1
00:00:00,440 --> 00:00:03,200
This episode of The Doctors Are 
Running podcast is sponsored by 

2
00:00:03,200 --> 00:00:05,400
Running Warehouse. 
Fall is here and winter's 

3
00:00:05,400 --> 00:00:07,480
coming, which means it's time to
get your cold weather gear 

4
00:00:07,480 --> 00:00:09,240
ready. 
Just because it's chilly though,

5
00:00:09,240 --> 00:00:10,760
doesn't mean it has to be 
uncomfortable. 

6
00:00:11,040 --> 00:00:14,400
Take the ultra soft logo long 
sleeve from, say, Sky A-Team 

7
00:00:14,400 --> 00:00:16,160
favorite. 
It's moisture wicking, super 

8
00:00:16,160 --> 00:00:18,840
stretchable fabric is a delight 
to run any distance in. 

9
00:00:19,480 --> 00:00:21,800
The Rabbit Easy Collection has 
been a favorite of the team 

10
00:00:21,800 --> 00:00:24,320
since day one, and their easy 
joggers are no exception. 

11
00:00:24,960 --> 00:00:27,160
We're completely unashamed to 
say we've gone from run to 

12
00:00:27,160 --> 00:00:29,000
lounge in these joggers many a 
weekend. 

13
00:00:30,040 --> 00:00:32,759
For you morning run warriors who
have to embrace the darkness, 

14
00:00:32,920 --> 00:00:35,440
the Brooks Run Visible 
collection provides both comfort

15
00:00:35,440 --> 00:00:39,040
and 360 degree visibility. 
For all these and more, Running 

16
00:00:39,040 --> 00:00:41,320
Warehouse has you covered from 
top to bottom with their fall 

17
00:00:41,320 --> 00:00:43,320
outerwear shop. 
Visit the link in the 

18
00:00:43,320 --> 00:00:46,040
description or head straight to 
runningwarehouse.com to start 

19
00:00:46,040 --> 00:00:57,200
shopping today. 
Hello everyone and welcome to 

20
00:00:57,200 --> 00:01:00,040
the Doctors Running Podcast 
where we, a group of doctors of 

21
00:01:00,040 --> 00:01:02,400
physical therapy, discuss the 
art and science of running and 

22
00:01:02,400 --> 00:01:03,720
the stuff that we put on our 
feet. 

23
00:01:03,720 --> 00:01:07,720
Today at the Round Table we have
Doctor Matthew Klein and myself.

24
00:01:07,720 --> 00:01:09,960
I'm Nathan Brown, I'll be 
hosting and today we are going 

25
00:01:09,960 --> 00:01:12,680
to be talking about tissue 
healing time frames and return 

26
00:01:12,680 --> 00:01:16,040
to run criteria. 
We actually had plans to do a 

27
00:01:16,040 --> 00:01:19,600
full episode regarding posterior
tibialis, tendinopathy, and a 

28
00:01:19,600 --> 00:01:21,480
lot of the questions that we got
from you all. 

29
00:01:21,480 --> 00:01:23,960
And by the way, it's been really
fun because we put out a 

30
00:01:23,960 --> 00:01:26,480
question and we had so many 
responses so quickly. 

31
00:01:26,480 --> 00:01:29,280
It's very fun to have that sort 
of engagement with you all. 

32
00:01:29,280 --> 00:01:31,880
But we got a lot of questions 
that centered around this 

33
00:01:31,880 --> 00:01:34,160
question about how long is it 
going to take for me to get 

34
00:01:34,160 --> 00:01:36,440
back, what do I do if it's not 
going to get back in time? 

35
00:01:36,560 --> 00:01:38,400
How do I know if I'm ready to 
get back to running? 

36
00:01:38,600 --> 00:01:41,720
So we thought that that was 
actually a more foundational 

37
00:01:41,720 --> 00:01:44,000
question, that there is a decent
amount of literature. 

38
00:01:44,120 --> 00:01:47,680
Around and a lot of clinical 
experience around that we have 

39
00:01:47,680 --> 00:01:50,400
in working with runners. 
So we wanted to address those 

40
00:01:50,400 --> 00:01:53,080
questions 1st and if we have 
time at the end, we're going to 

41
00:01:53,080 --> 00:01:55,880
circle back to a couple of the 
specific questions that we got. 

42
00:01:56,160 --> 00:01:58,800
But that is the plan for today 
and we are really excited. 

43
00:01:59,080 --> 00:02:02,320
But first, Matt, how are you 
doing in the midst of everything

44
00:02:02,320 --> 00:02:07,600
that you've got going on? 
I mean, not really exhausted. 

45
00:02:08,000 --> 00:02:10,800
Yeah, I love being a dad. 
It's awesome. 

46
00:02:10,800 --> 00:02:15,920
My daughter who is 9 weeks old 
as of yesterday, as of the time,

47
00:02:15,920 --> 00:02:18,000
this recording is doing really 
well. 

48
00:02:18,040 --> 00:02:20,760
Very motor driven, very happy, 
very healthy. 

49
00:02:21,560 --> 00:02:25,120
It's just hard to do multiple 
jobs and keep this going. 

50
00:02:25,120 --> 00:02:28,000
But I'm doing it. 
We need to do a dad episode on 

51
00:02:28,000 --> 00:02:32,920
like how to survive, running, 
work, relationships with while 

52
00:02:32,960 --> 00:02:34,960
with a kid. 
I feel like that's a whole other

53
00:02:34,960 --> 00:02:37,800
episode, but it's good. 
Just a lot going on. 

54
00:02:38,320 --> 00:02:40,240
Yeah, it is a lot. 
It's a lot. 

55
00:02:40,240 --> 00:02:40,960
A lot. 
A lot. 

56
00:02:41,600 --> 00:02:43,600
And it's a lot of fun, but it's 
a lot of work. 

57
00:02:44,240 --> 00:02:47,920
And for you too, you know, 
you're the nine weeks in phase 

58
00:02:47,920 --> 00:02:51,840
and so there's still a lot more 
in terms of what your child 

59
00:02:52,160 --> 00:02:55,200
gives back to you in terms of 
like smiling and engaging in fun

60
00:02:55,200 --> 00:02:57,000
things. 
Like I have a with a six and a 

61
00:02:57,000 --> 00:02:58,240
four year old, they play with 
me. 

62
00:02:58,240 --> 00:03:01,240
You know, we play together, we 
we do things where we joke 

63
00:03:01,240 --> 00:03:03,800
around. 
That early phase can become 

64
00:03:03,800 --> 00:03:06,240
draining because there isn't a 
lot of reciprocation. 

65
00:03:07,600 --> 00:03:10,080
From from the baby and you're 
starting to get there now, which

66
00:03:10,080 --> 00:03:13,080
is awesome. 
But I also had to almost laugh 

67
00:03:13,080 --> 00:03:16,320
when you said like only PT would
say like she's very motor 

68
00:03:16,320 --> 00:03:19,520
driven. 
She's 8-9 weeks. 

69
00:03:19,520 --> 00:03:22,880
She she's rolling already. 
She's got independent head 

70
00:03:22,880 --> 00:03:25,080
control. 
What else? 

71
00:03:25,080 --> 00:03:27,960
She's already like fine motor. 
She's already grasping and 

72
00:03:27,960 --> 00:03:30,840
pulling on things. 
And I'm like, Oh my gosh, like 

73
00:03:30,840 --> 00:03:34,920
you're progressing really quick.
It's just, I'm watching. 

74
00:03:34,920 --> 00:03:35,840
I'm like, oh, this is 
interesting. 

75
00:03:35,840 --> 00:03:37,520
I don't know how much I'm 
affecting that. 

76
00:03:37,520 --> 00:03:40,200
But yeah, it's interesting. 
It's great. 

77
00:03:40,200 --> 00:03:43,080
I think, I think most people I 
would say including myself, I 

78
00:03:43,080 --> 00:03:46,400
kind of like my PT self is like 
checked at the door when I get 

79
00:03:46,400 --> 00:03:48,840
in the house. 
So much so that Jan is like I 

80
00:03:48,840 --> 00:03:51,680
wish you would bring home like 
your massage type skills, your 

81
00:03:51,680 --> 00:03:55,360
soft tissue stuff sometimes and 
I was like, that's left at work.

82
00:03:55,400 --> 00:03:58,360
I'm just kidding. 
But she we have joked about that

83
00:03:58,360 --> 00:04:01,840
before I had a whole. 
Class in PT school on soft 

84
00:04:01,840 --> 00:04:04,360
tissue mobilization and my 
classmates went to her, 'cause 

85
00:04:04,360 --> 00:04:06,200
we were married at the time 
during school and they're like, 

86
00:04:06,200 --> 00:04:09,600
so you must have loved this 
semester because we had the, 

87
00:04:09,680 --> 00:04:12,680
like massage class and she's 
like, y'all had a massage class.

88
00:04:12,680 --> 00:04:17,720
I was like classic spouse and 
family member, by the way. 

89
00:04:17,720 --> 00:04:19,880
When we get home, the last thing
we want to do is do. 

90
00:04:19,880 --> 00:04:21,519
Soft tissue with the front of 
other people. 

91
00:04:21,880 --> 00:04:24,560
Well and I yeah. 
And I just I I got, I went home 

92
00:04:24,560 --> 00:04:27,920
and I was just home. 
You know, I have a pretty like I

93
00:04:27,960 --> 00:04:31,280
I separate those. 
Pretty starkly, which is which 

94
00:04:31,280 --> 00:04:34,520
is probably hopefully a good 
thing anyway. 

