Gymnastics Elbow OCD Best Practices

But , um , okay , first one was in workloads and the way we're going to try to put these together is literally it's just like a brain dump of everything that Aaliyah and I are thinking of or working on , and we take topics based on this Google sheet that we have .

Where I was , literally you know not that I text and drive , but I was in traffic statically sitting . Still , I actually turned my car off on 93 because there was an accident . I literally turned my car off and I had five minutes to go and I was like wrote down a bunch of stuff that I was thinking about .

Like you know , uh , I forget what it was like elbow OCD , which we'll explain what that is , but essentially , um , we are in the final stages of submitting a paper that is an entire start to finish of rehab for elbow OCD , and we'll explain what that is .

But , um , mike and Lenny made the same thing for Tommy John UCL repairs back in the day , which helps a lot of people and I see a lot of elbow OCDs but also things you know , media epicondyle fracture I think you were talking about . You have a lot of those UCL , uh , tommy John's and female gymnasts as well OCD paper .

So essentially there's no consensus on how to get somebody back to gymnastics

after they do any of these surgeries . Sometimes , like , the rehab process is very murky and I have a lot of people reach out to me and like don't see as many gymnasts for , uh , these issues , and they get to like three months and their elbow motion is okay or their strength is back and they're just like okay , like well , how do we do gymnastics ?

Like how do we get you back safely ? Throwing program is really basic , you know . You just like throw it 30 , then 45 , then 60 and it slowly goes up um , not so much for gymnastics . And so that's where the paper came from , was that ?

At the time it was Jen King , um , and her and I , and then a surgeon and his fellow essentially just wrote this monster rehab protocol for like here's how we rehab them , here's how we get them back to weight bearing , here's how we start the advanced power phase , here's how we get them back to gymnastics and we put that into a paper , but there's not a lot

of consensus on uh precautions for OCD , so that's kind of where I want to chat about this . But yeah , do you have any broad arching thoughts about like elbows , ucl , ocd , before we go into some of the stuff ?

But like from the pt side , I can just say from what we experience , like if someone is casted for four weeks or braced , locked in extension for four weeks or something like that , bro , it is a nightmare to rehab that person because they're so stiff and they're so painful and they're so sore .

So this fell out of fashion where , like you know , acls used to be non-weight bearing and locked in extension for four weeks . Then you go to PT at four weeks and Mike and Lenny are , you know , telling the surgeons that , like , this person's not bending at all . And the surgeon's like , well , just bend them more .

And it's like , yeah , but this person's crying on the table . This is not okay . And when you have an eight year old or a nine year old who's casted , um man , getting that that little kid to do rehab or getting their mom to bend their elbow or their dad to bend their elbow when they're , when they're not happy is really , really hard .

Um so I understand that , but I also see the other side of the side of the fence that a lot of places are really busy outpatient clinics where they don't have a lot of time with the therapist , and you know they're not , they're not , they're not really getting great hands on quality motion , and so that person maybe gets bent or is pushed too hard , too fast

early , maybe they get hurt . Maybe it's a surgeon's thought , as they , their elbow is is getting cranky from the rehab and they're not doing well , I don't know . I don't know .

But the kids that are like eight , nine , 10 , their elbows don't move , like if they get casted or stuck in a position for a while . They are so stiff and it's so hard to get their emotion back and it hurts so much . So just it's not ?

Like my mom tried so hard to get me to do rehab . There's no way it's happening . So like to get a kid to bend their elbow every hour on the hour to end range instead of going to play whatever , um is really hard to do , you know . So like , younger kids are having a tougher time with adherence to exercise .

And parents are busy , man , they're working , they have stuff going on , they can't be on their kid all the time . So I I'm empathetic to that . The other piece of it , unfortunately , is that it's grow like weeds , right . So when you get a stiff elbow and you know you cast somebody for four weeks or like three months go by .

Their humerus is growing , their form is growing , right , so like their biceps . Tricep is trying to keep up , but it's it's very stiff relative to the rest of them . So that's like a double whammy that they're growing as you're trying to get motion back and then they just don't have the attention span .

