So that is actually when I started working here and I met Mike and Lenny and I was actually talking with Dan a lot of the time . I started watching Stuart McGill's work quite a bit more , reading all his research , took McKenzie courses .

I did a lot of strength conditioning stuff then as well after my SDS . So like watching Eric Cressy and Mike Boyle and see how they deal with people after pain . So it was a lot to take in .

But I actually think it was the best thing that ever happened to me , because every single like system at the time from PRI to SFMA to McKenzie I just took every course and read every textbook and then took a huge step back and was like , okay , what's my system Like what works for me ? Probably 20 .

Back and was like , okay , what's my system like what works for me ? Probably 20 of every one of those systems I would say I probably don't really use and or think is solid for everybody . But if you pick the right things and apply them in the right spots , I feel like that's maybe what makes me a quote-unquote good clinician for spine pain , because one .

I've seen a lot of it and I know the research really well . But I also know when to pull out a mckenzie exercise or when to try something more pain sciencey with someone or when to do just straight up loading with someone and just get somebody stronger if they're like a younger athlete .

So yeah , that is that top chunk is like all the research and the textbooks and stuff are in the in-services . There's like docs from last ones they have . But I don't want to give you 49 pages of all the stuff . But if you have a specific question about where to look for those things , I can happily do it .

But so that is kind of the first two years I had and what I found from that . The summary is that 80% of pain science and biomechanics and pathomechanics overlap . Okay , so the same time when I was getting into the world of PT stuff Instagram , social media , advice was all time high .

Right , there was literally every day 40 exercises for back pain , 13 exercises for this and 19 things for that . And so , as a new grad , me and Dan were like dude , what the hell ? Like we have no idea what is going on , it's just tons of exercises . And that era was also like max bashing of anything that wasn't their own system .

So people were shitting on every other PRI or SFMA or whatever , just saying that nothing works . And it was really frustrating because like , okay , well , if nothing works , what do we do with somebody when they have ripping sciatica and they walk in ? What do you do with somebody who has a stress fracture and has like acute spondy ?

Like what do we do with these people ? So that's when I think Dan and I it was great to have Dan , because Dan and I were both like , okay , well , this is what I'm reading , this is what I'm thinking about , how do you treat this , how do you treat that ? But hadn't treated a ton of lumbar spine ?

So we could take all the stuff they use and then apply that even more right . And I would say again , 80% of biomechanics and pain science overlap .

If you look at the root level no pun intended of what is the mechanism of , like cellular physiology or pathomechanics , which we'll talk about here , like what is the actual baseline level , mechanical argument and or chemistry argument , whatever else , it is right .

So there's two examples here of things that would both help somebody to explain what's wrong with their back . Right , explaining what is going on after a good subjective is half the battle , because most people spend 10 minutes with a physician and don't actually know why their back keeps getting flared up .

So on the pain science side , you would explain to somebody like , all right , you're doing the same thing over and over again , right , what's happening is that areas of your back perceive that as a threat . Those are nociceptors , right ? Sends a signal up to your brain and your brain says , oh no , this is probably not good for us .

So let's create a pain response right Within a pain neurotag . One response is create a perceived threat , interpretate it as pain output right , and that causes the person to not move comfortably . Right , because now they have this guarding response Maybe it's a muscle spasm . Maybe it's a muscle spasm , maybe it's extremely sensitized

motion when they bend forward right . And what we're doing with exercise and PT is we're essentially giving somebody education to calm down their sensitivity level . Because when you explain to somebody like yeah , a lot of people get back pain , people have disc bulges , you know , people have arthritis . It's a thing You'd be totally fine . Most people get better .

Here's what's going on . Here's how we solve it . You're reducing threat at a central level . Right , because you're calming somebody down . They just feel better when somebody is oh , this person knows what they're talking about . They seem like they've seen this before . The other people have gotten better . I'm going to get better .

A lot of these things are helpful , along with exercise and activity modification . Like right , there is one part of the exercise exposure is that McKenzie exercises and McGill's exercises could be just reducing sensitivity because they're doing something that's not interpreted as painful or threatening .

Right , when you find exercises if they only deadlift or squat and that's all they know , for exercise they try to do really hardcore planks but maybe their QLs are sensitized , they spasm every time they do a side plank , right .

But if we teach them bird , dog , dead , bug breathing , positional work and it's not painful but they're using their back muscles , your brain's like , oh well , wait a minute , maybe I can use my back and it's not as bad as I thought it was . That's graded exposure to then have a lowered sensitivity , right .

And that is a lot of the stuff that we'll talk about after . The anatomy stuff is like exercise , all that kind of stuff we do , running programs , manual therapy it is just lowering the gate of sensitivity , right . So that is the entire explanation for flexion intolerant back pain . In the pain science world .

Somebody walks in and is terrified of their MRI , terrified of all the things that they've been said to . They said they're broken , their discs are slipped , their hips are rotated , they're never going to get better . That person needs just a solid dose of pain science to walk them off the ledge . And that can be super athletic people .

I've worked with pro athletes and Olympians who are just as nervous and are scared because they have to compete for a scholarship or they have to compete for a spot on national team and when you tell them you have a disc bulge and you start going anatomy route , it starts to freak them out as versus of the other side .

So it's not only about the pro athlete doesn't need that . But I would say , in general , athletic people , people who work out , people who are very active , they want the mechanical reason , they want to understand why their back hurts from a very nitty gritty patho anatomical model .

And so the exact same explanation would be that , okay , repeated or sustained movements have created a posterior lateral disc migration right that has put pressure on the annular wall . The annular wall has then abutted into the nerve root , the dorsal nerve root .

That has caused either local neuritis or some sort of chemical inflammation which then caused maybe a muscle spasm . As a protective splint , a multifidi has spasmed and then of course you have this large pain output to protect you and the reason you feel so crappy brushing your teeth or bending over to touch your toes , is because you have chemical inflammation .

You have true neural irritation from the disc bulge causing an annular wall fissure right . That's a true nociceptive structure that can create pain . Or there's true inflammation in the nerve root from a neuritis right From some sort of event where they threw really hard , they landed really hard on a ski jump and they flexed their back really hard .

That can cause an acute neuritis , the same way that when you whack your arm really hard on your funny bone you have that tingly sensation right which causes a sciatica and the whole nine yards .

So the way you would help that person to get better is what we're going to do directional preference movements to help reduce the pressure on the nerve root , not heal the annular fissure with exercise . But over time , if we take pressure from the things that are sensitive , the body will naturally reabsorb the posterior lateral disc wall .

If the annular fissure is not broken through to an excursion , it should more or less , you know , calm down on its own . A lot of people have these things . It's totally normal . You know , if I sat , probably after I talked for an hour and a half , I'll have a mild disc bulge , you know . But my back feels fine , you know , I'm okay .

So that is the entire thing for a disc bulge in the mechanical patho-anatomical lens , right . But I would say again , 80% of that overlaps , right . It's just a matter of how you deliver that with somebody . Yeah , are there any questions on that ?

In terms of those two things Because that's still a very popular school of thought that I think everybody deals with is the pain science biomechanical , pathomechanical and I still see it all on social media . I read it all , I understand it , I know what it is , but a lot of people who are yelling the loudest treat the least right .

Until you've treated 500 people for back pain , hopefully successfully , I'm not sure you have a leg to stand on and tell everyone that PRI is dumb or SFMA is dumb or McKenzie's stupid . You should never do that right . Like it's a little bit of a slippery slope there . Okay , so all the stuff more on that is in research evals books .

I don't want to bore you with explaining that . I'd rather just get to the clinical stuff . Okay , the subjective is probably the most important part of the entire eval For this in particular , I think that's in PT

as a whole . But really understanding what makes you worse , what makes you better . When was the first time you had pain ? What do you do naturally to make it feel better ? Like , do you have leg symptoms ? Do you not have leg pain ? What do you do naturally to make it feel better ? Like , do you have leg symptoms ? Do you not have leg symptoms ?

How would you describe your pain ? Is it sharp , is it achy ? All of those things ? If you ask a good subjective , the person will tell you what direction is cranky . Right , that's what we're looking for is the provoking directions , and then the directional preference is what alleviates that , which is typically the opposite .

Okay , so if somebody tells you , for example , the case study , at the end we'll talk about Frankie and actually Kylie . Ironically , kylie was like the first person I ever treated for back pain when she was younger was like tell me , what made you worse ? And they were like okay , I , uh , I was ramping up for season .

I got a bunch of hitting lessons the week after my back started to get stiff . I went for another hitting lesson Next morning . I couldn't wake up . You know , something happened in that lesson . Like , okay , well , what were they doing ? A lot of extension and rotation . It sounds pretty sharp and intense . Right now they're really having a tough time .

Right , you're starting to think , okay , extension and compression might be the one that makes them provoked and then the opposite would be the thing that makes them better . Right , same thing with the other case study is Matt . He was one of the adult fitness clients here .

He just came to me after two other PTs and doctors and injection essentially said that started with he worked at a lab all day as a chemist .

He went to the gym , drove to half hour to the gym , warmed up quick because he had to get home for his kids , did a deadlifting session , felt kind of weird during it , went home , sat on the couch with his kid all night , had dinner , woke up the next morning completely crippled so I couldn't go to work .

Right of telling you , sat at the lab all day , sat at the car all day , right , sitting's not bad for you . But it's a common theme there that probably over the course of multiple weeks he kind of skipped his warmup , kind of deadlifted a little too heavy , kind of did a bunch of things he maybe wasn't ready for right .

So he's telling you essentially what we're going to then do in the movement assessment . So , yeah , all those things , red flags , when did it start ? When's it better ? Do you have leg symptoms , do you not ? What have you done ? Have you seen another PT ? Have you had imaging ?

I really don't think imaging is the devil , as long as you use it in the right context . If someone hasn't gotten better in a month or two and they're still really struggling , that's a huge role to play in knowing what's going on , especially with the young athletic back pain population , like spondy concerns .