95
00:04:35,640 --> 00:04:39,200
So let's let's get back into it 
and what we are here for in 

96
00:04:39,200 --> 00:04:41,960
terms of subjective, we are 
going to be talking about kind 

97
00:04:41,960 --> 00:04:44,920
of general stuff regarding 
tissue healing, time frame time 

98
00:04:44,920 --> 00:04:47,080
frames. 
But if you have a specific 

99
00:04:47,080 --> 00:04:51,040
tissue that you want us to dive 
into and you want us to to go 

100
00:04:51,040 --> 00:04:54,520
into the nuances of how to 
rehabilitate and get through an 

101
00:04:54,520 --> 00:04:57,680
injury to a certain type of 
tissue meaning certain structure

102
00:04:57,680 --> 00:05:00,520
or an injury you've had. 
Leave that in the comments below

103
00:05:00,520 --> 00:05:03,280
and we'll keep that in our 
hamper for things that we might 

104
00:05:03,280 --> 00:05:06,800
come back to. 
So Matt, when we start talking 

105
00:05:06,800 --> 00:05:09,880
about tissue healing time frames
return to rent criteria, can you

106
00:05:10,120 --> 00:05:14,080
kind of deepen our understanding
of why we wanted to talk about 

107
00:05:14,080 --> 00:05:17,200
this in the first place? 
Yeah, I think one of the big 

108
00:05:17,200 --> 00:05:20,920
reasons is the most common we 
question we get either asked in 

109
00:05:20,920 --> 00:05:23,760
the comment section, which we 
love people asking, or in 

110
00:05:23,760 --> 00:05:27,520
questions that we get through 
e-mail on social media is, hey, 

111
00:05:27,520 --> 00:05:30,640
I've got this injury, how long 
until I can go back to running. 

112
00:05:30,640 --> 00:05:32,520
It's the same clear question we 
get in clinic, everybody that 

113
00:05:32,520 --> 00:05:36,880
wants to know the exact daytime 
hour that they can return to 

114
00:05:36,880 --> 00:05:38,640
running and it doesn't. 
It's not just runners. 

115
00:05:38,640 --> 00:05:41,320
It's every athlete or every 
individual looking to get back 

116
00:05:41,640 --> 00:05:44,640
to some kind of movement, which 
is again what we do. 

117
00:05:45,000 --> 00:05:48,880
And the challenge is for the 
longest time in the literature 

118
00:05:48,880 --> 00:05:53,040
and kind of across in healthcare
in general, not just PT but 

119
00:05:53,200 --> 00:05:57,000
definitely among the healthcare 
system in general IT we always 

120
00:05:57,000 --> 00:06:00,240
went based on time. 
And the problem with that is 

121
00:06:00,240 --> 00:06:03,480
time alone is not the only 
determining factor in getting 

122
00:06:03,480 --> 00:06:05,480
someone back to sport. 
This is near and dear to me 

123
00:06:05,480 --> 00:06:08,040
because I'm actually presenting 
at the combined sections beating

124
00:06:08,040 --> 00:06:11,840
CSM on this with some very smart
people in February. 

125
00:06:11,840 --> 00:06:15,480
So as we've kind of study stuff 
and we've had and this is not to

126
00:06:15,480 --> 00:06:19,920
create fear as we've progressed 
in the research and kind of gone

127
00:06:19,920 --> 00:06:23,080
all right, we've tried this time
based approach and we're still 

128
00:06:23,080 --> 00:06:25,680
seeing really high injury 
recurrence rates and we're 

129
00:06:25,680 --> 00:06:28,240
wondering you know are people 
actually ready to return to 

130
00:06:28,240 --> 00:06:31,120
sport. 
A lot of this has come from 

131
00:06:31,120 --> 00:06:36,160
areas like ACL or ankle sprains 
or Achilles tendon rupture stuff

132
00:06:36,160 --> 00:06:38,760
where people are coming out of 
surgery or had a significant 

133
00:06:38,760 --> 00:06:42,120
injury and getting back. 
And to be honest, after all the 

134
00:06:42,120 --> 00:06:45,720
crazy rehab, the crazy surgical 
techniques, the injury rates and

135
00:06:45,720 --> 00:06:48,080
the recurrence rates are still 
pretty similar. 

136
00:06:48,080 --> 00:06:49,440
Like we haven't really made a 
dent. 

137
00:06:49,440 --> 00:06:53,360
So the big question is how are 
is time alone enough to 

138
00:06:53,360 --> 00:06:55,880
determine when somebody's 
getting back to sport? 

139
00:06:56,000 --> 00:06:58,880
And based on the current 
evidence, and I think hopefully 

140
00:06:58,880 --> 00:07:02,120
I'm not speaking for you and our
clinical experience, time alone 

141
00:07:02,120 --> 00:07:05,600
is not the only thing. 
There are other criteria, and 

142
00:07:05,600 --> 00:07:07,800
there's a couple stages we're 
going to talk to that help give 

143
00:07:07,800 --> 00:07:10,240
you a better idea of when you 
ask, all right, I've got an 

144
00:07:10,240 --> 00:07:12,200
injury or something, how do I 
get back to this? 

145
00:07:12,200 --> 00:07:13,600
It's not to prolong, it's 
supposed to go. 

146
00:07:13,600 --> 00:07:16,480
Let's give you an accurate 
description of what that looks 

147
00:07:16,480 --> 00:07:19,040
like and give you some 
interesting kind of more fun 

148
00:07:19,040 --> 00:07:21,960
goals to work on instead of just
wait for however long. 

149
00:07:22,320 --> 00:07:25,160
And I think there there's some 
fun things that hopefully will 

150
00:07:25,840 --> 00:07:28,720
give people some things that 
they can work on long term. 

151
00:07:28,800 --> 00:07:32,160
Yeah, I agree. 
I think it is a bit of a time 

152
00:07:32,160 --> 00:07:35,280
based plus criterion based 
return to sports. 

153
00:07:35,280 --> 00:07:38,400
You need not just the time, but 
you also need the criteria. 

154
00:07:38,720 --> 00:07:40,760
The way I like to use time, 
which we're going to go into 

155
00:07:40,760 --> 00:07:44,680
this next, but I think that the 
key with time is that you can't 

156
00:07:44,680 --> 00:07:47,400
rush biology, you can't rush 
healing. 

157
00:07:47,640 --> 00:07:51,120
So there are healing time frames
that we're going to talk about 

158
00:07:51,280 --> 00:07:54,960
and those are in some ways the 
minimum standard for returning 

159
00:07:54,960 --> 00:07:57,240
to a sport. 
But then you have to add on the 

160
00:07:57,240 --> 00:08:00,760
criterion, those criterion what 
they are for each person. 

161
00:08:00,880 --> 00:08:02,840
We have not nailed them down 
perfectly. 

162
00:08:02,840 --> 00:08:04,520
Clearly we're having to re 
injuries. 

163
00:08:04,520 --> 00:08:06,400
The injury rates and running are
really high. 

164
00:08:06,400 --> 00:08:08,640
We haven't figured this out, but
we're learning. 

165
00:08:09,080 --> 00:08:12,240
And that's what we're hoping to 
share today is here are the 

166
00:08:12,240 --> 00:08:15,080
minimum here is the minimum time
that you're going to need to 

167
00:08:15,080 --> 00:08:18,560
consider and that's going to be 
part of how you process when you

168
00:08:18,560 --> 00:08:21,920
can return and you should start 
to think about certain type of 

169
00:08:21,920 --> 00:08:23,760
criterion based measures to get 
you back. 

170
00:08:23,760 --> 00:08:26,640
So it's the cross section 
between the two for sure, and I 

171
00:08:26,640 --> 00:08:29,360
will to tack on to that. 
A lot of people when will tell 

172
00:08:29,360 --> 00:08:31,800
them hey this is kind of how 
long it takes for you to recover

173
00:08:31,800 --> 00:08:34,360
from this. 
They'll often go oh you know and

174
00:08:34,360 --> 00:08:37,760
to make Nathan and David proud, 
I'm going to cite a sport 

175
00:08:37,760 --> 00:08:40,640
outside of running. 
If you look at baseball or 

176
00:08:40,640 --> 00:08:42,679
football you'll all we aren't 
you proud. 

177
00:08:43,120 --> 00:08:46,560
You'll always see some elite 
athlete that somehow got back in

178
00:08:46,560 --> 00:08:49,760
like a week or so and every 
patient's like, well, that 

179
00:08:49,760 --> 00:08:53,520
person got back and it's there's
two things on that A you don't 

180
00:08:53,520 --> 00:08:57,240
know exactly what was done and 
BI can almost guarantee you that

181
00:08:57,240 --> 00:09:00,040
them going back quicker is not a
good thing long term. 

182
00:09:00,680 --> 00:09:03,760
Elite athletes are not a good, 
are not good individuals to 

183
00:09:03,760 --> 00:09:05,240
compare to. 
There's nothing wrong with them 

184
00:09:05,400 --> 00:09:07,840
but you have to realize that 
their careers on the line and 

185
00:09:07,840 --> 00:09:10,080
they're going to do things to 
their bodies that you really 

186
00:09:10,080 --> 00:09:13,400
don't want to do and the long 
term consequences, we're only 

187
00:09:13,400 --> 00:09:15,480
just learning. 
So make sure don't compare 

188
00:09:15,480 --> 00:09:18,560
yourself to others, Focus on you
as the individual. 