Um , like , sometimes like heat pack on their elbow for like five minutes , just like letting it droop , and like pass the time of like put their elbow over edge , put a heat pack on their edge of their front , of their bicep , and maybe even like a light band pulling them down if they're cleared by a pt , and like let them scroll on tiktok for 10 minutes

while they , while they just sit there with the heat pack and like melt their elbow straight , like more active , focused , focus , like they have to be doing the thing staring at it , the board they're going to get . So find other ways to to keep them distracted .

Like you know , play cards with them or , like you know , do something else while they just let their heat do the work for them . I think that's probably a better uh approach than you know . Let's do this soft tissue where it goes bend every hour on the hour , like I don't

think it's going to work . So , yeah , that'd be my one tip of practical advice . Yeah , got to get creative and don't cast them , if we can . Um , okay , so elbow OCD long story short is a uh injury to the cartilage of the uh forearm area . So let me see if I can zoom in a little bit .

So , essentially , when you do gymnastics this happens in baseball too , but when you do gymnastics over and over again , your arm is not a leg and so your knee joint can take a lot of high force , but your elbow joint cannot . So in a young , growing athlete , that little bump you see there is essentially like a pothole deficit , that's that's developing .

Um , on what's called the capitellum . So the elbow side gets a big old pothole in it and because maybe the , maybe the bone down here is harder than up top , so radius is stiffer relative to the capitellum , that's one theory , but essentially you hit the same spot over and over again and it causes a bruising .

Bruising becomes damaged , damage becomes , cartilage gets kind of like again hollowed out in a pothole , and that is obviously not good . So they have to fix it . The procedure that tends to have the best outcomes is an oats procedure .

So , um , they take a small graft from your knee , where it's not weight bearing , and they essentially form into a bone plug , they put it inside the elbow joint and they stick it in there and then , um , they let that heal , they suture it down , uh , or they suture down , they , they fixate it down and then slowly over time the bone plug from your knee

becomes a new like covered over area of your elbow . That's what an Oates procedure is . There's a lot more dorky explanations for that , but in a nutshell , you know , gymnasts are young , their elbows are not knees .

They're doing probably too much , too fast , they're not that strong yet relative to how hard gymnastics is , and so this happens when high amounts of upper body impacts are going on slowly but surely and then unfortunately sometimes need a surgery . The first uh approach is a six month rest period , because I'd rather not do surgery .

But if surgery uh is indicated they , they base it on how big the lesion is and how deep the lesion is . So grade one , two , three , four is deeper down the bone itself , whereas wider is , like you know , eight versus six versus 12 millimeters wide . They make a bone plug .

So obviously the deeper the lesion with the more width , and if there's like bone fragments , the more severe the surgery is and the rehab is um versus not . But yeah , there's no um , gymnastics and baseball , get these , but there's no uh , really clear , I guess , guidelines on how to rehab these people .

So the paper that we are submitting essentially is saying that the first three months is more or less the same for any other .

You know surgery , you , you know , get their motion back , you let the swelling come down , you try to get their form stronger , you try to protect the graft for three months because it's a bone , it's a bony graft , integration , and so we're trying to protect that area , the same way that if you fractured your leg , you wouldn't really want to walk on it for

the first couple of weeks . So we put you in a immobilized and we get your emotion back and stuff . But then around three months it starts to become a large , I'd say maybe debate or point of discussion in the in the academic world of like , when do we start putting weight on the elbow that has this bone plug ?

And generally speaking , I would say my thought is 12 weeks for most stuff . If someone has a really big lesion or a really deep lesion , or there was an issue with the surgery where they had to do more work than they thought , maybe you push it out more . But I think 12 weeks is probably good because the bone is probably fixated .

And the debate that I had with some other surgeons is that other research shows the knee and the elbow , or the knee and the ankle , when it has elbow OCD , they start weight bearing , these people , at like six weeks or eight weeks because the thought is that early partial weight bearing helps to secure the plug in the pothole graft .