And then what other things are like in your daily life making really , really bad right , sitting versus standing , driving versus being up , walking around , laying on your stomach versus sitting on a couch , like they will tell you over time , the things that tend to make them worse . Okay , so , obviously red flags rule those out . That's pretty important .

But , um , yeah , I think that's pretty self-explanatory . I'm intentionally going through this fast cause I think it's boring . Um , okay , so my entire approach to helping people with back pain is a ton of education , right , like massive amounts of education , like there are four time .

There are four sections of back pain progress Acute oh my God , this is terrible , my life is ending is like the chemical irritation , probably two to four weeks in that phase , if it's pretty cranky .

Then you move on to like the be a normal human again phase , which is like can I go to school , can I carry my backpack , can I just exist in day-to-day life without my back feeling really like I'm walking around sideways ? That's the second phase . The third phase is be generally athletic . Again . Right , can I Squat ? Can I do hinging ?

Can I do some split squats and step-ups ? Can I run ? Can I jog ? Can I skip ? Can I just do athletic things without flaring myself up ? The fourth phase is getting back to whatever sport they want to do . I want to hike , I want to deadlift , I want to throw a baseball , whatever else . It is so educating somebody on how .

Hey , like something picked the scab and it's going to take a long time for us to get through this . On the earlier side , if it's the mild muscle spasm , it could be a month , it could just be like literally one week for each of those things .

If you have a mild facet syndrome where you just tweaked your back from a hitting lesson , it might be one week in each of those things . You might feel fine all the way to the opposite , which is a spondy or a stress reaction into a stress fracture , is a full bracing in California , or bracing in Boston , not bracing in California .

Three months of relative rest to let the bone heal and then another three months of slowly getting back to athletics . So that's six weeks for each of those phases . Or somebody has a micro disectomy and that's a really aggressive nerve root bulge that is causing foot drops , sciatica , really bad stuff .

They got to get a micro disectomy and a laminectomy and it usually takes them again three to six months to get back to all of their activities . Right , when we say cleared , we mean like I never had back pain , I'm pitching 95 miles an hour . We don't mean like I can walk my dog and I'm relatively okay , like our .

Our version of cleared and back to sport is like everything , like we feel really good . That's why we work with sporting people , right .

So I really want to spend a lot of time educating somebody on pain science , pathomechanics , the timeline , explain to them what we'll talk about here in some way shape or form in a very lay terminology of what happens to the disc or the spine or the facets when you move certain ways and how the sport they're doing or the activity that they're doing is probably

causing significant overload onto those structures and workload volume and like repetitions , like all that stuff is really important in the education . I am trying to put myself out of a job when I treat people for back pain . I don't want them to come here .

I've treated people once every two weeks who have the worst ripping sciatica you've ever had in your life , right ? So I want people to treat themselves .

I don't want them to need me to do some fancy manual therapy to then fix them and then they need me every single week , right , I want to get people on their own feeling better and feel like they know what they're doing and they can treat themselves as fast as possible , and so the educational piece serves that massively right .

Of course they will need some help from us to create programs to do that , but I'm more or less trying to do that , okay . The second piece that's really important , which sometimes gets lost in the world of physical therapy , is actually treating their back right .

Like people will spend 39 minutes on their hips and their T-spine and how their left lung is rotating their right back , and sure , that's definitely maybe a role for that . But if somebody pays you out of pocket because their back hurts and you don't work on their back , they're not coming back Like you're not going to help that person .

So the eval I could probably do in 15 to 20 minutes pretty well to get mostly there . I then continue the eval with treatment . So treating somebody with McKenzie exercises is a good way to treat them , but also confirm that they have a directional preference , right .

And then , of course , we have , like the , if you want to do manual therapy , if you want to make an exercise program , that's probably the next half of the , about two as well . So I'm trying to treat the thing that actually hurts Right , and again , by doing good subjective and ruling somebody in . The exercises you use are pretty straightforward , right .

If somebody has clear flexion , intolerant , discogenic back pain , cat cows and press ups and standing back bends , going for a walk is 90% of their program to start , right . Big thing that I think is different about me and the way that we treat here is like the other 23 hours of the day are more important than their hour that they're here with us .

So I care way more about what they're doing in their home life and their daily life that they don't realize is keeping them flared up than giving them a magical exercise that they think I'm a God , right , like I , the person , you listen to them , like Matt , for example , the chemist , like , walk me through a typical day before you were hurt .

And he's like , yeah , I , just I get up and I have breakfast with my kids . I uh , I drive 45 minutes into Boston and I have about a couple of meetings .

I work in the lab for six hours running experiments and then I usually get out of there , grab a quick bite to eat , drive 45 minutes to the gym and then I'm usually pretty crunched for time with traffic . I warm up real quick , get my workout in , I go home and I have dinner with my kids . What is consistent about the entire day ?

Homeboy sat for eight hours right . Sitting is not bad for you . Sitting is not like the devil . I don't want people to think that

Sitting is the new . Smoking was a huge rage thing and like your spine just needs to move a lot in different directions . Often it's too much of one thing is problematic . In the same way that I asked Frankie , I was like talk me through a practice . She's like well , I warm up , I do kind of stuff we do throwing drills .

I play long toss , I'm a catcher , so I do a lot of really explosive throwing to second base drills and then I sprint and I have hitting practice . I take a lesson after I go lift . My lift is mostly back squatting and dead lifting with some accessory work , and then I go home and I do my homework .

That girl's just living in extension rotation for four hours . In practice she's lifting in back squats , right . It's very common of what her thing is . So everybody has a thing , right . The gymnast , you could argue , is a extension rotation too . But if you listen to their stuff it's like just all landing compression over and over and over again .

They're taking thousands of impacts at multiple times body weight . So compression and the end plate hitting the facets is the big thing for them , right . So that's why this objective is so important , because the actual exercise application becomes much easier if you spend the right time to rule somebody in right into the right category .

So I try my best to get a lot of education , give them some basic things to do to remove the thing that's cranky . Modifying sports , you know , changing their practice routine . Maybe they're not doing as much flexion in one thing or extension in the other , but trying to modify their workload right . And then trying to give them exercises is the opposite .

So I usually tell people in the acute phase every two hours for the first two days I want you doing some sort of exercise that's going to help you Backbends , press-ups , going for a walk , whatever else you need need , right .

So the other person it's cat cows , rock backs , deep belly exhales to try to open the facets up and open up the space in there , yeah , okay . So treat the thing that hurts , take away the things that are causing the issue , right . And then the next thing is trying to get some sort of an understanding of what's above and below .

So Matt , for example , stiffest hips on the planet right Could had like 95 degrees of hip flexion and IR , but he was deep squatting because he was doing CrossFit . I love CrossFit , but homeboy doing a front squat when his shoulders are stiff and his hips are super stiff , he's going to round his back very aggressively at the bottom of cleans right .

And so he needs hip mobility and ankle mobility and T-spine mobility to help pull off some of the flexion forces on his spine right . He also probably needs to do a different version of squatting for a while that isn't as back intensive , right .

So a low bar box squat , for example , is the most back intensive , whereas an upright goblet squat is more knee intensive . So maybe we give him single leg exercises for a while until he feels better , but when he does reenter , it's going to be goblet squats , not low bar box squats . Yeah , same thing with Frankie .

Frankie was back squatting right and her workouts . So she was doing heavy back squats because that's just what her team was doing and not inherently bad . Back squats aren't bad , but when she already has extension and compression based issues and rotation based issues , then putting her into extension and asking her to back squat a lot might be problematic .

So maybe for her as well , we can switch her to a different version and when she does go back to it we can find some other way to make her feel better . Okay , so subjective , treat the thing that feels bad , try to help above and below Right , and then eventually the goal is to get them back to a two day strength program .

Right , the role of manual therapy we do manual therapy . I think it's important , I think it's really good . All manual therapy is just a way to reduce sensitivity . It is non-specific , nociceptive , anti-nociceptive input . Right , I am not repositioning someone's QL or moving someone's upslip , right , and I have yet to find research that shows that's what we're doing .

You know , I've read a lot of research on soft tissue stuff , all that jazz , and I don't think the evidence is strong for alignment , repositioning or upslips and downslips . I used to teach that , literally took an entire course on it for two years and taught it and did it .

But then I realized that I was full of shit when I started treating people and I was like , yeah , I just popped your hips back into place and like you should be fine , come back next week .

We'll be Like straight up lying to myself , right , and so when you dig really deep in the research on all that stuff upslips , downslips , positional alignment it doesn't really have a strong leg to stand on right Versus exercise and pain . Science and workload management is pretty solid .

There's pretty good evidence on exercise , managing someone's workload and then trying to help somebody . Mckenzie's hit or miss , depending on the studies that you look at . Some say it doesn't work at all . Some people say it's like really good , like reduces the disc bulge , pre-post MRI .

So I'm a big fan of what helps people feel better and I've definitely seen that McKenzie acutely helps a lot of it .

I want to move away from it as fast as I can when somebody feels better and go to exercise , but generally speaking , in the acute phase it's one of the things that we have for the biggest categories we see , which are flexion intolerant or extension intolerant , tolerant , okay , so yeah , but exercise workloads and pain science education have really strong evidence and

I find that the majority of what we do is there . But if someone is in a lot of pain and a heat pack and five minutes of manual therapy and or dry handling is very effective Sometimes . If that makes them feel 20% better to then go exercise more comfortably , of course I'm going to do that right .

The big thing for me is using manual therapy to help them do directional preferences and like midline core work faster , right .

So if we do stuff with them and they feel better for a couple hours and they can then go home and do more press-ups or go for a walk or tolerate being on their feet maybe it's all placebo , I have no idea , but if that helps them exercise more comfortably , that's the first goal is to get somebody into the exercise move because they're terrified , right .

Anybody here who's had acute back pain knows if you don't actually understand what's going on in your back , it's pretty terrifying , right . It does not feel awesome . So , yeah , okay . So , locally , treat people with that . Above and below , we talk about hip mobility and orthorhizic mobility along with exercise . Selection is a big one .