189
00:09:18,560 --> 00:09:23,200
Focusing on yourself is is huge 
and the the reality of 

190
00:09:23,360 --> 00:09:24,840
everyone's going to have their 
anecdote. 

191
00:09:24,840 --> 00:09:26,880
They're going to have their 
friend who recovered and it took

192
00:09:26,880 --> 00:09:31,280
them so long or whatever and. 
I think it's just a it's a 

193
00:09:31,280 --> 00:09:33,880
dangerous game to play, very 
dangerous game to play. 

194
00:09:34,160 --> 00:09:35,680
And you you kind of touched on 
this too. 

195
00:09:35,680 --> 00:09:38,760
But so we have time. 
We have the criterion that you 

196
00:09:38,760 --> 00:09:41,400
might have to meet to get back. 
And it's not. 

197
00:09:41,600 --> 00:09:43,720
It's not just the time, it's 
what you're doing during that 

198
00:09:43,720 --> 00:09:46,120
time. 
And there are many times that 

199
00:09:46,120 --> 00:09:49,040
we're going to make decisions 
either individually or through 

200
00:09:49,040 --> 00:09:52,600
the guidance from your PT even 
in like the best educated guess 

201
00:09:52,600 --> 00:09:55,640
where you're going to do 
something that sets you back and

202
00:09:55,640 --> 00:09:58,600
then you reset the clock. 
The clock has to reset and 

203
00:09:58,600 --> 00:10:00,920
you're not going to have this 
perfect linear progression. 

204
00:10:01,280 --> 00:10:05,640
Just because you reached day 21 
doesn't mean that it racks the 

205
00:10:05,640 --> 00:10:07,800
heels. 
What if on day 11 you did 

206
00:10:07,800 --> 00:10:10,000
something that you rotated it 
and brought it back a couple 

207
00:10:10,000 --> 00:10:10,640
days? 
So. 

208
00:10:11,680 --> 00:10:12,920
There's no perfect way to 
measure that. 

209
00:10:12,920 --> 00:10:15,880
But that is the nuance of this 
whole thing and that's why 

210
00:10:15,880 --> 00:10:19,440
criterion can be nice because 
you have time and the measure of

211
00:10:19,440 --> 00:10:22,000
criterion. 
So again, we'll circle back to 

212
00:10:22,000 --> 00:10:24,440
those concepts as we go. 
But I think like that was a 

213
00:10:24,440 --> 00:10:28,960
great intro, Matt, in terms of 
the main question that you get 

214
00:10:29,000 --> 00:10:31,760
and kind of some potential 
problems with that. 

215
00:10:31,760 --> 00:10:34,920
So let's start talking about 
this time variable. 

216
00:10:34,920 --> 00:10:39,720
So when we think about time. 
What do you usually think about 

217
00:10:39,720 --> 00:10:41,040
when it comes to tissue healing 
and. 

218
00:10:41,040 --> 00:10:44,120
And what's going on? 
Yeah, the classic thing I think 

219
00:10:44,120 --> 00:10:47,840
about, and then also I teach my 
students is there's a couple 

220
00:10:47,840 --> 00:10:49,560
different phases of tissue 
healing. 

221
00:10:49,560 --> 00:10:52,720
So the first one when just when 
you injure something, when 

222
00:10:52,720 --> 00:10:56,560
you're like, oh, you either you 
know, you step wrong or you do 

223
00:10:56,560 --> 00:10:58,680
that one step or you finish the 
run, you start the run, 

224
00:10:58,680 --> 00:10:59,680
whatever. 
And you're like. 

225
00:10:59,680 --> 00:11:03,520
Now this is starting to hurt. 
It's things have swollen up like

226
00:11:03,520 --> 00:11:05,400
you see what's called an acute 
injury. 

227
00:11:05,760 --> 00:11:09,120
That is the initial phase. 
Things just and this things just

228
00:11:09,120 --> 00:11:10,640
got irritated. 
You're seeing things swell. 

229
00:11:10,640 --> 00:11:14,000
Get rid all that kind of stuff. 
That is the first stage of 

230
00:11:14,000 --> 00:11:17,080
healing, right? 
It's inflammation, which is 

231
00:11:17,080 --> 00:11:19,200
actually a good thing. 
You want that because that's how

232
00:11:19,200 --> 00:11:21,800
your body gets materials there 
to start cleaning stuff up and 

233
00:11:21,800 --> 00:11:24,360
fixing things. 
But you've just really damaged 

234
00:11:24,360 --> 00:11:26,280
the structure enough that your 
body is now paying attention to 

235
00:11:26,280 --> 00:11:29,120
it. 
Now this phase involves, like I 

236
00:11:29,120 --> 00:11:31,240
said, inflammation. 
Your body's got to send 

237
00:11:31,240 --> 00:11:34,920
materials there, send blood flow
to a stop, whatever tissue 

238
00:11:34,920 --> 00:11:36,440
damage. 
In terms of stop, it's like 

239
00:11:36,440 --> 00:11:39,680
clotting stuff off, getting a 
bunch of blood flow to get some 

240
00:11:39,920 --> 00:11:43,120
like things around there. 
Make sure that things are safe 

241
00:11:43,120 --> 00:11:46,040
and clean. 
This phase can take it. 

242
00:11:46,040 --> 00:11:50,560
It starts at this is time that, 
you know start time .0 and then 

243
00:11:50,560 --> 00:11:53,760
this can last anywhere from 
about 7 to 14 days. 

244
00:11:53,760 --> 00:11:56,040
You'll know it because it's 
usually pretty painful. 

245
00:11:56,040 --> 00:11:58,880
And again pain is your friend. 
It is trying to tell you 

246
00:11:58,880 --> 00:12:02,120
something it's not oh this is 
just this annoying thing that's 

247
00:12:02,120 --> 00:12:04,400
getting the way because I want 
to run my marathon next weekend.

248
00:12:04,640 --> 00:12:07,760
This is your body's like hey, 
can we, like hold on a second. 

249
00:12:07,760 --> 00:12:10,680
I'm I'm, I'm trying to like do 
damage control and figure out 

250
00:12:10,680 --> 00:12:13,920
what's happening here. 
So again, it can last anywhere 

251
00:12:13,920 --> 00:12:16,960
from 7 to 14 days. 
Some people can get through this

252
00:12:16,960 --> 00:12:18,880
really, really quick. 
Other people take a little bit 

253
00:12:18,880 --> 00:12:20,600
more time. 
It really depends on both the 

254
00:12:20,600 --> 00:12:23,760
severity of the injury and 
sometimes some personal factors.

255
00:12:23,760 --> 00:12:26,720
As Nathan mentioned, we are so 
individual on a response to 

256
00:12:26,720 --> 00:12:27,920
this. 
That's why there's a huge 

257
00:12:27,920 --> 00:12:30,000
variation of this. 
So this is the acute phase. 

258
00:12:30,240 --> 00:12:33,240
What you do in the acute phase 
is you protect this thing, You 

259
00:12:33,240 --> 00:12:35,600
try to protect it, you let your 
body do what it's going to do, 

260
00:12:35,760 --> 00:12:38,960
but you also try to maintain as 
much as you can without doing 

261
00:12:38,960 --> 00:12:41,000
further damage. 
Trying to maintain appropriate 

262
00:12:41,000 --> 00:12:43,520
mobility, trying to keep your 
muscles from atrophying. 

263
00:12:43,520 --> 00:12:46,840
You know, not crazy lifting or 
anything, but just keep the 

264
00:12:46,840 --> 00:12:48,600
muscles working. 
So you'll commonly hear people 

265
00:12:48,600 --> 00:12:52,440
suggest maybe some gentle muscle
setting, like very lightly 

266
00:12:52,440 --> 00:12:54,440
getting the muscles to fire 
without going through full 

267
00:12:54,440 --> 00:12:57,320
range, but you're just doing 
damage control, right? 

268
00:12:57,320 --> 00:13:00,080
That doesn't sound good, but 
it's like your body needs this 

269
00:13:00,080 --> 00:13:02,640
face. 
If you rush this, people 

270
00:13:02,640 --> 00:13:05,880
commonly get stuck here and it 
becomes this chronically 

271
00:13:05,880 --> 00:13:09,080
inflamed tissue. 
So yeah, you got to modify some 

272
00:13:09,080 --> 00:13:13,840
stuff that might be backing off 
that might also be hey, like I 

273
00:13:13,840 --> 00:13:16,840
just need to like rest this and 
I know frequently as PTS were 

274
00:13:16,840 --> 00:13:20,360
like, oh you shouldn't rest, but
activity modifications probably 

275
00:13:20,360 --> 00:13:23,040
the better term to make sure you
protect the areas of things. 

276
00:13:23,560 --> 00:13:26,560
Can heal. 
So this, this first phase, this 

277
00:13:26,560 --> 00:13:29,200
kind of acute injury phase is 
sometimes called the 

278
00:13:29,200 --> 00:13:32,440
inflammatory phase of healing 
because of the types of cells 

279
00:13:32,440 --> 00:13:34,720
that are rushing to this area 
that you had injuries. 

280
00:13:35,200 --> 00:13:38,640
And usually the Monica mnemonic 
that's used or the acronym or 

281
00:13:38,640 --> 00:13:42,360
whatever the right term is, has 
been like rice or price, right. 

282
00:13:42,360 --> 00:13:47,160
So it's like, you know, rest, 
ice compression, elevation, but 

283
00:13:47,160 --> 00:13:51,200
the newest demonic that's been 
utilized in the research. 