So the thought is that if you're , if you're fixating the graft in via some partial weight bearing , it's allowing the graft to more um , you know , to have a better fit , be more congruent . I would sort of speak . And my uh contrary to that is that oftentimes the ankle has like an evolutionary mileage of like 10,000 years that it's been built for this .

The talar dome is like this wide , flat , very supportive structure , tons of cuboid bones around it , tons of ligaments around it , and the knee is this giant like spherical shape joint that's made for weight bearing . Right your elbow is like so not the same , and also it's all these OCDs are in kids that are young and that are growing and are not that strong .

So I think the elbow OCD tends to be younger and kids that are not as strong and they're doing a lot more activity on their elbows , which makes it harder versus typically an OCD and like a knee or an ankle . That's like . That's like an adult injury .

Right , that's a college , that's a lacrosse field , hockey , jumping , running , end stage career , someone who's been running and jumping and playing a sport for their whole life , professional athletes knee and ankle stuff is almost always college and above level . Uh , athletes and status , not elbow , which is like the youngest amateur athlete .

So yeah , big picture , those are my thoughts , but what do you think ?

Um , if it's a big one , they're usually wait until about four but or four months .

But I think it's interesting with the eight weeks because , because the elbow is such a congruent joint , sometimes I feel like giving it a little bit of weight bearing , like just very low level , like even just like you know , like putting your hands like go on hands and knees , like rocking forward , backwards , side to side , just to get a little bit more motion .

I have a hard time with elbows trying to get all of my extension back actively without doing any weight bearing . It's really hard for me like they can get almost there , but that like active without doing weight bearing gets really hard .

So it'd be nice if I was able to do a little bit more weight bearing , like closer to like eight to eight , maybe 10 weeks , where you're just working on like very low level , just being able to like push against something and get your elbow straight to like start working on strength in that position , rather than like actual loading or like impact .

So you could argue that that's like one sixth of their body weight , right , it's like so small , and I actually I agree with you , though , that like one sixth of their body weight , right , it's like so small , and I actually , I , I agree with you , though that like , I think , I , I think a lot about acls too is I have one case right now like just a bit

stiffer , she had an lat , so the swelling was more , and like she has passively , when I do it like eight degrees of hyperextension in her knee , but she cannot lift her own heel off to get to eight degrees .

Eight degrees of hyperextension , it's just a zero , and that tells you that , like her quad is the reason why she can't get her legs super , super straight .

I think , the same is true for elbows right Like you have somebody who passively is getting to like zero after an OCD or UCL or whatever or a medial epicondyle fracture , but then like actively it's like negative 10 .

That means their tricep is not able to overcome its relative strength right , their tricep is not as strong to overcome the stiffness of the front of their elbow . So in that situation I agree with you , I think it's good to get somebody quadruped and do like the version of tkes .

But for their elbow right , just have them do hyper , like uh , tricep firing in neutral on maybe a dumbbell with neutral wrist , just to get their wrist super duper straight and their elbow super duper straight . And then you add some resistance around and maybe that closes the gap between , like what they passively have and what they actively have .

So yeah , I think I'm okay with that . You know , I think at 10 weeks I'm down to do some like quadruped rocking and some like put them on dumbbells with their wrists are neutral and have them rock forward , backward , side to side more .

So maybe for the strength piece of end range , like active range of motion , before you start progressing somebody into like the strengthening side of weight bearing , yeah , Sure , yeah , I mean , even when we're in like a dumbbell program .

And I think , too , like I haven't had a lot of these where I've had issues where it feels like the joint isn't as smooth when you're doing motion . But I've had a couple where I'm like I wanted to do weight bearing because I'm like it doesn't feel totally smooth .

It feels like there's a little like I don't want to say the word crunch , but like a little sticky you can just feel it a little bit and you're like a little bit more than you want and I feel like early on , when it's still trying to like get integrated into the bone and kind of shape itself out like remodeling of that bone , it might be I don't , I

don't know if that would be beneficial to like have a little bit of weight bearing . That way it can start to like shape , go like , get the correct shape . That way you're not feeling like this stickiness or losing motion because it's not the correct shape that it needs to be .