People don't realize that your self-esteem should not be rested on how much you can clean . Right , you can definitely just front squat to a box , and you'll be okay . If their goal , though , is to clean an Olympic lift , then that's up to them , and we have to help them get back there .

But in the short term , there's many other ways to help modify someone's activity . Okay , that actually worked out really well , where we got through most of the eval stuff in like 20 minutes that the strength coaches could jump in . Are there any questions on the eval stuff ? Because we're going to go through some special tests that match after the anatomy .

But on the medical side , do you guys have any questions about stuff ? Keep in mind , in three months , someone's going to walk into your clinic with raging sciatica and you have to treat them . So if you have a question , ask now . Do you tend to see some people with just one direct or preference ? Yeah , that's a good question .

So what if someone comes in with a bunch of them Totally ? Yeah , so they're usually overlapping . I would say the only overlap , though in the super duper acute phase . So somebody with a spondy fracture gymnast , dancer , baseball player , hockey player , whatever they have acute back pain from the fracture and they describe any extension .

Compressions like the sharp , bright , take your breath away pain , but then forward hurts also because the muscles are extremely spasmed right and sensitized right , and we'll talk about why that is because Stu McGill's work has shown that in deadlifting it tends to be like a buckling event which causes like a multifidus spasm , which is like that really intense flexion

forward , sharp , like kind of stabby pain you feel when you have flexion and tall and back pain . But those don't , those people don't feel awesome when they extend , right . And that first two week period it's generally that one is clearly the mechanism of injury and the other one just sucks because everything is so sensitized .

So , yes , I will see it , but I think I'm much more aware now of why the other direction may help and if they're completely different forms of pain . One is like sharp acute matches or subjective matches , a special test that we do and we'll talk about like a sensitivity algorithm and it matches all that . I'm like , okay , this person's got more .

I think it's more extension based . I'm going to go with this theory for a week or two and then we'll reevaluate in two weeks and if they're better , right , there are times when somebody , literally we had someone . We treated somebody for Lisa last week who was a rower .

She had just gone through like a brutal rowing erg workout and this girl could not even stand or something . Everything just hurts . Right now let's just try to help you feel better and give you like a lot of exercises and then , like , as weeks go on , it maybe will emerge more .

But yeah , there's definitely a a problem sometimes when you just keep hammering special tests on somebody who's painful , um , they get pretty upset and you just start to murky the waters .

So , yeah , maybe that's a clinical expertise thing , but , like I don't know , after 15 to 20 minutes of just not really getting anywhere and not being able to someone to move at all , I'm like , all right , this is like an ethical thing . Like I just feel bad to making you keep doing stuff . And well , I'd rather treat that person and see if they get better .

Right , treat them with the press-ups or going like for directional preference stuff and see , let me know how you're feeling and if you're not better , we'll figure out another way to kind of go forward . Yeah , does that answer your question ?

Yeah , okay , anything else , how do you talk someone off the ledge that comes in , yeah , like oh , I'm not going to need surgery , stuff like that . Yeah , that is a great question . So I think explaining to somebody the timelines is really important .

Because if you explain to somebody the natural timeline of somebody who has a really bad disc bulge or sciatica or a spondy , and you say like , yeah , well , generally it's four to six weeks for each of these phases . So you're coming to me at three days or week one , someone will text us and say , like I'd like something happened last night .

Can I come in tomorrow ? Like yeah , it's going to take four to six weeks in the best case scenario . So like , let's not jump to conclusions and say that , like you know , my back's going to fall off , I have to quit sports forever . You know , let's try to get through the first couple of weeks here and see how we're going .

I try to tell people to think in weeks , not days , with back issues , because if every week you're slightly better than the week before , we're moving in the positive direction , then that's good , right .

So , week after week after a week , if they realize that you know , four to six weeks is a long time , you know , for someone to kind of go through all that . Usually , if anybody has a back pain the day the second you have back pain . You want to not have back pain . Like God damn it , I can't work out , I can't go to gym .

Every time I move it hurts , like this is fricking annoying . You know , you want it to go away right away , right , and so three days even , or five days , I don't feel great , but like I'm definitely not like , oh my God , I'm dying , phase Right , um , yeah , so talking about the timelines is really really important .

And also just like I don't want to say normalizing this , but like when you're calm and you're like , yeah , like this happens , everybody a bummer . And then like they're going on , like man , it hurts so bad , like I can't feel my leg , it's in , and they're like my back hurts oh my God , what , your leg it's not moving .

Like we're so fucked , like you're going to like if you start panicking , they start panicking , which I think is part of being a new grad . It's just like it's stressful , bro , when you see a post-op rotator cuff repair the .

So the same thing happens for a back pain , when you sit with a lot of people and you hear the same things and you understand that these people get better and even if it's the worst case scenario , right , minus red flags , but the worst case scenario somebody literally comes in with a huge lateral shift , raging sciatica , foot drop .

You know that 5% of people who have that they need surgery . But they do really well with microdisectomies , right ?

So even in the worst case scenario , when someone is really having a tough time , they can't even lay on the table If they get a few weeks into it and you realize like hey , unfortunately , you know , I think the MRI shows you have this huge annular wall fissure and , like you have this huge disc bulge that's pressing on a nerve root .

That's why your foot's not working . That's why you , like , you know you need , you probably do need a microdiscectomy

. Like I can think of one guy he's like always sticks out to me . He's a construction worker . He was swinging a hammer for a sewage tunnel and he missed the dirt and he hit the concrete and so he literally swung a hammer , hit a concrete and just like you talk about the worst case , no , he literally blew his disc out .

Like I never used rare case but like even he was better . In three months he was back to work , he was totally fine . So like , once you see a couple of those . You can be a lot calmer on the other side of the table . But a lot of high level athletes come to you when their or figure it out and they're worried about you know their job .

Like the pro guys are worried about their job . People are worried about their scholarships . People are worried about , like , do I have to stop sports ? And like , if you can remain calm and just be like , yeah , we're going to , we're going to get through this . It might be a bumpy road but , like takes a long time .

Unfortunately , you know , these things are like six months in nature , but so is the . They tend to be a little bit better . Yep , good question . Okay , so this is perfect to transition to .

I personally think and I think maybe I learned this from back stuff but also I thought I knew a lot about the shoulder till I met Mike and then Mike explained like the capsule , ligaments and all the different things . I was like I don't know anything . I was like I'm a moron .

So I think that when I really understood the anatomy , it helps me put people in categories better .

But knowing the anatomy really well and the biomechanics really well helps you be like agile on your feet when something's not making sense or when , like , you want to change an exercise , you can think about like , well , how does a split squat change it versus a regular back squat , like you know what's happening to the disc and the pedicle and stuff like that .

Cause , spines are the same , right , if you treat a 70 year old with back pain , right , or a 13 year old with back pain , the spine itself is the same . Obviously they mature in different phases of growth , plates and stuff , but more or less the anatomy and the structure is the same .

So if you understand how certain things work and forces work , I think when things are happening in front of you in the clinic you're like , okay , that makes sense they have . You know , matt has 40 degrees of uh , or sorry , has uh , 140 degrees of hip flexion . He's going to deep squat , super duper . Well , it's going to make sense .

But now he has 95 degrees so he tries to squat really narrow his hips don't move . Well , it puts a flexion force on the back relatively . Maybe that's contributing to some of his issues .

Or you understand that when Frankie hits really hard and she has no hip adductor mobility to stride well or throw well , she's going to turn into her spine early and she might get a right sided pars issue right . She might get a right-sided pars issue right , like that's how these things kind of come together .

So yeah , I tried to draw my best diagram here , so I'll go through this quickly and then we'll talk about this . This is like a if I just summarize my whole career , it'd be like in one box right there it's just all the movement patterns and what things we're testing .

But when somebody essentially comes to us we're trying to figure out what quadrant is most provocative or both . So I kind of so this is a top-down view of the spine and I kind of think about this into four quadrants , so this way and this way .

So annular wall , the outer part of the disc nucleus , discogenic material on the inside , the nerve root and the central nerve spinal cord is actually really close to the annular wall . In textbooks it looks like it's so far away , but they're just mushed in together really far . Spine is process and then transverse process this is a side view .

So bone , disc bone , uh , spine is process , and then facet joints , that kind of overlink this way . So obviously we'd be like drilling a line through there this way and then a line through this way to the front to see how this moves . So when somebody has um , you to see how this moves .

So when somebody has , you know the basic movements that you can do , right , like what ? Forward , backwards , rotation , hanging and compression , right , that really is more or less all of us in a nutshell .

So we either bend forward or backwards , we rotate to one side and then we can stretch or we can compress , compressing , being , landing , hanging , being like gymnastics , circus , trapeze , a little more rare , but essentially it's an opposite motion . So when you bend forward and you rotate to the right , which way is the disc moving ?

Yeah , back into the left , right . So if I have someone who comes in and they have one sided um , disc issues and or back pain with like a butt nerve pain , right , if that person , I can think of the guy who was shooting last week . He's a sailor . He sails to one side , right .

So he's always turned and rotated to the right , this way , so he flexes and then rotates and compresses to the right , right . So the opposite motion of the disc , right , if he spends most of his time in this direction right Forward , right rotated and side bent , the disc tends to be moving this way right .

So he might over time and this was over like multiple days of sailing he said that his back was getting stiff and then he went for some really , really choppy waters and he was hitting a lot of like really heavy wakes right .

So essentially what's happening is that the the , the disc is essentially moving more kind of backwards this way until eventually it bumped onto the nerve root . That's when he started feeling like hip and buttock traveling pain , more sciatica type stuff , and then it's not worth going down the rabbit hole of this .

But obviously there's a huge spectrum of how involved that is . You have someone who just starts to kind of have flexion forces and they have no disc bulge at all but the annular wall can transmit nociception . The structures , the multifidi , the nerve itself can be sensitized to that right . There's ligaments that are on the back structure posterior anterior .