284
00:13:51,200 --> 00:13:52,560
And I have a couple notes up 
here. 

285
00:13:52,560 --> 00:13:56,000
So sorry if I refer to them down
here, but it's peace and love. 

286
00:13:56,000 --> 00:13:57,280
So Matt, I don't know if you 
knew. 

287
00:13:57,360 --> 00:13:58,560
I like that I had a piece of 
love. 

288
00:13:58,560 --> 00:14:01,640
Before so this is what this is, 
what peace and love stands for. 

289
00:14:01,640 --> 00:14:04,560
So the P is for protection, so 
it's avoiding activities that 

290
00:14:04,560 --> 00:14:06,480
increase. 
The pain during those first 

291
00:14:06,480 --> 00:14:09,440
couple days to the site 
elevation still stands. 

292
00:14:09,440 --> 00:14:13,480
That's a good way to manage pain
and allowing blood flow, it can 

293
00:14:13,480 --> 00:14:16,360
help with that, avoid anti 
inflammatories. 

294
00:14:16,360 --> 00:14:20,360
So this is a big one. 
Early after an injury, the 

295
00:14:20,360 --> 00:14:22,680
inflammatory phase as Matt said 
is a good thing. 

296
00:14:22,680 --> 00:14:27,040
We want anti inflammation or we 
want inflammation to come to 

297
00:14:27,040 --> 00:14:30,960
help with this healing process. 
So if you are taking anti 

298
00:14:30,960 --> 00:14:33,920
inflammatories like higher doses
of ibuprofen. 

299
00:14:34,680 --> 00:14:38,080
That can hinder your ability to 
go through this inflammatory 

300
00:14:38,080 --> 00:14:39,680
phase. 
It's a necessary part of 

301
00:14:39,680 --> 00:14:42,640
healing. 
Swelling isn't necessarily a bad

302
00:14:42,720 --> 00:14:45,880
thing, so it's actually 
recommended to avoid anti 

303
00:14:45,880 --> 00:14:48,600
inflammatories early on after 
you're an injury because it can 

304
00:14:48,600 --> 00:14:51,160
actually impede the healing. 
So we have protection, 

305
00:14:51,160 --> 00:14:52,960
elevation, avoid anti 
inflammatories. 

306
00:14:52,960 --> 00:14:55,520
Compression still can be good 
for managing some of the 

307
00:14:55,520 --> 00:14:59,360
swelling that can lead to that 
discomfort without decreasing 

308
00:14:59,360 --> 00:15:03,560
the inflammatory markers, right?
And then education, so helping 

309
00:15:04,080 --> 00:15:07,080
the so from APT perspective or 
from your own perspective 

310
00:15:07,120 --> 00:15:10,560
helping yourself understand the 
source of what's going on so you

311
00:15:10,560 --> 00:15:12,680
can be confident in it and then 
love. 

312
00:15:12,680 --> 00:15:16,760
So LOVEL is for load. 
So let pain guide you but try to

313
00:15:16,760 --> 00:15:20,040
load the tissue as much as you 
can unless of course it's a 

314
00:15:20,040 --> 00:15:22,080
fracture of some kind. 
You won't want to be loading 

315
00:15:22,080 --> 00:15:25,480
that which that's part of load 
is you may need to remove some 

316
00:15:25,480 --> 00:15:27,560
load and and change the amount 
of activity. 

317
00:15:27,760 --> 00:15:31,600
O is for optimism, the amount of
connection between how we. 

318
00:15:31,680 --> 00:15:35,920
Approach our new injury and how 
we go through recovery in this 

319
00:15:35,920 --> 00:15:39,200
early phase matters. 
And so having a positive outlook

320
00:15:39,200 --> 00:15:43,600
on this and confident that it is
going to heal makes a very real 

321
00:15:43,600 --> 00:15:45,880
difference. 
V is vascularization. 

322
00:15:45,880 --> 00:15:48,360
So you want to do things to 
promote blood flow. 

323
00:15:48,360 --> 00:15:52,880
So you want to like be active 
and do some sort of aerobic 

324
00:15:52,880 --> 00:15:57,760
activity as long as it's not 
again leading to irritation 

325
00:15:57,800 --> 00:16:01,640
going back to the P for. 
The protection on that first one

326
00:16:01,640 --> 00:16:05,000
there and then E is exercise. 
And so those would be exercises 

327
00:16:05,000 --> 00:16:07,840
specific to the thing, restoring
mobility, restoring strength 

328
00:16:08,040 --> 00:16:10,000
that are appropriate based on 
everything above. 

329
00:16:10,000 --> 00:16:12,640
So that's peace and love. 
I find that a really helpful 

330
00:16:12,640 --> 00:16:14,840
mnemonic. 
It's a lot more than just rice, 

331
00:16:14,840 --> 00:16:18,760
a little bit more nuanced, and 
it takes into account a lot more

332
00:16:18,840 --> 00:16:20,680
of what you're going on. 
So peace and love during the 

333
00:16:20,680 --> 00:16:22,600
inflammatory phase. 
Of healing, yeah. 

334
00:16:22,800 --> 00:16:25,560
Just just to clarify on RICE and
no rest, ice, compression, 

335
00:16:25,560 --> 00:16:28,600
elevation, the individual that 
came out with that, not was it 

336
00:16:28,600 --> 00:16:30,920
not too long ago actually that 
came out and said like please 

337
00:16:30,920 --> 00:16:33,040
don't use this. 
We have learned so much more. 

338
00:16:33,640 --> 00:16:36,720
I will say I am not a physician,
so please take what I'm about 

339
00:16:36,720 --> 00:16:40,080
ready to say with a grain of 
salt that there are some 

340
00:16:40,080 --> 00:16:43,800
instances that if you cannot, if
your inflammatory response is so

341
00:16:43,800 --> 00:16:46,880
bad that you cannot sleep, you 
may want to consider talking 

342
00:16:46,880 --> 00:16:48,760
with someone that can prescribe 
medications. 

343
00:16:48,760 --> 00:16:51,920
In that case, a physician can 
help figure out, you know, 

344
00:16:51,920 --> 00:16:53,840
because sleep. 
If you can't sleep, then you're 

345
00:16:53,840 --> 00:16:57,440
definitely not going to heal. 
Sometimes it can be worth it if 

346
00:16:57,440 --> 00:16:59,560
it means getting things down 
enough that you could so you can

347
00:16:59,560 --> 00:17:01,560
sleep. 
But that's a conversation with 

348
00:17:01,560 --> 00:17:04,160
someone who's going to prescribe
medications. 

349
00:17:04,160 --> 00:17:07,200
But generally, you typically 
want to avoid those because, 

350
00:17:07,520 --> 00:17:09,800
yeah, inflammation is actually a
good thing. 

351
00:17:09,800 --> 00:17:12,440
It's a natural response. 
And this is not just like you're

352
00:17:12,680 --> 00:17:14,440
oh, all natural. 
It's like, yeah, we actually 

353
00:17:14,440 --> 00:17:18,440
have great evidence that it if 
you overdo the NSAIDs, it can 

354
00:17:18,720 --> 00:17:20,160
really delay your healing. 
So. 

355
00:17:20,160 --> 00:17:22,119
Right. 
This first phase is really, 

356
00:17:22,119 --> 00:17:25,040
really important. 
It doesn't mean don't move at 

357
00:17:25,040 --> 00:17:26,640
all. 
It means you're going to need to

358
00:17:26,640 --> 00:17:29,760
modify things appropriately and 
let this tissue heal. 

359
00:17:31,200 --> 00:17:32,960
Absolutely. 
So that's phase one. 

360
00:17:33,200 --> 00:17:36,240
That's phase one. 
And these can be spread out into

361
00:17:36,240 --> 00:17:37,800
a bunch of other things, but 
these are kind of the general 

362
00:17:37,800 --> 00:17:40,880
ones we'll teach individuals and
especially UPT students. 

363
00:17:41,240 --> 00:17:43,760
So the second phase is the 
subacute phase. 

364
00:17:43,760 --> 00:17:48,480
This can start anywhere from 
like four to seven days up to 21

365
00:17:48,480 --> 00:17:51,400
days afterwards, assuming you 
let your the tissue heal enough 

366
00:17:51,400 --> 00:17:54,000
to actually get here. 
Very strong assumption there 

367
00:17:54,000 --> 00:17:56,360
because you can stay in the 
early phase of keep irritating 

368
00:17:56,360 --> 00:17:58,360
it. 
But what happens is once the 

369
00:17:58,360 --> 00:18:01,520
inflammatory response has calmed
down, now that your body has 

370
00:18:01,520 --> 00:18:03,840
cleaned everything up, now we 
can start putting the 

371
00:18:03,840 --> 00:18:06,120
scaffolding in to start 
repairing this stuff. 

372
00:18:06,120 --> 00:18:08,360
So on a cellular level, it's 
going all right. 

373
00:18:08,360 --> 00:18:11,600
So we've cleaned everything up. 
Now we can start the building 

374
00:18:11,600 --> 00:18:13,520
process. 
And part of the building process

375
00:18:13,520 --> 00:18:17,320
is once you get material down, 
you do need to appropriately 

376
00:18:17,320 --> 00:18:20,720
move and load it to help 
facilitate some of the building 

377
00:18:20,720 --> 00:18:23,440
and strengthening. 
You can't do too much because 

378
00:18:23,440 --> 00:18:25,480
you can very much. 
If you do too much you will 

379
00:18:25,480 --> 00:18:27,320
break stuff down and send 
yourself self back. 