So if someone's around 10 weeks and you're feeling a bit iffy , maybe instead of going to quadruped and then like bird dogs and like crawling and stuff , maybe you do like a floor press overhead , dumbbell press week where you're just saying like all right , let's do like five , 10 pounds , try to get your elbow fully locked out so it's less weight .

But you're doing active range of motion and that's kind of an indicator of like whether the next phase is going to go really well . Right . Like if you're going to have somebody who's able to um press overhead to full end range and then also do a floor press to end range , you're getting two vectors there of overhead and floor press .

That sets somebody up to do well on a quad rocking or something like that .

Not necessarily , but in gymnastics they're , if they're locking their elbow out in any way , like they're going to be off center if they can't get their other elbow , the other like the same amount . But you know what's ? What are the limits ?

You know , like I think I've seen a lot of people either elbow like OCD or Tommy John or media up condyle , who get like five and 10 . Right , or like or like seven and 10 or like , you know , six and five or whatever .

I think within within a like five to 10% of the other side is probably okay Because I am willing to bet that naturally , over time as they go back to full gymnastics it's going to kind of slowly get a bit more .

You know they're oftentimes lax and very loose , so I don't want to let somebody get away with like missing five degrees on one side and having plus 10 on the other , because that's a 15 degree swing . But if someone only gets to neutral when they had , you know , plus five or plus 10 after a surgery , that's probably okay .

I think particularly in like UCL rehab end range , hyperextension stresses the anterior bundle quite a bit which is where their you know their job graft was . And then you have a lot of dynamic restraints of like the flexor digital rooms and stuff like that . They're overlying the tendon .

So I don't know if I want to get somebody all the way to hyper end range , where we're stressing a graft and then asking the dynamic stabilizers to do extra double duty . Sure , I think . Personally , I think they're probably going to be okay if we just get them to like a little above or neutral and their body will probably figure it out .

You're like you have to be symmetrical , like if you can't be on a bar , and like one elbow is over extended 20 degrees , the other one's only five , like you're going to be off center and you're going to feel that yeah , to that point .

Like you can't not ish degrees of risk , right , but like your elbow needs to be really , really close and then maximize the rest from your shoulders overhead , right , yeah , yeah , I would say that close enough is probably good in a young pediatric elbow for sure .

But it's that active and range extension that we always have a hard time with , especially once we start getting into like like true weight bearing , like enhancing positions or L holds or whatever we're doing working on like pushup positions . They just have a really hard time getting their elbow to maintain like their full extension .

A lot anecdotally I have seen I don't know how true this is or you can you've seen a lot more than me so you'll be able to like comment on this but I see a lot of the kids that I've seen with ocds are ones that will like literally like turn their hand out and like hyper , although out completely , when they do skills which you don't really see much at

the high level , because their coaches are not . They're going to fix that .

I know this , I saw this paper the ? yeah , I think I know what you're talking about yeah , the t position round off yeah so yeah , essentially this paper was just showing that you know it's in a round off , but doing a T position is probably a little bit better versus like rotating all the way in or all the way out .

I don't get to pull it up , but essentially when you fully rotate all the way out , like that , you're asking the joints to do all the work right . Your tricep can't help out a ton .

When that maximally externally rotated position is versus if you're really all the way in , you're just like really all muscles , no bones , and so you're kind of asking the opposite side .

So I think that you know , neutral or slightly turned in is probably good and even slightly turned out because of like wrist or shoulder mobility , but I think anything beyond like the basic , you know what would that be like ? 10 to two position on , like a clock .

I think , when you dance too far outside of 10 to two , you're asking one or the other to do a lot of work . Really far outside . It's a lot of joints , really far insides , a lot of muscles . You're probably gonna have performance issues here and ouchy issues on the other side . So I like how I'm trying to fit it in frame , so yeah .