The repetitive flexion force . Somebody can tend to have like a sensitization of this back of the area and it usually goes from like nothing to stiffness , stiffness to soreness , soreness to bad back pain , bad back pain to leg pain right and then leg pain to like crippling both . And then you have people that have like really bad sciatica pain but no back pain .

And then after they get better , their leg gets better but their back gets worse . So kind of like it travels down farther to the leg . The more intense it gets , it gets better . It's coming up the leg typically with people like that . Is that a bird ? I thought that was Kelsey , I'm just kidding .

So as they go forward this way , so that way , so this person , their provocative stuff is going to be so flexion right , and that would be right , rotation right , and then you would argue like compression right , arguably also right side bending . So what exercises when we talk about treating somebody , are going to make that person better ?

Extension right , insert McKenzie right . So usually extension is always the directional preference of choice . To go central first , because if the annular wall is intact , there's no fissure here and there's no exclusion .

There's a closed vacuum circuit like a labral seal where there actually is an internal pressure state where you can have somebody do central extension exercises and have a migration of the disc forward . Right , because it's like a ball bearing that when you lean forward it goes back and back goes forward .

So if the negative pressure system is maintained , you'll actually have movement back and forth . When someone has an excursion . It's like letting the air out of a tire right . It doesn't really matter if you push really hard the other way , it can sometimes cause no movement because they've lost the vacuum seal . Yeah , make sense . Pressure is deep focused right now .

I just want to make sure that makes sense . Hey , the other thing that sometimes people get rarely is a lateral disc bulge where it goes straight sideways and then that person someone's forward and backwards does not make that person feel better .

So you would exhaust exemption and then go to the opposite side bending right , which would be this so left rotation , right or left side bending right . Traction hit or miss , because traction does change this . But it also is pulling on the ligaments and the structure that also might be sensitized muscle ligament areas .

So I do have like , if you traction somebody and it feels better , do it , but some sometimes people just hang and it like makes their back feel not great after a long time . But so extension would just be press ups right , this way , and then lateral side gliding would be .

If I hurt this way , this way and this way , the straight lateral bulge would be going against the wall and doing side glides right . So I'm trying to close down this side this way .

And then there's a version of McKenzie exercises where you like lay on your stomach , you flex your left leg up and you side bend and then you do press-ups , which is the opposite motion . It's called like a roadkill press-up , right or reptile press-up . So that's like closing down the opposite side .

If somebody had a right posterior lateral disc bolt or right into tolerance with a left disc bulge , posterior laterally , they would side bend , extend and then come up this way , yeah . Or people can kind of go like side glide this way and lean backwards this way , like that's also an option for people .

So generally you do extension first and then you have somebody do the opposite . Yeah , questions on that . That's 80% of the people you're going to see it's like flexion , intolerant back pain in some way shape or form . Okay . So the opposite of that . I don't have an eraser . So the opposite of that would be baseball player , softball player , lacrosse , maybe .

Sometimes Field hockey tends to be more flexion intoler talent because they're bent over all the time . But let's say Frankie hitting lesson or Kylie sitting in the back Just kidding , lol . So Frankie's was a right . She's a right sided hitter , so she had extension was painful . Right , rotation Right . So extension and rotating to the right .

We had extension was painful . Right rotation , right , so extension and rotating to the right . And you could argue , obviously that's side bending as well . So what exercises will make her feel better ? Deflection , right , so that she actually enjoyed sitting in class because it made her back feel better .

Left rotation , right and left side bending , so that is having somebody go on hands and knees and do cat-cow's just in the hollowing part and then they rock back and do like a quadruped rock back which flexes L5-S1 .

And then they do a little bit of like deep exhale , breathing in that last rock back because it opens the facets up , it opens up some of the space , right . So having somebody rock back in an exhale , you could have somebody kind of lean to one side and do that , if it feels good , like reach over to one side and take exhales that way .

But generally for these people the facets on both sides are cranky , so opening up the facets bilaterally feels better . Yep , okay , and the reason I have the side one over there is because I think that you have to remember that this stuff is all mushed in a very small space , right . So here this is just like the bones and neural .

But there's multifidi right Between each level . Here there are transverse alleys , there are rotaries right . Those are all like the joint position level things . They're interspinal segments . They're not unconscious control , they happen automatically as you weight shift , go back and forth . They're very low distance , but they're like joint position sensors .

They sense when vertebrae are moving side to side or out of alignment or they have like a buckling event or they're very much there for like subconscious repositioning right . So you can't control them , right ? I can't be like flex your L5 multifidi , but you can flex your transverse or your abs or stuff like that . So you have these little guys right .

And then we have like just like the meatiest of the meaty , huge back extensors , iliocostalis , like massive , massive guys that are on top of all that right . And then of course you have obliques that would be over the top here , obliques this way , obliques this way . You have transverse , like it's like a lot of stuff in a small space .

So I personally , I just kind of abandoned the idea of telling somebody exactly what's wrong . I tried so hard to prove to myself that it was like like facet , you could argue right , when you see a fracture on an MRI , you could argue that the facet is obviously involved .

But how do you know it's not also the nerve root or a multifidi , or an end plate or the annular wall , like it's all very much sensitized , like really really bad so plate or the annular wall , like it's all very much sensitized , like really really bad so instead .

That's why I go towards directional preferences and movement categories , because I don't know if I can prove to somebody that it's going to be one multifidi or one side like a facet is a little bit more obvious . But in generally speaking , you're probably stressing all of it right .

When you have a really aggressive disc bulge and that's causing neural stuff , you could argue the ligament , the joint space , the annular wall , it's all probably symptomatic and so we would treat everything with extension-based issues right . So yeah , I kind of talk more in movement categories now than I do specific structures .

If somebody wants to get real nerdy , then I'll explain to them all the possible things that are involved structure-wise if they want to be that granular . But generally speaking , most people don't care . Um , and I think that's actually a good . One moment is like most people don't care , I just want to feel better , right , like .

The analogy I always use is that I know nothing about my car .

If I bring my car to the mechanic with the check engine light on and I can't drive it because something is making a loud noise and they give me a 30 minute explanation of the carburetor and the reverse engineering and all the mechanical pieces and the fluids and this , I'm like , bro , I don't give a shit , I just don't want to die on the highway , right , I

just don't want my car to blow up . Like I understand it has to be fixed and like I'll do it . But like they , I just want to know what to do to fix my car Right . And the same thing . People come to us they want to know that you know throw like I just want to play right . So like that's more of the conversation we're having with people .

Like all the back end work , the thousands of hours behind the scenes , to know this really well and have this in your head is important . But like very few of this will , like very little of this will come out and be explanations to the person , right , unless they want to go down that level , right .

But in general I would say that people don't care and I think that sometimes we over-explain because we want to sound smart because we have an ego and we're insecure about sounding smart , and then we lose the person in the process . Right , like I can't , unless I have a student I can't remember the last time I explained this in depth here .

The student I'm obviously talking somebody through like generally speaking , get like 15 minutes into a vowel . I'm like all right , I think I kind of got this like all right , like let's just treat you , let's make you feel better , let's make your program blah blah . What do you watch on netflix ? Like all that kind of stuff . So , yeah , people don't really care .

Um , all right , any questions on the background ? Because this chart will not make sense , if anything .

This is confusing here and this is probably like the bread and butter of like what you're going to do with people and the bread and butter on the strength side of when somebody comes back to the gym , what we're being very careful about if we know what category they are . Cool , okay .

So I think , for the sake of argument , I'll have somebody demo these , just so we can see them and go through them fast . There are three columns Okay so , high , high gravity , high force , medium force and low force columns . Okay so , high , high gravity , high force , medium force and low force .

This is personally the system I've developed is I want to know if somebody is so painful , so sensitive , they can't even exist and they're so cranky that I'm not gonna be able to do much with them .

But if they get like through the first level of tests and it's really painful , but then as they go farther down the line they're less and less sensitive to not sensitive at all , I know generally we're probably going to start exercise farther along to treat them . Yes , multisegmental flexion those are all SFMA terms .

So multisegmental extension , a stork test , quad rock back , msr is multisegmental rotation . Yeah , the right side is the tissues that we think are involved more or less . The right side is the tissues that we think are involved more or less .

Kyle , you are right in front of me . Do you want to be the demo ? Okay , so this obviously overlaps to a bit with , like you're looking at someone's movement , assessment , if you like to , their other hip stiff or their shoulder stiff , whatever .

So if you just stand right in the middle and I'm probably gonna use that table buddy if you want to , just a flippy floppy .

So if we're suspicious that somebody has , would you guys rather me go down one entire line of tests or do all the standing ones , then all the ones on your back , then all the ones on your what's ones , like all the flexion ones and all the extension ones . All right , you're gonna be up and down a lot , I apologize .

Okay , so I do these all on an assessment together , right , I do like forward , backwards standing , all the standing stuff .

So the first thing to be if somebody has leg pain and symptoms that were concerned , or a disc , would just be toe touch , so feet together and just do three toe touches , right , and we'd be like how does your back feel , how does your leg feel ? Give me a number one to ten how bad your leg pain , how bad your back pain , right more or less .

And then the next thing with that would be same movement but not as much gravity . So hands and knees on the table , you know , quad , rock back . So she'll just go hip distance apart and just rock your feet all the way back and you would say does that hurt your back ? Does that make your leg change at all ? Do you have more or less back pain ?

So this is the same flexion motion at like L5-S1 , without gravity's force and compression , which would be a little bit more intense standing up versus sitting . And the last one would be all your special tests of like a slump , straight leg raise right , sit on the edge . Do the tension test , leg raise on your back .

That is stressing the sciatic nervous system in the back right . Got it Okay ? So if those were all positive , we would be pretty confident . Somebody has discogenic back pain positive . Special test for slump positive numbness , tingling , traveling pain .

Ridiculous stuff kind of makes sense , right , and those would be my like asterisk signs that I keep coming back to week after week . So let's have you stand back up . So if we thought that it was one sided disc pain , we'd have somebody flex and rotate to the opposite side .