380
00:18:27,320 --> 00:18:30,360
As Nathan mentioned you can't 
have a flare up again because 

381
00:18:30,360 --> 00:18:33,920
now the tissue is a little bit 
vulnerable, but you you do still

382
00:18:33,920 --> 00:18:37,080
need to load it appropriately. 
Things like you know for the 

383
00:18:37,080 --> 00:18:39,160
physical therapist and and the 
healthcare providers out there, 

384
00:18:39,560 --> 00:18:43,440
isometrics, maybe introducing a 
little bit of tissue mobility 

385
00:18:43,440 --> 00:18:45,280
and stretching because 
stretching can be fairly 

386
00:18:45,280 --> 00:18:48,080
aggressive. 
Like things that just begin to 

387
00:18:48,080 --> 00:18:50,600
load this stuff and really start
to push a little bit more. 

388
00:18:50,840 --> 00:18:53,080
This is where you can do this. 
But again, you have to be very 

389
00:18:53,080 --> 00:18:56,360
careful not to overdo it and 
send yourself back. 

390
00:18:56,400 --> 00:18:59,880
So this is now the this is the 
sub acute phase. 

391
00:19:00,120 --> 00:19:02,880
Now you can start pushing this. 
My brain is I'm having a brain 

392
00:19:02,880 --> 00:19:05,640
fart on the other official term 
for this. 

393
00:19:05,640 --> 00:19:07,480
Proliferative. 
The Proliferative Sage. 

394
00:19:07,520 --> 00:19:10,480
Thank you. 
Yeah, I have nothing to add for 

395
00:19:10,480 --> 00:19:11,720
that one. 
It's basically, yeah, you're 

396
00:19:11,720 --> 00:19:13,440
actually, you're actually laying
stuff down. 

397
00:19:13,480 --> 00:19:16,560
You know the first phase is like
let's try to send all of these 

398
00:19:16,560 --> 00:19:18,200
healing factors. 
Now it's like, hey, let's put 

399
00:19:18,200 --> 00:19:20,200
down the building blocks to get 
you back. 

400
00:19:20,200 --> 00:19:23,000
So and I think, I do think 
loading is important there. 

401
00:19:23,000 --> 00:19:24,120
Maybe I do have something to 
say. 

402
00:19:26,120 --> 00:19:29,200
You know, loading it is 
important there because as it's 

403
00:19:29,200 --> 00:19:32,040
laying down, you have to tell it
what is it supposed to lay down.

404
00:19:32,360 --> 00:19:35,520
So if you are just doing 
complete bed rest, the cells 

405
00:19:35,520 --> 00:19:38,560
that are laying things down have
to guess about the orientation 

406
00:19:38,560 --> 00:19:41,200
to construct its matrix, all 
this kind of stuff. 

407
00:19:41,360 --> 00:19:44,400
So if you're putting the 
appropriate direction of load 

408
00:19:44,400 --> 00:19:46,680
through the tissue. 
This is particularly true for 

409
00:19:46,680 --> 00:19:49,280
like tendons. 
That's gonna help with this 

410
00:19:49,280 --> 00:19:53,280
healing phase so that it it does
its proliferative act, meaning 

411
00:19:53,280 --> 00:19:55,560
the laying down of all whatever 
the building block is for the 

412
00:19:55,560 --> 00:19:57,880
particular tissue. 
It's gonna be done in the right 

413
00:19:58,240 --> 00:20:00,760
direction and in the in the best
way. 

414
00:20:01,400 --> 00:20:02,880
All right, let's go to phase 
three. 

415
00:20:02,880 --> 00:20:04,840
Yeah. 
No, I got to say exit first 

416
00:20:04,840 --> 00:20:09,320
exercise has a major impact on 
cellular proliferation and 

417
00:20:09,320 --> 00:20:11,520
organization. 
So if you think, oh, I'm just 

418
00:20:11,520 --> 00:20:14,120
doing these dumb exercises like 
you really need to be doing 

419
00:20:14,120 --> 00:20:16,440
things that are specific to 
helping the tissue figure out 

420
00:20:16,440 --> 00:20:19,640
like how does it grow, what's 
the orientation as your body 

421
00:20:19,640 --> 00:20:22,960
starts laying the fibers down. 
Like it has a cellular impact. 

422
00:20:23,320 --> 00:20:24,960
What you do has a cellular 
impact. 

423
00:20:24,960 --> 00:20:28,600
So please be aware of that of 
don't rest it completely, but 

424
00:20:28,600 --> 00:20:31,400
you do need to load it enough 
that it does this but not too 

425
00:20:31,400 --> 00:20:33,880
much. 
It's like that middle ground. 

426
00:20:33,880 --> 00:20:36,920
All right. 
On to the supposed final phase, 

427
00:20:36,920 --> 00:20:41,360
although final phase actually 
has many other components, but 

428
00:20:41,360 --> 00:20:43,200
this is generally what we were 
taught and organized. 

429
00:20:43,400 --> 00:20:47,280
This is called the maturation 
phase, remodeling phase. 

430
00:20:48,520 --> 00:20:53,720
This is also called in terribly 
by the way, the chronic phase of

431
00:20:53,720 --> 00:20:57,320
healing which totally confuses 
my patients and students who's 

432
00:20:57,320 --> 00:20:59,160
like, wait, is this the chronic 
pain phase? 

433
00:20:59,160 --> 00:21:01,680
Like, no, it's just like the 
final stage. 

434
00:21:02,080 --> 00:21:05,720
So this can be anywhere from 
like 21 ish days to three months

435
00:21:05,760 --> 00:21:09,080
and really beyond this because 
you really shouldn't just stop 

436
00:21:09,080 --> 00:21:10,480
at three months. 
And there's a lot of tissues 

437
00:21:10,480 --> 00:21:13,520
that need you to continually 
build them well beyond that. 

438
00:21:13,840 --> 00:21:16,440
But this is where things are 
actually getting tough enough 

439
00:21:16,440 --> 00:21:19,040
that you need to start pushing 
this stuff to really get this 

440
00:21:19,040 --> 00:21:21,400
tissue to remodel and heal the 
way you want it. 

441
00:21:21,760 --> 00:21:25,480
You still, I mean it's you're 
not may not be ready for all out

442
00:21:25,480 --> 00:21:29,160
110% effort, but you got to 
start pushing a little bit more 

443
00:21:29,320 --> 00:21:31,680
and getting ready for your 
returning to function. 

444
00:21:31,840 --> 00:21:33,480
You should not be going all 
right. 

445
00:21:33,480 --> 00:21:36,040
I'm going to do an all out 
effort at this point like you 

446
00:21:36,040 --> 00:21:39,360
know you're racing or for other 
sports like getting back into a 

447
00:21:39,360 --> 00:21:41,320
game. 
This probably isn't the best 

448
00:21:41,320 --> 00:21:45,240
time, but in terms of returning 
to practice or getting maybe 

449
00:21:45,560 --> 00:21:48,440
depending on you maybe 
initiating some little more 

450
00:21:48,440 --> 00:21:51,680
intense activities Pios, things 
like that. 

451
00:21:52,040 --> 00:21:54,760
This is the phase you do it 
because now the tissue is really

452
00:21:54,760 --> 00:21:57,000
sensitive and you really need to
push it because and it's much 

453
00:21:57,000 --> 00:21:59,120
stronger at this point. 
It's remodeling. 

454
00:21:59,320 --> 00:22:01,040
You're pushing it and it's 
helping mature. 

455
00:22:01,560 --> 00:22:04,920
I think what gets so confusing 
with the transition we're about 

456
00:22:04,920 --> 00:22:08,880
to make is that the you the 
words acute, subacute and 

457
00:22:08,880 --> 00:22:12,640
chronic are used in different 
ways in the stuff we're about to

458
00:22:12,640 --> 00:22:14,680
talk about. 
So just to make sure that we 

459
00:22:14,680 --> 00:22:18,960
contextualize this. 
These phases of healing happen 

460
00:22:18,960 --> 00:22:22,400
with an acute injury, meaning 
you go out and you sprain your 

461
00:22:22,400 --> 00:22:25,360
ankle, or you go and you're 
sprinting and you strain your 

462
00:22:25,360 --> 00:22:27,760
hamstring. 
These are the phases of healing 

463
00:22:27,760 --> 00:22:30,280
that an acute injury is going to
go through. 

464
00:22:30,840 --> 00:22:33,560
The these phrases of acute, 
subcruit, chronic are going to 

465
00:22:33,560 --> 00:22:36,640
come back when we talk about 
tissue specific healing time 

466
00:22:36,640 --> 00:22:39,960
frames, but they're referring to
the duration in which that these

467
00:22:39,960 --> 00:22:43,040
symptoms have been around and 
the irritability of those 

468
00:22:43,040 --> 00:22:46,520
symptoms not to the timeline 
from the initial injury. 