So I think that , uh , if someone is really far out , they're oftentimes trying to make up for an overhead flexibility position . They don't have enough flexibility or shoulder flexibility or thoracic spine mobility to go overhead . So I would probably spend more time addressing that If someone's really far in .

I think it's more of a coaching , technical correction than it is um . You know a you know performance based PT issue . So yeah , I would try to figure that out in the rehab process or ideally before Um .

But you definitely don't want to be hanging your hand Like you don't want to rotate your hands out too far or too in , uh , or either sides of the issues .

way out and like using their joints as their stability .

Doing early like active motion , concentric , more consistently , and then like using BFR on someone who's probably appropriate , who's a little older , like upper body BFR , when you can't lift a , a lot of weights but maintain metabolic capacity or strength training , is the same as like acl bfr , right , like .

I don't think we're getting someone's quad stronger with bfr in the first eight weeks . I think we're minimizing loss by making it a lot harder . Same can be true for the upper body . Maybe bfr can help us in the first couple months to minimize tricep and bicep loss so that when they do eventually get the 12 weeks , you know .

The second piece is , you know , quadruped rocking becomes bird dogs , which becomes like a static bear crawl position , which becomes crawling , which becomes a tall plank , which becomes a pike , which becomes a handstand .

That progression over , you know , whatever it is , eight weeks of weight bearing reintroduction is good because it allows us to slowly add more to the tricep load and maybe get off BFR . But you know you also got to be doing like high , high load , high volume , hypertrophy work of the tricep right .

That thing's been really like not worked quite a bit if they're pre-op and then post-op .

So just doing like good old fashioned you know four by eights or like three by tens with moderate to heavyweight skull crushers , like bodybuilding stuff , like really important for like the younger post-op people to do because they're going to eventually need just raw tricep cross-sectional area to support the progression of whatever they're doing .

Um , grip strength side to side shows me the dynamic stabilizers are supporting the elbow right . So like there's one piece which is that , yeah , if you have a UCL , the flexor pronator mass is very much needed to protect that . If you have an elbow OCD , um , your forearm and your grip strength is uber important to protect you during bars and weight bearing .

So I want to make sure you're not going to peel off right on bars but also have enough forearm strength to handle handstands and handle back handsprings and stuff . And then you can also do like a dynamometry of like tricep and bicep , just to make sure we're side to side strength . That's probably like the surgical uh uh issues themselves .

The same way , like I want to see torque in an acl be whatever above their uh .

I think it's like two point something for girls or guys but I want their torque side to side , to be high in their leg , in the same way that I want their bicep tricep to be symmetrical in their upper body , because that's like do not pass , go unless you , you know , move on to the next one sure , yeah , we've been playing around with some like upper

extremity functional test stuff , um , creating like a formal , I guess , test similar to what we do for acls to clear patients for sports .

Like I have a hard time with triceps , particularly because I've been doing it supine , where their arms kind of like up this way , and then I'm like here and it's just it's so hard for them not to like go this way , like in or out or like push the whole shoulder up . So yeah , that one's not .

You're stuck at 90 degrees , you're belted down and you're sitting up tall and you have a true extension . Like getting to the point where you can set up somebody on a chain to be isolated , like it has to be , like sitting with a chain over their shoulder and just like literally at 90 degrees going straight . Like that .

Like that's a very unrealistic setup that's what I'm trying to accomplish .

You probably just need a smaller chain to make sure that it's not awkward . Uh , on top of them , but yeah , that's a . The only other way I think is lying prone , but that's kind of awkward too . Um um , yeah , so this paper that we're trying to put out , uh , I think 12 weeks is probably good .

I think 10 weeks I can understand maybe doing a little bit on the way on the front end , um , weight bearing progressions probably take like four weeks to go all the way from quad rocking to doing a tall static push-up position , shoulder taps , and then going from static to tucked to piked , to one-legged handstand , to handstand , to handstand walking on the wall .

That's probably another four weeks and I think that that probably is the whole process of weight bearing progressions is , at the same time you're doing a strength training program of like floor presses , um , to , yeah , floor presses , to like knee elevated pushups to regular pushups .