So obviously we're causing rotation , we're causing flexion and causing side bending and you would have somebody who has a posterior lateral disc bulge the opposite way . And then when you do the hands and knees position , we're going to go like a .

It would be a thoracic mobility drill on the strength side , but elbow reaches under and try to touch your opposite knee right . So creating flexion there when they reach all the way through is less , less gravity , same motion , yep . And then on your back we would have somebody . If they're , we're really worried , they're extremely sensitive .

If she had right-sided flexion disc issues , I would flex her up and then adductor and rotate her across this way to see if just that little motion of coming up and across is sensitizing . You know buttock pain , back pain at all .

But if , generally speaking , if somebody can't even get on their back and do a flexion adduction without sciatica symptoms , they are like super duper flared up right and they'll usually do like one of these and they'll just like lay in the back and and they can barely rock backwards .

And then you do one of these and go over and like , oh yeah , it's getting me really bad . I'm like , all right , a vowel's pretty much a wrap , I'm going to go the other way and treat somebody OK . So that is all flexion and then flexion and rotation . The one that is not on here is compression . Maybe it's on this one . Oh , yeah , it .

Yeah , we'll do that , sure . Um , okay , do you need to write anything down ? No , I was moving maddie . Okay , pepper . Um , did you just thumbs down me ? Your emoji is thumbs down , okay . Extension . Um , so hands on hips , just three backbends . This would be for suspected bilateral pars . Bilateral facet um , feels pretty shitty when you have something acute .

Press-up test on your stomach . So the thing we use to treat somebody with flexion-based back pain , it's a special test for this . So just relax , press all the way up . They would have localized very bright bilateral pain .

Okay , and then on your elbows for me the hands-on PA shearing test , palpate to find S2 on the sacrum first , so the PSIS is around S2 , come into the middle , move up one more level , that's S1 , and I'd move up to L5 . And I'm kind of going between those two levels because I'm trying to shear the bilateral pars right or the bilateral facet .

So I'll use the back of my hand here and I just do a PA mob on each level to see if it reproduces very similar types of pain . Right , put them on their elbows and intentionally to have them in relative extension that way , okay . And then standing , so a stork test up , down , up down . But you're helping learn so much . So stork test .

So just stand here , reach down , touch the back of the opposite thigh is the cue . I usually come back here and I put a hand on their shoulder and give them a little overpressure to kind of get a little extra and then the version of this on their stomach is a prone on elbows with rotation .

So back to your prone on elbows position and you're going to put one hand behind your back . Yep , I'm going to take my hand and hold her hand down there and then she's going to rotate and I'm going to over pressure her into extension rotation . If she did right side there I'd obviously go the other way .

But to show you guys , so you're pushing someone into unilateral extension rotation , right . And then the same test you can go on your elbows is , instead of doing a bilateral pa like this , you grab one hand on the opposite hip like cool if I grab , yeah , so here , and then the other hand goes on .

Thumb is going to be actually , I'll show this one is going to be right off spinous process , like off maybe an inch is is the pars , is where the pars is underneath . So this hand is going to pull back up towards the ceiling and this hand is going to push down . So I'm doing a unilateral shearing force this way .

So hand here , hand here , and I'm shearing one level and then I would feel the spinous process move to four , come back over PA , shear this way and you're essentially trying to ruin a unilateral pars issue . So I would say I'm doing both at the same time . My movement is this so I'm pulling the hip up as I push the spine down .

So you're trying to cause the facet to move forward relative to the one below it . Yeah , are you directly on my spinous process ? Yeah , I'm just off it right . So you can actually feel when you do QL work . If you come up higher , like if you go into QL , you can feel someone's transverse process .

If you push far enough , that like bony thing you feel in QL is transverse process and then spinous process is obviously what you can feel . So somewhere between you know , the intersection between those two points is where the facet is and the transverse process comes off right , so the spinous process moves over .

That will be along the area of the pars articularis . I'm so far away from it because there's so much tissue in between . But if you push you're going to move the pars relative to the one below it because they they angulate at at 45 degrees .

So when you are here and you push you're hitting one on top of the other and the pars interticularis and the neural ring is right behind that . So someone has an acute fracture . They'll be an unhappy camper . Yep , um so bilateral . Sorry , uh , stork prone on elbow . Unilateral pa shearing .

We're trying to go for pars facet neural arch and the neural ring , cool . And then let's stand up for compression . So compression is a little bit tougher because there's not as much tests on it , but jumping would just be the first one . So just jump up and down . Yep , exactly so , multiple hops in a row . Heel drop test is from Stu McGill .

So push up on the balls of your toes and drop down really hard , like try to give yourself a thud .

So if the shearing , if the same jumping and landing , is more forces like a depth drop , but if just the small movement of hitting your heels causes like axial back pain , you would think that either bilateral pars are being stressed or the end plates might also be stressed . They have some like issues with that . Some people are just compression intolerant .

And then sitting on the corner we do a seated compression test . I actually use this one for the other to rule inflection , extension too .

But sit up nice and tall , you're going to grab the bottom of the table right , and then now , if we think it's extension , I want you to just arch your back as much as you possibly can , and then pull up into the table , and then you would obviously have pain there .

That's someone who jumps and lands a lot like volleyball players , basketball players , gymnasts got this too as well . And then the opposite if we think somebody has like a flexion and compression intolerant uh , follow through of baseball is a big one um , landing and forward like skiers , for example . So around as much as you can grab the table , pull down .

That would cause back pain too as well . Mm-hmm , uh , yep , Okay , cool . And then last one , very unique , but sometimes it happens . It's just like the traction forces can pull on Sharpies , fibers , which cause pain as well .

So it's like mostly like gymnastics , circus , trapeze , crossfit sometimes is very rare , but they would just hang and just see if that hurts their pain . They'll tell you that my back hurts when I hang . So you probably skip that test .

But on your stomach , with your knees very close to the edge , like here for me , there's a prone spondy test as well , but it also gives you traction forces . So , bend knees up , you're going to grab the back of her calves , I'm going to traction and then extend her and that's going to mimic the same type of traction forces . So here .

I'm going to pull back and then up and I would just kind of let her hang there and I would just see , obviously , if that causes similar back pain . So cool , you're trying to hold that for a specific time . Are you looking for provoc ? Just provocation ? Yeah , like this is probably a good thing to know too .

Like I don't use the prone instability test , like I just don't know . Like I'm pretty sure that when somebody comes to me that's a young gymnast who's super floppy doesn't really work out a lot of physical prep , I'm pretty sure she's lax and it's going to have some instability .

But I just don't know if the prone instability test tells me more than just doing a directional preference , than treating somebody with exercise , you know . So the clinical guidelines are tough , because I've had people email me and say my PT used the clinical practice guideline for manipulation because I fit that criteria and they had a spondy .

They manipulated somebody with spondy because they followed the guideline , not just using your brain , right ? So , yeah , it's a way to lose your license . Okay , I think we're good . Thank you , okay . Does anyone have any questions on the special tests ? We are perfecto .

Okay , I'm going to skip the above and below assessments , right , like you should know how to assess thoracic mobility , hip mobility , but it's more so the connection of like if someone's flexion intolerant , the thing we want to look at overhead mobility , thoracic spine mobility , hip flexion and hip IR , ankle mobility , and then knowing how to brace under like heavy

loads , versus with extension . Right Overhead mobility , thoracic extension and rotation , hip extension and hip rotation is a big one and just having the lacking hips means more happens at the back . Right .

Frankie's case study right , if she steps like this and she doesn't have adductor stride and she doesn't have the right hip mobility to dissociate , she's going to turn early from her back and that's why she was getting a lot of right-sided back pain because she was leaning into her back when she tried to hit .

Yeah , same thing happens with throwers over the top Gymnast . There's overhead mobility , hip extension mobility , back bends in half like a teepee Deadlifting .

Right , if I don't have the ability to really hinge well and keep my hamstrings to move and my hips to move back , I tend to have a little bit more of a flexion position , right , but even so , if someone got perfect alignment , but if their hips are stiff , the flexion forces are high on the low back .

So , yeah , you're just thinking about like , okay , what's missing above and below that might be , because when someone's in a lot of pain , they can't do a ton of exercise . This is a good time to clear up a lot of that extra work .

Okay , so I do want to talk about the other sheet , which is like the exercise one , because this is helpful for you guys to treat people , but then also for the strength coaches too as well . So , any questions up until this point . Let me pull this up .

So I think something that we do really well here I learned this a lot from Dan , I think we put our heads together quite a bit is people can actually exercise a lot when they are in , when they're kind of coming out of pain , I guess I would say . But people are able

to do a lot . So the first phase , the first month , I would say for most people , I would say the first month , I would say for most people then we need this , we're good , I would say the first month for most people .

The goal is to get somebody to a two day exercise program that has mostly , I would say , midline core exercises , trying to get every category anti-flexion , anti-extension , anti-side bending , anti-rotating , breathing work , positional work , all that kind of stuff . So you want to get somebody to all of that whenever they can tolerate it .

Right , it might be a bent knee side plank . It might be a regular dead bug , not a wall press dead bug . Maybe it's going to be just a bird dog and not a bear crawl or a cross crawl .

But generally speaking , between home exercise programs for their directional preference , mobility work for above and below , and then for single leg , things are typically tolerated much better in someone who's got back pain . So split squats , step ups , sleds , single leg hip thrusts those are generally treated more comfortably in somebody with acute back pain .

Between those movements , body weight and then all the midline core stuff , you can write a full , good program , right , and I'm just going to quickly show what that looks like , because this is everybody that I treat with any type of directional preference .

I'm trying to get back to something like this so all of their mobility work above , so T-spine hip , whatever their directional preference , right Times 10 in a warmup and then maybe a split squat and then a dead bug , a single leg hip thrust and a bird dog , and then this day over here would have a step up side plank , and then , what am I missing ?