469
00:22:47,120 --> 00:22:49,840
So I hope that that distinction 
makes sense, but I do think it's

470
00:22:49,840 --> 00:22:53,880
really important what we just 
went through is the you just had

471
00:22:53,880 --> 00:22:56,200
an acute injury. 
Here are the time frames of 

472
00:22:56,200 --> 00:22:59,160
healing that the tissues will go
through in the face of a new 

473
00:22:59,440 --> 00:23:02,560
injury. 
The key there is a new injury 

474
00:23:02,560 --> 00:23:04,560
because a lot of the things that
we experienced, and I will say 

475
00:23:04,560 --> 00:23:07,160
this is someone who studies 
master's runners, a lot of the 

476
00:23:07,160 --> 00:23:11,240
actual injuries we see actually 
have been brewing for a long 

477
00:23:11,240 --> 00:23:13,600
time. 
A great example this 50% of 

478
00:23:13,600 --> 00:23:16,560
runners actually have Achilles 
Hadenopathy and have no idea and

479
00:23:16,880 --> 00:23:19,840
it's not until they actually get
pain and symptoms that they're 

480
00:23:19,840 --> 00:23:22,280
actually aware of it. 
So pain and inflammatory 

481
00:23:22,280 --> 00:23:26,400
response don't always coincide 
with the start of an injury. 

482
00:23:26,400 --> 00:23:28,880
That's what's called an acute on
chronic injury, meaning you've 

483
00:23:28,880 --> 00:23:32,800
had something going on for a 
while and only now has it gotten

484
00:23:32,800 --> 00:23:36,720
irritated and these timelines 
really change with that. 

485
00:23:37,200 --> 00:23:41,000
So that's why again, the concept
of maybe we need to start 

486
00:23:41,000 --> 00:23:43,960
thinking about a criterion 
bridge approach of you need to 

487
00:23:43,960 --> 00:23:48,680
be able to do XY and Z to prove 
you're out of this phase. 

488
00:23:48,960 --> 00:23:51,840
Maybe more important than hey, 
it's been 3 days or it's been 

489
00:23:51,840 --> 00:23:54,080
this many now you can start 
loading this and people go, 

490
00:23:54,360 --> 00:23:55,960
well, I just did that. 
Now I'm hurt again. 

491
00:23:55,960 --> 00:23:58,320
Like I don't understand. 
It's like, well, that's because 

492
00:23:58,320 --> 00:24:00,720
there's a lot more to it and 
trying to figure out. 

493
00:24:01,000 --> 00:24:03,280
I mean, there's some subjective 
stuff you can do to figure out, 

494
00:24:03,280 --> 00:24:06,800
but sometimes things don't 
behave this way because it's a 

495
00:24:06,920 --> 00:24:09,360
it's a different timeline. 
And that's why the Criterion 

496
00:24:09,360 --> 00:24:12,480
based stuff's potentially more 
helpful, or at least not more 

497
00:24:12,480 --> 00:24:14,560
helpful, but a good idea to 
think about. 

498
00:24:14,880 --> 00:24:17,680
OK, well, let's start to make 
this transition into talking 

499
00:24:17,680 --> 00:24:19,840
about tissue specific healing 
time frames. 

500
00:24:19,920 --> 00:24:24,200
So I think that the main ones 
that we in terms of talking 

501
00:24:24,200 --> 00:24:27,240
about running will go through in
this episode are the healing 

502
00:24:27,240 --> 00:24:31,800
time frames for different. 
Grades of muscle tears or 

503
00:24:31,800 --> 00:24:34,360
strains. 
We'll talk about tendon and 

504
00:24:34,360 --> 00:24:37,960
we'll also talk about bone for 
sure and maybe a little bit of 

505
00:24:37,960 --> 00:24:41,120
ligament. 
Ligamentous injuries are usually

506
00:24:41,120 --> 00:24:44,600
not caused by running. 
Usually there maybe you did 

507
00:24:44,600 --> 00:24:47,200
something else, but then if you 
are a runner, you have to think 

508
00:24:47,200 --> 00:24:48,440
about when can I return to 
running. 

509
00:24:48,440 --> 00:24:52,000
So we can talk about that, but 
we're going to start with muscle

510
00:24:52,120 --> 00:24:54,680
and work our way through. 
So Matt, if you want to talk us 

511
00:24:54,680 --> 00:24:57,800
through kind of how long it 
takes a muscle to heal. 

512
00:24:59,040 --> 00:25:00,680
What sort of thoughts do you 
have for us there? 

513
00:25:00,840 --> 00:25:03,720
Yeah, that's a great question. 
And what we're not going to dive

514
00:25:03,720 --> 00:25:06,680
into the deep Physiology of 
this, but just know that a 

515
00:25:06,680 --> 00:25:10,240
muscle damage, usually called a 
muscle strain, there's usually 

516
00:25:10,240 --> 00:25:12,560
the delayed onset muscle 
soreness that people know of and

517
00:25:12,560 --> 00:25:14,200
that is actually tactically 
muscle damage. 

518
00:25:14,200 --> 00:25:16,880
You have done exercise and 
created damage and your body 

519
00:25:16,880 --> 00:25:18,360
needs to recover from that to 
heal. 

520
00:25:18,360 --> 00:25:20,880
That's why we suggest if you've 
listened to other training 

521
00:25:20,880 --> 00:25:24,440
episodes, you shouldn't be 
hammering runs every single day.

522
00:25:24,600 --> 00:25:27,280
If your body sore, it's trying 
to tell you something it's it 

523
00:25:27,280 --> 00:25:29,480
needs a chance to recover. 
Adapt to what you did. 

524
00:25:29,480 --> 00:25:31,680
So that takes a couple days. 
That's normal. 

525
00:25:31,680 --> 00:25:34,000
That's why you shouldn't train 
really hard every single day. 

526
00:25:34,000 --> 00:25:36,200
The hard, easy model works a lot
better. 

527
00:25:36,520 --> 00:25:39,720
But then we actually get to the 
to the point where you've 

528
00:25:39,720 --> 00:25:43,240
actually caused some significant
damage where it's like, OK now 

529
00:25:43,240 --> 00:25:46,600
it's not just, I'm sorry, it's 
this really hurts like I heard 

530
00:25:46,840 --> 00:25:50,000
something like something kind of
like I felt something snapper, 

531
00:25:50,160 --> 00:25:52,360
like like shooting something 
like that. 

532
00:25:52,360 --> 00:25:55,320
I'm sorry I'm shaking the table 
for those watching on YouTube. 

533
00:25:55,440 --> 00:25:56,760
You need to get my elbows off 
there. 

534
00:25:57,360 --> 00:26:01,560
A grade one is kind of the 
lowest level of a muscle strain 

535
00:26:01,560 --> 00:26:04,680
and that can take anywhere from 
a couple days up to a couple 

536
00:26:04,680 --> 00:26:08,160
like 5 to 6 weeks and sometimes 
a little bit longer to truly 

537
00:26:08,160 --> 00:26:10,200
recover from that. 
And that's the the the first 

538
00:26:10,200 --> 00:26:13,800
level, like you push the muscle 
really beyond its capacity in 

539
00:26:13,800 --> 00:26:16,360
that moment, not just, oh, you 
worked it, now it's sore. 

540
00:26:16,640 --> 00:26:19,880
So that can take up to a couple 
weeks to really recover from. 

541
00:26:20,640 --> 00:26:23,880
Grade 2 is now you're doing a 
significant amount of damage 

542
00:26:23,880 --> 00:26:25,720
there. 
You've got real like ruptures in

543
00:26:25,720 --> 00:26:27,280
the muscle. 
You may have definitely heard a 

544
00:26:27,280 --> 00:26:30,480
pop and things like that, like 
within the muscle belly and you 

545
00:26:30,480 --> 00:26:32,880
might be having a hard time 
walking on this and definitely 

546
00:26:32,880 --> 00:26:36,600
producing force is difficult. 
That can take at minimum not a 

547
00:26:36,600 --> 00:26:40,200
couple days, three to four weeks
up to sometimes several months 

548
00:26:40,200 --> 00:26:42,920
like three to six months at 
times for that kind of thing to 

549
00:26:42,920 --> 00:26:44,600
heal because the body is not 
just going to do some 

550
00:26:44,600 --> 00:26:48,280
microscopic stuff. 
It's now got a macroscopic large

551
00:26:48,280 --> 00:26:50,200
tear. 
It's got to heal and that's 

552
00:26:50,200 --> 00:26:52,320
something or you go hey I might 
need to think about rehab and 

553
00:26:52,320 --> 00:26:55,040
definitely activity modification
not hey I gotta wait a week or 

554
00:26:55,040 --> 00:26:58,280
two it this might take some a 
little more serious stuff and 

555
00:26:58,280 --> 00:27:01,320
then we have grade 3 which is 
you have really ripped the 

556
00:27:01,320 --> 00:27:03,040
muscle. 
You might even be able to see it

557
00:27:03,240 --> 00:27:05,280
actually within that these are 
not fun. 

558
00:27:05,280 --> 00:27:08,800
I've seen a couple of these on 
field doing sports BT and the 

559
00:27:08,800 --> 00:27:11,680
first one I saw actually passed 
out so I was completely useless 

560
00:27:12,360 --> 00:27:15,240
as I saw a big yeah it was. 
I did not know that story. 

561
00:27:15,240 --> 00:27:17,880
Yeah, so I have a tendon rupture
story that'll tell. 

562
00:27:17,880 --> 00:27:22,880
And the muscle one where I saw 
somebody'd hamstring tear and 

563
00:27:23,120 --> 00:27:26,120
both passed out like I saw it, 
saw the the bruising 

564
00:27:26,120 --> 00:27:27,240
immediately. 
That happens. 

565
00:27:27,240 --> 00:27:29,200
It's really classic with an. 
Answer passed out. 

566
00:27:29,760 --> 00:27:31,040
Yeah, I did. 
You did. 