Right , it's the same as like going from um half kneeling cable pull downs to a static hang , to a pull up with the body assistance of of a pull up band , then to a full pull up , like those are all a parallel-up with the body assistance of a pull-up band , then to a full pull-up , like those are all a parallel track of like the hanging pull-up progression

is also the pushup progression , which is also the weight bearing overhead progression , and eventually you get to the point where somebody should be able to do , you know , a couple sets of good pushups , couple sets of good pull-ups . They should be able to hold the static handstand and walk sideways on a wall .

That's how you you're doing well and you're probably going to get cleared at six months and go back to a return to sport program which has to have tumble track for two weeks , three days per week , and then rod strip , and then rod strip goes to hard tumbling and hard bars , stuff like that , but adding in the less intense stuff first yeah , I haven't tried a

lot of sideways handstand walking it's good you go to a lot of forward backwards , but I haven't really tried that I'll do like shoulder taps or hand taps yeah , it's good because you can move more of the handstand yeah , you can take away the , the balance skill of handstand walking and just do like the loading of the joint .

So we'll have someone go like tuck , tuck walks on a box , then pike walks on a box sideways and then do like a 45 degree wall hold and just do taps and then when they get the full handstand here , you just pivot them and you walk like side to side down the wall . It's a better way to do it versus front to back .

I think that hopefully the paper will get submitted soon in a month we're like literally in the final editing process to submit it to the journal and sports PT and then hopefully it's accepted and it has like an appendix .

That's literally like seven pages of like from the day they come from you from the surgeon day , post-op one to six months when they're going back to like the hardest gymnastic skills ever . But hopefully it's a bit of a guide for people who maybe aren't like I .

I just think about like when I had a baseball player and I was like I don't know how to cheer baseball player um mike and lenny's papers were so helpful .

So our hope is that we can make something similar to that for , like , the average everyday sports clinician who doesn't see a lot of elbow ocd and they can just like look on the journal sports pt and see a whole protocol rehab that cause like .

Unfortunately a lot of people have career ending OCD lesions because a lot of reasons , but unfortunately one of them is that they don't have a great progression back to sports and they get like a good intention from their PTs or doctors but nobody really knows gymnastics so they go back too fast , it starts to flare up again .

The parents are like , yeah , we're not doing this again . They just you know they're done , so hopefully that stops happening .

Do you use any of those or you just kind of make them ?

So I usually provide the protocol by emily sweeney because I like how it separates it by joint yeah , I think those are .

Um , I will just pull up , not this one , but this is , uh , this is an Achilles , but whatever , this is going to be good enough just to show the principle . But essentially I think you can , can you can take the basis of those .

I think the hard problem comes up to when they have optional level skills and they're doing not as many events so they have kind of stuff going on um , that's not only compulsory , compulsory , it's easy , right , compulsory . Like , have the same plug and chug program but um , window boop , boop , uh , is that up ? Yeah , oh no , it's not there we go .

Um , add to stage , it's not working . Hold on pause for dramatic effect oh , there we go . So yeah , I think I take their um . This girl had an achilles repair um , and so it's obviously not the same , but essentially like taking her skills that she does for level 10 gymnastics .

You take those and then I make the first two weeks is always like one of the events is not the thing . So you're not doing um vault bars being for one day per week . She happened to not vault , so that was actually very convenient . Um , but the first weeks are going to be her skills on softer surfaces , about three to five repetitions of low level stuff .

So drills , basic tumbling , you know not her full hardcore um tumbling uh all the way on on tumble track , but just basic level stuff . And so we do this for two weeks where she's doing three to five on softer surfaces four days per week , with a built-in off day in between to kind of give her her arrest . This would be the same thing .

It'd be three days per week or four days per week of like upper body loading , three to five skills , softer surfaces , um , with basic drills and conditioning . Then the second two um weeks , weeks three and week four . We uh , we'll add in more repetitions of harder skills .