Split squat , step up . If they can do a box goblet squat , maybe , if it's too high or it's uncomfortable , they could do another single leg hamstring or double leg hamstring , like maybe a physio ball curling to substitute for the lack of deadlifting , so something else that feels comfortable . And then an anti-rotation press out .

So something else that feels comfortable and then an anti-rotation press out , right . So three sets of eight to 10 . And after this a 10 minute walk if they are flexion intolerant , and a 10 minute interval of a bike if they are extension intolerant . Right the opposite motion to get them .

So that's a good 30 minute program , right , somebody could do that every single day and feel fine . But like I've had people who are like super acute and really are like nervous to load at all , but all body weight , all basic dead bug stuff , maybe some breathing work and beginning , they can tolerate this pretty well .

So I would say 80% of people with back pain can do much more than they think that they're ready for , depending they know positionally how to do it and they understand why we're avoiding certain exercises , right , sleds are a really good option to here as well . I'm a big fan of like doing a sled push there . I'm just a March that way .

So Alex , who Kelsey's treating and is just starting fitness now , but this is , this was her program for like three weeks and she's like likes being able to do something right . There's a whole argument of exercise , endorphins , pain , science , that kind of stuff , but I'm trying to get everybody to a two-day program .

This is like the second phase for most people . Yep , okay , so just want to review on this chart real quick . Then we'll talk about some case studies of exactly how we treated these people . We could use ones that are not Frankie and Matt , because obviously we just talked about them , but in this chart .

So this is a little bit of Dan , a little bit of me , but every lower body pattern is important to treat somebody with low back pain and we're trying to pick options that are more or less friendly for their back . Right , if somebody comes in , I always go the opposite .

If somebody comes in with raging patellar tendinopathy and you have to give them a squat pattern , if you want to lose your license or lose your job , what was the first exercise you would give somebody ? What's the most ? Knee dominant patellar tendon loading .

We can give somebody A sissy squat or a single leg slant board squat , right , like that person's knee would just feel horrific , right so what's the complete opposite end of that spectrum ? So what's the first thing the least amount of patellar loading , most amount of hip and back loading that we could give somebody .

So say , everybody like comes into you guys , like I don't know what I did , man , my , my back's really sore , you know , and you want to avoid that . What's , what's the thing that would make you lose your job ?

If somebody had back pain flexion , intolerant back pain , like I sit all day and like something's wrong with me and like my back's killing me and they had to do a squatting pattern , a low bar box squat , right , you're literally just tipping over . It's like an RDL or like a good morning , right ? So think of the opposite .

Now , if somebody comes in with flexion , tolerant back pain and you want to give them the most knee dominant squat to take them away from that forward tipping , what's what's more ? Knee loading , a goblet squat or even a Spanish squat right , spanish squats are great , right .

So up , very upright torso , very you know vertical right so very upright torso , very you know vertical . Up and down . They're pretty much a neutral core alignment right . They're really not flexing their spine at all . What about positions of the weights ? Because that's another big one too as well . When you have a goblet squat , what's happening on your back ?

Relative force wise , it's extension force , flexion force , it's flexion right . So they're bracing into flexion . So we use that in new people to activate their core more , which is helpful . But the weight is in front of them and the lever is pulling them forward . It's a mild amount of flexion force .

So what could you do with the weight position to change that Less back ? Where would you put the weights from a goblet position ? Where else can you hold weights by your sides ? We got this guys yeah , just holding weights by your sides , right , so someone's no longer tipped forward .

So an upright goblet or an upright um dumbbell suitcase carry squat or farmer carry squat to a bench is like minimal back stress . So that's a really good thing to start somebody with when they're first nervous and getting back to I threw my back out last year and I'm really nervous . I don't want to do anything .

So , like we would do an upright , just dumbbell squat , just quad city , you know what I mean ? Okay , so with the hinging patterns , right , let's talk about that . So if you wanted to lose your license or get someone's back extremely flared up with flexion , intolerant back pain , what would you give them for an exercise ?

What's up A good morning , right , a super aggressive good morning . What about deadlifting ? Cause like there's a lot of variations of deadlifting . What's up A barbell deadlift , conventional right On a deficit ? Right , they're on a plate and they're going to a deficit . You'd fuck that person's back up , right .

Which is why sometimes I'm hit or miss on Jefferson curls , because long-term maybe it has a solution , but like that's a slippery

slope there , right . So extended range of motion conventional narrow stance , barbell deadlifting is like extremely back intensive . If you're trying to get your back jacked in your training , it's perfect . I do so many D-ball carries and so many back extensions because I want my back to feel good .

Reverse sled drags , but like it's just not the right option right now , okay . So think about another hinge motion . That is way the other end , right . Not loading the back as much . Much more user-friendly doesn't have to be a deadlift . A glute bridge , right . So a single leg hip thrust is awesome here .

That's why we start almost everybody with single leg hip thrust when they're getting back , because you can choose the loading on your hips right . You can move your leg out more to get more hamstring dominance .

You can really isolate one side and go partial range of motion to get maximal glute engagement right and that person can control their spine really really well . Right , almost every gymnast that we treat here I always start with single leg hip thrust . Back in the day it was just me and Duesh .

We had a ton of really high-level college girls coming that all like didn't have back pain but definitely had back pain at some point in their career , and I was like we're not doing any deadlifting for the whole summer because if they hurt their back they're going to say it's my fault or Duesh's fault , with deadlifting equivalent of like 18 chain hip thrusts for

the entire summer and got so jacked . But we were just so nervous to load them because we didn't want someone to think that the deadlift is what caused their back pain , right , um , even though it's probably all of their tumbling and series that has a stress fracture , they assume that deadlift equals back pain .

So , yeah , so a single leg hip thrusts are really great , right , let's talk about , um , split pelvis . What's a really good starting spot ? Single leg work and split pelvis work is fantastic for people with back pain because of what we talked about . But what would you start with for somebody to test the waters ? Yeah , body weight , split squat right .

Maybe the two AirX pads , if they're really nervous , right . If you wanted to make it more extension based , how would you progress that ? So you want more extension load on somebody's split squat . What are you going to do with their position where the weight is all that kind of stuff ?

So Frankie's coming back from spondy fracture , she's braced , she's six months out , she feels great , but she hasn't lifted in a while . What do we want to avoid ? What's going to put a ton of stress on her back in a split pelvis position ? Think about elevation of the leg Rear foot elevated , split squat , the barbell . So back squat position .

Rfes are a ton of extension force on the back right . So how would we ? What's the opposite of that ? How would we start here ? What's the complete opposite of that ? Front foot elevated and you would hold the goblet right Because somebody else who had flexion intolerant back pain .

We'd avoid goblet , but we want her to have a goblet position to put her more flexed right To tip her forward . So , front foot elevated deeper into flexion . Lean forward a little bit , hold the goblet right . That's exactly what we want and we're thinking more . Don't make the back get flared up , not what's optimal strength and performance ?

Loading right , because by your side you can lift 70s , probably for sure . Definitely can't hold a 140 goblet right . That's probably probably not going to happen . So split pelvis for there . And what about single leg ? What's the first thing we'd do with somebody's single leg ? Step up , yep , high box , low box . Where are we putting the weight ?

Low box , Less hip flexion . If they're flexion intolerant On the sides , exactly . So by your side . Step ups right , very good . So entry point if you're trying to load somebody and not make it , you know only body weight , split squats , regular . We'll just load and then change the elevation based on what intolerance they have .

Step ups right , by their sides , right , and then whatever hinge feels comfortable there squatting . When they go back , we just pick the squat . That is the opposite of how they got cranked right . So back squat versus extension right . So back squat people . Frankie didn't do back squats for a while .

She front squatted with straps into a box and then Matt did back squats because he needed a little extension to get him out of flexion , okay . And then all the accessory work . You know everything under the sun for their hips , for their upper back , right . So Copenhagen , psoas , flexor marches , all that kind of stuff is really appropriate .

I do think that there's definitely a role to play in just hammering someone's glutes too as well . So lateral sled drags , copenhagen's for adductor , side plank clamshell all that stuff's really really good right , because you could argue that's overlapping a bit . So okay , yeah , any questions on exercise programming selection .

We're going to go through a couple of case studies , but this is the majority of what I do .

I'm more of a strength coach than a medical provider , I think after the first month of somebody with acute back pain , I think that's way more about knowing what exercises stress what parts of the back , what to put somebody to start with when they've come from somewhere else .

And I think a lot of my discussion why people get better is because they come here where Matt had never learned how to deadlift properly . Jonah was literally the first person who taught him how to deadlift properly .

He just deadlifted because he just deadlifted in college but he never really got proper instruction on how to brace , where to put his hands , where to think about putting his torso .

So he really didn't have a good education there and Jonah was a huge part of him getting back safely and not being so worried because he knew how to brace , he knew how to actually position himself and Matt literally PR'd his deadlift last year on like 405 for three , like something ridiculous , after blowing his back out twice in a row last time he tried the

deadlift . So a lot of that's to Jonah and not to me , because Jonah actually was helping him program the right way . Yeah , so that's all the exercise selection stuff . But let's go through two case studies . We have perfectly 20 minutes for each . Let's go through .

I want to go through a case study that is the worst , like your worst nightmare walks in the clinic and I want you guys and you say you have a strength coach that they're going to go back to eventually , but like what would be the most terrifying thing to walk into your pending . Someone doesn't like cancer , right ? The other 95% , what do you think ?

Someone that's walking out with excruciating pain . There we go . All right , here we go . Let's do the real bad one . So we have , let's go . Let's do flexion . Let's do like an . Let's do somebody high stakes . Let's say we have a 21-year-old . What sport do we want to go here ? Baseball , because we're in the element . So a baseball player .

We'll say it's a catcher . So they have a cute right-sided sciatica and low back pain . Let's just say you're not an athletic trainer who's literally at their school . So one week ago so let's just say they had a huge practice they're getting ready for preseason was deep squatting , throwing a ton of you know , catching , second whatever else it is .