567
00:27:31,040 --> 00:27:36,560
So I was AI was a resident and I
was with our PTA TS over at 

568
00:27:36,560 --> 00:27:39,360
Claremont Pomona, one of the 
track meets and we saw a 

569
00:27:39,360 --> 00:27:43,240
sprinter tear her hamstring and 
we went over and like you could 

570
00:27:43,280 --> 00:27:47,440
actually see in the biceps 
femoris like in the muscle belly

571
00:27:47,440 --> 00:27:49,880
there was a clear like tear 
there and you could see it 

572
00:27:49,880 --> 00:27:53,120
through the skin and it was 
immediately bruising and I was 

573
00:27:53,120 --> 00:27:55,880
assisting anyway. 
But I kind of saw that step back

574
00:27:55,880 --> 00:28:00,680
and then fell backwards on the 
field much better now after 

575
00:28:00,680 --> 00:28:03,400
doing that a couple times. 
But I was like and it was also 

576
00:28:03,400 --> 00:28:06,640
looking at this poor girl's face
like she saw it and knew it was 

577
00:28:06,640 --> 00:28:08,400
going on, it was it was pretty 
bad. 

578
00:28:08,760 --> 00:28:11,840
So those definitely, you 
definitely need rehab. 

579
00:28:12,040 --> 00:28:14,160
In certain cases there is a 
potential that you might 

580
00:28:14,160 --> 00:28:16,160
actually need surgery to repair 
that stuff. 

581
00:28:16,320 --> 00:28:19,040
Not to freak you out, but that's
definitely going to take 6 to 8 

582
00:28:19,040 --> 00:28:23,520
weeks up to like 6 to 12 months 
for this to really heal and 

583
00:28:23,520 --> 00:28:25,920
really get through that. 
So that is a serious muscle 

584
00:28:25,920 --> 00:28:28,160
injury. 
So you can tell I'm starting to 

585
00:28:28,160 --> 00:28:29,760
go, we're starting to go up to 6
to 12 months. 

586
00:28:29,760 --> 00:28:32,760
That's kind of expanded beyond 
that like 21 day to three month 

587
00:28:32,760 --> 00:28:36,240
things that these depending on 
the type of injury, the tissue 

588
00:28:36,240 --> 00:28:39,640
healing phases are going to 
dramatically change and that's 

589
00:28:39,640 --> 00:28:43,000
just for muscle. 
I missed anything on that. 

590
00:28:43,000 --> 00:28:45,760
No, I think that's good. 
I think just keep it in mind 

591
00:28:45,760 --> 00:28:49,720
that you know these specific 
grades are a continuum, you know

592
00:28:49,720 --> 00:28:53,640
they're this we've we've created
these numbers to try to really 

593
00:28:53,640 --> 00:28:57,440
quantify a spectrum that has 
very incremental things. 

594
00:28:57,440 --> 00:29:01,400
But in general, you know a grade
one strain you're not going to 

595
00:29:01,400 --> 00:29:04,120
see a whole lot of bruising. 
You might You might just feel 

596
00:29:04,120 --> 00:29:06,160
like I just felt it kind of 
pulling on me. 

597
00:29:06,160 --> 00:29:08,000
It felt now it feels really 
tight. 

598
00:29:09,200 --> 00:29:11,800
And so that's going to be where 
you have that, you know anywhere

599
00:29:11,800 --> 00:29:14,240
from very quick where it might 
resolve really fast. 

600
00:29:14,400 --> 00:29:17,360
Someone who has a grade one 
might just be, it might be very 

601
00:29:17,360 --> 00:29:20,080
small couple, couple muscle 
fibrils involved or something 

602
00:29:20,080 --> 00:29:21,880
like that. 
But then some people it's going 

603
00:29:21,880 --> 00:29:24,240
to take them multiple weeks to 
try to come back. 

604
00:29:24,560 --> 00:29:27,040
Today is a Sunday. 
The Packers just. 

605
00:29:28,160 --> 00:29:32,200
Lost again, which is fine, but 
you know, I don't know what 

606
00:29:32,200 --> 00:29:34,880
happened to Christian Watson, 
but he's been battling A 

607
00:29:34,880 --> 00:29:37,800
hamstring thing and he kind of 
pulled up again. 

608
00:29:38,040 --> 00:29:39,280
But I don't know if he tweaked 
his sneaks. 

609
00:29:39,280 --> 00:29:40,920
He went down. 
Odd, but it was. 

610
00:29:40,960 --> 00:29:43,480
Wouldn't be surprising because 
it can take, you know, a very 

611
00:29:43,480 --> 00:29:46,160
long time for these, you know, 
muscle strains to come back 

612
00:29:46,320 --> 00:29:49,920
grade 2, if you are seeing some 
level of bruising in the area of

613
00:29:49,920 --> 00:29:52,560
the muscle, it's likely that 
you're beyond kind of this grade

614
00:29:52,560 --> 00:29:54,720
one type strain and you're into 
this grade 2. 

615
00:29:54,720 --> 00:29:57,760
So you can kind of push yourself
into the like month plus 

616
00:29:57,760 --> 00:30:00,440
category, which again that's a 
long time. 

617
00:30:00,440 --> 00:30:02,920
That doesn't mean you can't do 
activity, it's just you have to 

618
00:30:02,920 --> 00:30:07,400
modify based on the symptoms. 
And then it yes, you've you hit 

619
00:30:07,600 --> 00:30:09,680
the the phase through the the 
grade threes are going to be a 

620
00:30:09,680 --> 00:30:11,360
bit more obvious. 
They might be visual. 

621
00:30:11,480 --> 00:30:14,520
They will definitely have tons 
of that bruising that you see 

622
00:30:14,520 --> 00:30:17,960
immediately. 
But and I I will say though, 

623
00:30:17,960 --> 00:30:20,560
sometimes bruising doesn't show 
up for a day or so. 

624
00:30:20,560 --> 00:30:23,880
If you've had like a deep, a 
deep strain you might feel it, 

625
00:30:23,880 --> 00:30:25,960
but no bruising. 
Then maybe a day or two later it

626
00:30:25,960 --> 00:30:28,600
works its way to the surface and
it kind of pops out at you. 

627
00:30:28,720 --> 00:30:32,800
So just keeping that in mind, 
yeah, the the immediate ones are

628
00:30:32,800 --> 00:30:35,120
kind of scary. 
Yeah, yeah. 

629
00:30:35,200 --> 00:30:36,440
You know something's going on 
there. 

630
00:30:36,480 --> 00:30:39,080
Yeah, you're. 
Like I think the next 

631
00:30:39,080 --> 00:30:41,000
interesting one is, oh, do you 
have something else for muscle 

632
00:30:41,000 --> 00:30:43,520
before we move forward? 
No, I thought we're, we're going

633
00:30:43,520 --> 00:30:44,640
to move forward to tendon, 
right? 

634
00:30:44,840 --> 00:30:46,280
Yes. 
Yeah, yeah, yeah. 

635
00:30:46,280 --> 00:30:47,600
Do you? 
Go ahead, take it away. 

636
00:30:47,600 --> 00:30:49,040
No, you you take it. 
It's. 

637
00:30:49,200 --> 00:30:51,960
Fine. 
OK, so with tendons, I think 

638
00:30:51,960 --> 00:30:55,720
that this is actually a pretty 
interesting one because as Matt 

639
00:30:55,720 --> 00:30:58,960
said, there are so many of us 
who are walking around with what

640
00:30:59,160 --> 00:31:02,360
with. 
Per an ultrasound image or an 

641
00:31:02,360 --> 00:31:05,400
MRI would tell us that we have a
tendinopathy, meaning an 

642
00:31:05,400 --> 00:31:08,200
unhealthy tendon based on the 
cellular matrix. 

643
00:31:08,480 --> 00:31:10,760
But we have no idea because it's
not symptomatic. 

644
00:31:10,880 --> 00:31:14,600
So I think this is where it gets
a little bit interesting when it

645
00:31:14,600 --> 00:31:17,680
comes to the healing time frame 
that we talked about generally 

646
00:31:18,120 --> 00:31:22,440
and if you have, but if you have
an acute strain of. 

647
00:31:23,200 --> 00:31:26,360
A tendon that could take 
anywhere from three weeks to go 

648
00:31:26,360 --> 00:31:29,480
through its healing time frame. 
So if you've really irritated 

649
00:31:29,480 --> 00:31:32,320
your post tip tendon, or your 
peroneal tendon, or your 

650
00:31:32,320 --> 00:31:35,320
Achilles tendon, it can honestly
take three weeks before it's 

651
00:31:35,320 --> 00:31:37,520
even on a good track. 
And it can still go up to a 

652
00:31:37,520 --> 00:31:39,640
couple months, even the 
smallest. 

653
00:31:40,520 --> 00:31:45,720
Level of strain to a tendon can 
take that long, mainly because 

654
00:31:45,720 --> 00:31:49,440
they're the main transducer of 
force from the muscle to the 

655
00:31:49,560 --> 00:31:52,880
bone and so they are always 
going to be active. 

656
00:31:53,400 --> 00:31:56,800
If you go a little bit more 
subacute again, and this is not 

657
00:31:56,800 --> 00:32:00,440
so much the the degree at which 
it's torn, but also the duration

658
00:32:00,440 --> 00:32:03,120
in which it's been around. 
It can take anywhere from two 

659
00:32:03,120 --> 00:32:06,200
months all the way up to six 
months to a year. 

660
00:32:06,400 --> 00:32:08,720
So think of how big that 
spectrum is. 

661
00:32:09,280 --> 00:32:11,040
It's because everyone responds 
differently. 