So now , instead of maybe just doing singular roundoffs or singular back handsprings on tumble track , you're doing round off by can't bring back tuck for a low level athlete or for an older level athlete , it's you're doing .

Instead of just like layout , you're doing double backs or double pikes or fulls on tumble track and then you'd spend half the time on a harder surface . So , tumble track , you would do harder skills of like full , full tumbling , and then , after you do five or seven of those , you go to floor and you would do your basics on the harder surface .

So you do static , you know roundoffs or back handsprings or single level skills , try to go back and forth , and then the same thing happens . Down here is that weeks five and week six , you do your hardest skills on rod strip and your less intense skills on floor .

So , like rod strip to a resi would have double backs , double pikes , um , or full tumbling , and then you'd go over to your floor and just do layouts front and back or full front and back . So it's like you're always stepping up half the time on the harder surface with less intense skills , but they're always around like five to seven repetitions .

And then the last bit is you do seven repetitions , um , of any skill you want on harder surfaces , but that's like your skill cap . So , yeah , I think almost everybody I read a program for has some flavor of that . What are your skills ? We're doing three days per week taking one event off to your home program three to five reps to start , easier skills .

The second week bumps up the surface half the time , a little harder skills , maybe five reps . The third phase of those two weeks is seven reps on harder surfaces , but we're we're just being careful about total volume . And then , lastly , they kind of expand .

So , yeah , whether it's OCD , whether it's ankle , whether it's Achilles , whether it's back , tends to be the thing I do which is based on how they got hurt for their back . It might be hyperextensions for their legs . It might be impact . Upper body . Elbow might be impact too as well .

They're doing a strength program with us maybe one day per week Because if they go to the gym they get bummed that all their friends are doing skills and upgrades and they're pissed . Older athletes that are more like , you know , high school whatever they can go , they want to be there .

It's better for their mental health to be there because they're with their friends , they can help coach the little ones , they can do some drills , so they go home early . Um , younger ones , especially with their parents .

It's like they're worried that if they go there they're like going to just like do a couple of things here and there and oh , it feels pretty good . I'll try this . So I would say it's almost always dependent on , like the kid , their parents and their coaching situation .

If the coaching situation is great and they know that , like you know , we'll see you in three months . And I have situations too , where not to go down the weed on who or where or what , but like the coach that is working with the athlete is like I'm a coach and I love it , but I don't want them here if they're not ready to go fully .

So like it's like elite , high level , whatever . And like they were like yeah , yeah , I have a bunch of tens and a bunch of elite girls we're coaching whatever . Like I love that you come and buy and you swing and you hang out once in a while , but like don't come back to the gym till you're fully cleared .

You can do all the assignments that we want you to do and I'm not worried about you getting hurt , which is fine . That's one way to coach .

But like essentially it's like I kept them for way longer , like I did like lily didn't text that coach until six months and be like all right , and they hadn't done like the hardest of hard stuff in the PT room that I could possibly give them and then I feel pretty safe . They're going back to a good environment , but that was their choice .

You know , other people literally are in there with their brace on week one doing leg conditioning and , like you know , trying to people .

So like yeah , we're doing quadruped and rocking and you know tabletop type stuff , but like true plyos or like handstand type work doesn't come for later but traction earlier because the traction on the joint is not that dangerous and we want to develop the forearm .

The flip is true for TJs and for so Tammy James we call them the gymnasts that come females but um , compression is good for the TJ earlier because that's not how they got hurt right , they got hurt from a hyper extension and probably a dislocation .

So traction and and uh , traction and um compression are not inherently the bad thing , but traction is a lot of stress on the flexor pronator mass , which is a lot of stress probably around the elbow joint . So I tend to progress the compression side of Tommy John UCL rehabs a bit faster than earlier , than traction , whereas an OCD it's traction not compression .

Okay , yeah , so probably around four months . I would say they're both in some way shape or form going for it . Okay , sounds good . All right , we'll leave it at 30 something minutes . We're close . We're close

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So we'll see you guys . I don't know what the next one will be , but whenever we do it , we'll see you guys . Then See ya .