Woke up the next day , went to class and just got horrific sciatica . Had to cancel class . And he's now a couple of days later to get to you . Let's say he's walking in with a really , really bad left lateral shift and they're definitely flexed . Okay . So that person is here and over to the side , right , they don't put any weight on their right leg .

They're doing one of these guys , right , they feel real bad . So about a week goes by and you're the first person who's seeing them . You're in a cash-based clinic . Heard Kylie's the best PT in town . I got to go see her . So what are you starting with ? They're sitting on the table . They're like leaning against the table like this , like what's going on ?

What do you ask them ? First , yeah , and he says well , I was practicing last week and I fucked my back up . He says I was . I caught a huge pen for my catcher and we did a bunch of drills a week ago on Saturday , woke up Sunday , was in horrific pain , couldn't go to class Monday and then it took me three days to get to you . It's Thursday now .

So I was huge catching practice . You know I'm D1 catcher for whatever getting drafted If I get a scholarship goes through all that . Yeah , he's a big dude , hardcore . So , yeah , just caught one day .

Woke up the next day , real bad pain Next day couldn't walk , couldn't go to class , hasn't seen doctor said you know , go to PT first and then we'll get you an MRI in the in the wings . Yeah , okay , great . So this , yeah , exactly so 90% of these people . They wake up , roll out of bed eight minutes before class . I go to class , I sit in class .

I go to lunch , I sit in class again , I go to practice , I warm up and I play . He sits in class all day long . That's like every college kid . I sit for homework , sit for class . Yeah , good question . So sitting all day makes him bad ? He says I feel better when I'm up , moving around . I'm not lying to feed this case study .

This is actually what people come to you with . I want to walk , I want to get around , I want to wear my backpack and I want to just lay down . I don't want to be sitting or moving forward . I want to be up and moving or I want to be flat . People want to go from here to here all day long . That's all I want to do .

Feel better from here to here all day long . That's all I want to do . So , yeah , feel better when I'm walking around . Leg kills me when I put pressure on it , but generally speaking , feel better moving . Tried to bike , didn't go well , yep . So , yeah , foot's working fine , but definitely feel butt and hamstring .

He's got like traveling pain into hamstring and butt . So right-sided buttock pain and like thigh hamstring is the worst . Back feels we'll say this is probably a seven out of 10 . Back feels like a five out of 10 . Definitely the leg is the worst part . I want to know if something like this has happened before . Leg is the worst part .

Good question , yes , in high school . High school had a little flare up of his back . Um , no , leg pain got better in two weeks PT . Interesting , yep , just stop playing , stop catching for a couple of weeks , got better . This is a person , by the way , I'm not bullshitting . So , yep , all right , cool . So we got kind of what we think , right .

What do we think ? What category ? Flexion , intolerant flexion , rotation , right . And I'll speed run this this didn't happen . This was extremely painful . This didn't happen . This was extremely painful , right . And then the only thing that felt a little better on his leg was lying on his stomach .

So lying on his stomach and just being there for like 30 to 60 seconds made his leg feel better and his back feel worse . What do you guys do with that ? Keep going , exactly right . So you educate that person like , hey , this is actually a good thing , right .

There's like a stoplight in mckenzie that if you do an exercise and it makes your leg symptoms get better , but then , uh , over time it gets worse , that's a red light . Goes farther down to his calf , farther to his foot . That's a red light , right . Everything else is a yellow light or green light .

Lays on his stomach , does some press-ups , does whatever legs getting better , backs feeling worse . Generally speaking , you keep going right . So , with this , the , with this , the hands-on part of this eval lasted seven minutes . He couldn't move at all . Every single position was terrible and he was like in a giant lateral shift .

I'm like I think I know what category we're in . So we did three rounds of 10 press-ups , baby press-ups , plus 30 seconds of prone on elbow lying , and I would say it made his leg pain slightly better .

I have a question so lateral shifts kind of trip me up . Are we treating that ?

Yeah , yep , so you treat lateral shifts with an anti-gravity extension , so like if you have someone who's standing is really all the way over here , you want to lay this person down right and they're probably going to be over here , and you just see if this person can kind of army crawl back to midline and that usually makes their back feel really bad but their

leg feel like not worse , and then you just see if somebody can literally just go like this 10 times and you just then you rest for 30 seconds like start , yes , or I would have them lay on their side .

I would have them try to see if they can lay on their left side with their knees in a bolster , because that's going to give them a right lateral glide or a left lateral glide to help the right side . Yes , so long story short here is that for three days he just did walking , press-ups , lateral shifts , manual therapy and drugs .

He took a lot of NSAIDs , high degree NSAIDs from his doctor , not weed , okay . So he comes back . That's Thursday , he comes back Monday . So by Monday he's been doing religiously all his exercises . So he has one out of 10 leg pain and he has still like five out of 10 low back pain Feels okay but not better .

So before we treat him again , what other things do you want to test now that he's not so miserable ? What's really important for catchers ? Hip mobility , right . This dude needs hip mobility , right . Homeboy had hockey hips . He's like no IR and no hip flexion and he would always just be way up on his toes in a deep squat because he had no hip mobility .

So he would try to like rest on his ankles . Way more Shocking that his knees also hurt . He had a meniscus tear . So yeah , he's got no hip mobility . So today , along with whatever we give him for a home program , we also want to give this dude any mobility . He can just kneeling .

Literally just do just kneel and a mild adductor stretch and just see if you can just rock a little bit to open your groin up Right . Or , you know , figure four stretching won't go great . But anything this guy can do for adductor and outer glute , you know , eventually it'll be IR . But IR might make the back a bit cranky , so we add that in .

What are we going to do now for his back Right , also included , we did some manual therapy . Dry needling just helps get him over the hump . But that's not treating him a ton . The exercise matters more . So what , what's the new thing ? What are we trying to get him to do ? A little too early . I like the thought , but a little too early .

Yeah , we need exercise right . So , exercise-wise , what are we starting with him ? Right , we do some bodyweight stuff , maybe a bodyweight box squat . Maybe we try the split squats , we try the step-ups , all bodyweight . Maybe Bfr is great here just to get him to do something that's a little bit like active right .

We're not going to bike , we're not going to do a deadlift , we're not going to do any deep squatting right , but all single leg work and then all the midline core work .

See if we can get a dead bug , a bird dog , a side plank , an anti-rotation , press out , build that two-day program that we talked about right , and see if he could just move a little bit and educate him like , hey , I know it's going to feel a little uncomfortable maybe during it or after , but as long as the next day you wake up and you're okay , like we

need to be active , we need to move , we want to get you to keep it going . Now , dork aside , side note , the thought process here is that exercise helps also because when you have acute nociceptive drive Paul Hodge's work shows there's like a redistribution of activity within muscle groups .

So if your back is really splinted your QL , your low back you're not going to want to load your back , so you're going to lean on other muscles , which is why they limp a lot and leave the other way . But also within muscle fibers there might be like a redistribution of activity .

So we're trying to get someone to use the muscles that are acutely guarded or sensitive , right , ql , low back , multifidi . I don't think we're getting someone stronger , I really don't . I think we're reducing sensitivity through graded exposure and then we're also trying to give somebody something to load the areas that are acutely spasmed and sensitive .

Again , with the thought process being is like normally , this is a pain science thing . Your tolerance for activities here . Right , throwing , swim , you can just more or less destroy your back in a good way , right , and take a lot of training load .

When you have some sort of a nociceptive drive that shuts things down , your body plummets down right your tolerance of load in that position . So , brushing your teeth , putting your shoes on right , like sitting for a long time , going to the bathroom , those things trigger pain because it's so guarded , right .

So the role of physical therapy and whatever is like okay , can we lay on our stomach ? Can we walk ? Can we do a dead bug ? Can we do a bird dog ? Can we do a goblet squat ? Right , we're trying to bring somebody through this graded exposure to restore their activity tolerance .

Whether that's true mechanical desensitization and we're just taking pressure off the nerve root , or it's more of a pain science side of grad , of like graded exposure . That way , right , but that is what's going on . So , yeah , a full two-day program , right , for this catcher is the next thing . So we do that for two weeks . So he's three weeks out now .

We have no leg pain . Yeah , yeah , heat , 10 minutes of soft tissue cupping tools to feels better and then maybe some dry handling if that person likes it . Right , but only in the in the hope of exercising more comfortably . I just want to do that for 10 minutes so that he can then go to the gym and work out Exactly .

Yeah , so three weeks no leg pain , stiffness in the back , but no pain , feeling overall better , but no leg pain , no stiffness , pause . What would you do if three weeks he comes back and he's still real jacked up , like shifts a little bit better , but like legs killing him , not getting better ? You're trying everything , can't exercise , can't tolerate .

What's the next thing in the clinical guideline ? You're trying everything , can't exercise , can't tolerate . What's the next thing in the clinical guideline ? Yeah , so what needs to happen ? Yeah , refer him .

Refer him to a doctor because maybe he needs an MRI , right , maybe he does have a huge-ass disc bulge and or like an excursion of his back and he needs some extra attention . The algorithm is PT right .

After four weeks I usually try to send somebody back and then it's usually going to be some sort of uh , increased pharmacologically of like an oral dose pack , right and or MRI to see exactly where it maybe is a lateral bulge , and I missed the boat completely .

And he's not posterior lateral right , maybe he needs more lateral work and then from there maybe an injection right . Maybe he needs more lateral work and then from there , maybe an injection right , maybe a corticosteroid injection directly to the nerve root space to help calm that area down .

And then if somebody has , you know , that rare five to 10% case so they have a huge disc bulge extrusion , they might need a surgical consult to get a microdiscectomy . Sports are hard man . So yeah , I think sometimes PTs are like no , no surgery ever , no drugs ever . I can do it all , I can fix it all myself .

But if somebody comes back to you in a month in and they're still frigging , struggling man , think about you . A month goes by , you're going to PT once or twice a week and your leg is still killing on you Like my guy , I need to see somebody else right . Like something is definitely off here .

It's just pending that homie is doing everything that he's asked and is not getting drunk and going to a party and like jumping off a stair , which you would believe happens a lot more than you think . People tear their ACL and say like , oh , he's like no , no , he's like fell , fell . No wine involved at all Okay .

So leg zero , back three out of 10 , feeling pretty good , more or less feeling good . He has a little bit of hope here . He's like when can I play ? I got to play . What's the next phase for this gent ? We're probably in phase two-ish , three , if we're thinking about one , two , three , four . So he's got daily life , feels fine , can go to school class .

Those are all okay . But he's a little nervous about the weight room and or catching . So what's the next thing we have to do ? There we go . Now we're starting to get in there , right . So this is actually where I'll start to add back in the other exercises . We would avoid it previously . So I'm actually going to have him quad rock .

I'm going to have him do a little bit of light rocking back and forth through exposed flexion a bit I'm a big fan of that . Maybe do a little bit of toe touch just to test the water , see how we're going . So that's good . The strength stuff , just all increased load .

So all the exercises that we did split , squat , step up , sled , whatever we're going to add harder degrees , okay . The other thing that I think I like to add in here too , one is I do want to try to add some power work and that's typically done via med balls .

So a med ball slam or a throw or rotational shot put right , that starts to stress the back a lot more and you have to use the hip mobility that you hopefully got over the last month right . So med ball slams are flexion , med ball reverse throws , our extension , med ball shot put sideways is rotation .

So , whatever the categories that they have , carefully start with the other ones and then work your way back into those . Then we're doing , you know , this is where box jumps come in , this is where broad jumps come in , double leg , this is where we're doing some running drills right . Obviously , just force overload is kind of what we're working on .

So we have the actual flexion exercises a little bit , we have some power right Work and then also , uh , I think this is a good time to start adding in some direct low back loading . I think sometimes people are scared to load anti-flexion uh , reverse sled drags .

So reverse sled drags , um , ghd holds , hyper holds you could argue , suitcase carries or unilateral for QL , d-ball holds and carries . That's why I do a ton of them , because it helps my back a lot . D-ball carries those are all directly going to pull somebody into flexion if they don't do it . So they're working their low back quite a bit . That makes sense .

So I actually think that's really important to add in stuff in this third phase , because goodness knows that , uh , they're going to get rocked when they go back to sports . They have those forces are really high . So there's the next month . Right , this is probably the majority of the next month is just scaling these things up .

Uh , and again , they're probably not going to be in a ton of pain . They might be a little stiff , but nothing too crazy . So that's the third phase . And then what about the fourth phase ? Got to catch man , I got to catch a game , yeah , exactly . So what do we do with throwers after Tommy John Throwing program , right .

So what would you do with a catcher after a disc injury ? A catching program , right . So what would you do with a catcher after a disc injury ? A catching program , right . So let's have you sit first and sit on a bucket and just catch , play in light toss , roll the balls back . Next phase you know 30 of those .

And then we'll have you squat for 30 , hop up on your knees , light toss back . Things progress more and more and more . You know hitting as well , all that kind of stuff . But yeah , just do a good old fashion and return to throwing and hitting program

. I would say , in here you can probably start exposing deep goblet squats , some of the things that will put him in a similar position . I think this is actually where I like front foot elevated foot squats for these people because it puts them in a really low flex position , but on one leg .

So you want to add the things in that at first you would not want to use at all . Yep , there you go . So that's one . Let's do one more . For the other direction , let's pick like extension , compression . What do you guys think ? What do you want to do ? You want to do a baseball person ? You want to do a gymnast ? You want to do a regular human .

Again , if it walked in the door , what would scare the shit out of you ? Let's go . You guys want to use kylie's . Can we use yours ? Kylie was 14 when I met her , so if kylie walked in the door , shit your pants . Right , I'm kylie . Makes me nervous still so , 14 year old gymnast , level 10 .

You guys don't know what that is , but , um , bilateral back pain , sharp , it's about , uh , eight years in duration , I'm just kidding . Bilateral back pain Sharp , it's about eight years in duration , I'm just kidding . Probably like I don't know . Two months , three months , two months , three months , maybe in season Slowly over , worse in season .

Now it's like I think this is right , but like states and regionals Trying to go out , and then NCAA is the goal . So what are you going to ask ? Yep , my daily routine is gymnastics , school gymnastics , said with love , Nothing but gymnastics . These people train all day , every day , four hours a day , six days a week .

So goes to school , goes to gym , does homework , wakes up and does more of the same . Good question , right ? So this is gymnastics . Diving , baseball gets this too . So it's like a little bit of a slow burn and then like one thing , like blows them up . So in gymnastics sometimes it's like landing on floor .

A skill called the one and a half is a lot of extension , compression , load , um , their beam series , uh , and there's sometimes these . They're called releases , but you guys don't need to know about that , but they're just violent extension , they're like hardcore extension , um , and so usually they're doing lots and lots and lots of repetitions .

And then something happens where we had two consults last week One girl she did one and a half punch felt something go , couldn't breathe after . Another girl was doing a drill punch , front tuck landed on her butt and it hit her back really hard . So she got like this huge axial loading force . But it's almost always hurts .

They keep going , something goes , not allowed to keep going because it hurts so bad . So , yep , that's good questions . What else ? Yeah , sitting being in class so when I'm not up walking around , makes it worse . There's a heavy backpack . These folks usually wear a heavy backpack and it feels really bad .

So long walks in Boston with my friends being up walking around makes it worse . There's a heavy backpack . These folks usually wear a heavy backpack and it feels really bad . So long walks in Boston with my friends being up walking around . But I feel better sitting in class . I feel better on my couch at home . That's where I want to live .

Yep , I think the only thing to ask here is how you describe the pain . It's almost always very sharp . It's like this like takes your breath away , like right and speed . Run this um so positive , stork , positive pronon , elbows , rotation , positive pa and unilateral camera . I can't believe . I remember this a long time ago .

Um , so that's all the things that were positive . What other things do you want to ask about above and below ? Leg pain no , leg pain . I think the other dude was like so cripplingly side bent we couldn't test his hip and thoracic . But like , what else do we need for this population ? Yeah , right , so t-spine extension , that's actually pretty good .

But overhead mobility this is where we got sticky , like 165 maybe so of lats and terries , super duper flexible , lots of laxity , but but very , very stiff . We tested this with a back to wall shoulder flexion , sit down , reverse grip on a dumbbell or a PVC pipe . Couldn't get her arms overhead . Most gymnasts are like that . So very stiff .

And then no hip extension . So positive favor adductors super stiff . And then positive , two-joint Thomas . Okay , I think we're getting the hang of this . What's the first thing we're going to give to make her feel better ? Yeah , bilateral quads , bilateral adductors .

I'll be stiff just because this is not just gymnastics , but just so much adductor , so much quad work . It's a whole nother discussion about strength programs and they do like a thousand jump squats but never any hinging work . So just super roped up quads and a lot of the lat terry stuff is .

People who are good at gymnastics , are very strong that area because of how hard they tap , just like when you throw hard . Your lat has to be very strong to throw very hard , but if it gets so stiff you can't raise your arm overhead , you lose lay back and you get elbow issues . So , yep , that's all positive . How do we treat yep ?

So cat cows rock backs and then deep exhales , and then deep exhales . I think sometimes people like the deep exhale rock back on a TRX . So you hold the TRX and sit all the way really , really low breathe . That one's pretty good . You could sit , reach forward too . That's a PRI one . It's pretty good , I will say .

There's a couple of PRI courses where these bilateral extension people actually I use a lot of those drills . So , yep , I'm going to do that again 10 times about every two hours . What are we not going to do ? What are we going to take away in your daily life ? Yeah , so don't wear your backpack .

Try to carry your books between classes , try to not lay on your stomach or sleep on your stomach . Let's not go for long . Two hour Boston walks . Let's try to break it up and sit on a bench throughout it or whatever else it is .

And then , of course , the things in gymnastics . We're not going to do any extension or compression , but there's many other things they can do . So there's still plenty to do . But yeah , that's the first month , right ? Just take away the things that hurt , add the things that are better . Got it , okay , that feels better .

Two weeks go by , more or less better , but still sore . What's the first thing we're writing back in for strength programming ? More of the same , the exact same thing as the other person all the midline stuff , split , squat , step up , uh , dead , bug , bird , dog , side plank , like it's the whole program , right , the whole thing .

And then when you get back to the third phase , you would not do reverse med ball first , you would do slams first and rotational stuff first . You probably still do broad jumps , but box jumps might be a little bit too much because the axial load .

So you'd start with like single leg versions , maybe like low pogo hops , low banded hops , and then eventually add in med ball , reverse throws , um , standing reverse throws are the most force , uh , depth drops , and then it would be like the reverse sled drags , maybe the d-ball stuff . It would be all that jazz .

So , um , yeah , I don't want to bore you with the exact same answer , but 80 of them or 70 of them , I would say the same . Once you have like this treatment system down , most athletes fall into some of that category .

The last 30% is where catching program , return to gymnastics program , which you're not going to go into a throwing program , a hitting program , a walking my dog program , whatever they want to get back to . But yeah , that's more or less the nuts and bolts of it . So any questions Last five minutes I know it's a lot of information in 90 minutes .

Going back to the baseball guy in the beginning , you're obviously telling him to not touch the ball . Yeah , none , he can hit , maybe Even that you know when they're that painful I would say probably no baseball at all and they know it . They're like , yeah , I can't really do much . These people can't walk , you know , let alone hit .

But if I was going to go back at the end , I'd actually probably want to have that person do some light swings first before we do like really deep squatting and heavy flexion based stuff . So , yeah , um , just like the uh TJ people can hit before they throw .

The catching people and the back people could probably throw or could hit before they throw as well , hit and throw before they squat . I think that's the right way to say that . Yeah , people who have hip injuries , fai injuries , like big hitters . They want to throw before they hit .

If they have a labor repair and they like have a huge bat , they'd want to go the other way . Yep , cool , all right , that's it , no problem , it's my entire career in an hour and a half .