662
00:32:11,040 --> 00:32:13,920
We haven't been able to nail 
down how to fix these things 

663
00:32:13,920 --> 00:32:16,560
based on these categories and 
then chronic ones can take. 

664
00:32:17,040 --> 00:32:19,520
I think ultimately the message 
to take if you've had a chronic 

665
00:32:19,520 --> 00:32:22,400
tendinopathy, these are things 
that can last more than a year 

666
00:32:22,600 --> 00:32:24,240
and it can take a really long 
time. 

667
00:32:25,560 --> 00:32:29,920
And go ahead, Matt and Dave and 
I have both talked about this 

668
00:32:29,920 --> 00:32:32,640
with tendons and something that 
I tell any of my masters runners

669
00:32:32,640 --> 00:32:36,280
or anybody that's had like a 
tendinopathy before you went 

670
00:32:36,720 --> 00:32:41,720
your pain and your is going to 
go away long before the tendons 

671
00:32:41,720 --> 00:32:44,600
actually healed. 
So when we tell people, hey, I 

672
00:32:44,600 --> 00:32:46,960
love to give like one or two 
exercises and just say, hey, 

673
00:32:46,960 --> 00:32:50,880
you're going to do these three 
times a week for at least nine 

674
00:32:50,880 --> 00:32:52,880
months, if not the rest of your 
life. 

675
00:32:52,880 --> 00:32:54,560
Not that your tendons going to 
take the rest of your life to 

676
00:32:54,560 --> 00:32:57,560
heal. 
It just takes tendons a long 

677
00:32:57,720 --> 00:33:00,640
time to remodel. 
They don't get the same blood 

678
00:33:00,640 --> 00:33:02,200
flow. 
They don't respond the same way 

679
00:33:02,200 --> 00:33:04,560
that muscles do, and so it takes
a lot longer. 

680
00:33:04,560 --> 00:33:07,040
It's not that you can't do it, 
you just got to invest a lot 

681
00:33:07,040 --> 00:33:10,000
more time in them. 
It's worth it because tendons 

682
00:33:10,000 --> 00:33:12,200
are super important, especially 
in running. 

683
00:33:12,800 --> 00:33:15,000
There's some very cool 
literature that's come out 

684
00:33:15,000 --> 00:33:17,320
recently that's blowing my mind 
about muscle tendon 

685
00:33:17,680 --> 00:33:20,560
interactions. 
But you really got to make sure 

686
00:33:20,560 --> 00:33:23,480
you load those things for a long
time because they're just slow. 

687
00:33:23,640 --> 00:33:25,120
They're like, I'm going to take 
my time. 

688
00:33:25,120 --> 00:33:27,560
I'm just going to hang out here 
and then if you push them too 

689
00:33:27,560 --> 00:33:30,360
fast to get pissed off and can 
get inflamed again, so it's like

690
00:33:30,440 --> 00:33:32,680
they're kind of annoying. 
But they're really helpful. 

691
00:33:32,680 --> 00:33:36,320
Tendons are, I would say tendons
are the most naggy of all of the

692
00:33:36,320 --> 00:33:38,760
injuries. 
They just they stick around and 

693
00:33:38,760 --> 00:33:40,800
it shows based on the healing 
time frame. 

694
00:33:40,800 --> 00:33:44,160
So it makes sense, which 
sometimes for runners or for 

695
00:33:44,160 --> 00:33:47,480
whoever's healing from some kind
of an injury, that's helpful. 

696
00:33:47,480 --> 00:33:50,120
Just to know that this is 
normal, that these take this 

697
00:33:50,120 --> 00:33:52,040
long. 
I do think part of the reason 

698
00:33:52,040 --> 00:33:56,200
they take long, especially for 
runners, is the nature in which 

699
00:33:56,200 --> 00:33:57,840
tendons work. 
And you kind of just started 

700
00:33:57,840 --> 00:33:59,800
referencing this, but I went to 
a conference. 

701
00:33:59,800 --> 00:34:01,640
Oh, it was like two or three 
years ago now, but. 

702
00:34:01,920 --> 00:34:05,640
It was news research on on the 
function of the calf complex 

703
00:34:05,640 --> 00:34:08,760
during running and the thought 
was that as you're running, the 

704
00:34:08,760 --> 00:34:12,159
calf muscles go through this 
eccentric loading and concentric

705
00:34:12,159 --> 00:34:13,679
loading. 
But what they found is that the 

706
00:34:13,679 --> 00:34:16,159
calf muscles, so the gastroc and
ciliates, are actually 

707
00:34:16,159 --> 00:34:19,080
isometric, they hold themselves 
height. 

708
00:34:19,480 --> 00:34:23,800
They just stay in this taut, you
know, position and you're going 

709
00:34:23,800 --> 00:34:26,760
to watch people running like no,
I see their muscle flexing. 

710
00:34:26,760 --> 00:34:28,920
Yes, it's flexing, but it's not 
changing length. 

711
00:34:29,239 --> 00:34:31,239
What it's doing is it's holding 
really still and what's 

712
00:34:31,239 --> 00:34:34,480
happening is the Achilles is 
going through a ton of stretch 

713
00:34:34,480 --> 00:34:38,000
and then recoil over and over. 
So the amount of work that the 

714
00:34:38,000 --> 00:34:42,159
tendons are doing as we're 
running is so, so high. 

715
00:34:42,159 --> 00:34:45,239
They have to go through a ton of
strain and handle a lot of load.

716
00:34:45,480 --> 00:34:49,199
And so imagine just trying to 
return to running on any sort of

717
00:34:49,199 --> 00:34:51,840
tendon injury, you're putting so
much demand through it. 

718
00:34:52,080 --> 00:34:56,040
So I also think. 
Maybe a reason why it's so long 

719
00:34:56,040 --> 00:34:58,760
is because we don't manage the 
load appropriately. 

720
00:34:58,840 --> 00:35:01,400
We don't give it the right 
amount of stimulus, we overwork 

721
00:35:01,400 --> 00:35:04,240
it too quickly and we just 
continue to perpetuate the the 

722
00:35:04,240 --> 00:35:06,760
process and it Part of that's 
because we're learning about 

723
00:35:06,760 --> 00:35:09,120
what it means to prepare a 
tendon for activity. 

724
00:35:09,320 --> 00:35:12,520
So tendons are naggy, they stick
around for a long time. 

725
00:35:13,040 --> 00:35:14,240
It can be. 
It can be tough. 

726
00:35:14,640 --> 00:35:17,040
I'm going to argue that it. 
I think there is a certain 

727
00:35:17,040 --> 00:35:19,400
population that overloads them. 
I think there's also the group 

728
00:35:19,400 --> 00:35:23,000
that under loads them where they
complete rest and tendons are 

729
00:35:23,000 --> 00:35:25,120
super sensitive to complete 
rest. 

730
00:35:25,120 --> 00:35:27,320
In fact, they do not actually do
well unless you've got a 

731
00:35:27,320 --> 00:35:30,880
rupture, like unless you've had 
surgical rupture like if you 

732
00:35:30,880 --> 00:35:34,640
have a tendinopathy and you just
let it rest, it can get worse 

733
00:35:34,880 --> 00:35:37,160
because tendons definitely are 
sense of the load. 

734
00:35:37,160 --> 00:35:39,520
They just take forever to 
respond for it. 

735
00:35:39,520 --> 00:35:42,600
So I think we're not very good 
at knowing how to appropriately 

736
00:35:42,600 --> 00:35:44,000
demote them. 
Yeah. 

737
00:35:44,160 --> 00:35:47,280
And that's kind of key also that
that was my exact thing about 

738
00:35:47,280 --> 00:35:50,080
the, like the the calf complex 
where I learned that part way 

739
00:35:50,080 --> 00:35:53,000
through my PhD. 
And I was like, I felt so stupid

740
00:35:53,000 --> 00:35:56,480
when I I thought, like I thought
I studied running and I have a 

741
00:35:56,480 --> 00:35:59,040
doctorate in physical therapy 
and I'm working on my second one

742
00:35:59,040 --> 00:36:01,320
and I'm like, I didn't know 
that. 

743
00:36:01,760 --> 00:36:03,440
What? 
It's it's new though, right? 

744
00:36:03,440 --> 00:36:05,880
Like yeah, I just. 
I don't know I felt like I felt 

745
00:36:05,880 --> 00:36:07,760
so. 
I mean I'm not judging for the a

746
00:36:07,960 --> 00:36:09,760
lot of audience members are 
probably like, oh I didn't know 

747
00:36:09,760 --> 00:36:12,120
that here I just the amount of 
studied running. 

748
00:36:12,120 --> 00:36:15,200
I was like how? 
And I also think so I think to 

749
00:36:15,200 --> 00:36:18,800
the to to the everyday runner or
even to the competitive runner, 

750
00:36:18,960 --> 00:36:21,400
this realization probably 
doesn't mean a whole lot. 

751
00:36:21,520 --> 00:36:23,920
But I think to our physical 
therapists who are listening, 

752
00:36:23,920 --> 00:36:25,880
who are trying to help people 
rehabilitate. 

753
00:36:26,120 --> 00:36:28,560
I think what it does is it 
emphasizes the importance of 

754
00:36:28,560 --> 00:36:32,880
including plyometric work into 
your and quick bounding work 

755
00:36:32,920 --> 00:36:35,320
into your rehab. 
Because if you're just doing 

756
00:36:35,560 --> 00:36:39,240
eccentric are very yes, yes, 
once you're in this further out 

757
00:36:39,240 --> 00:36:42,400
stage but like the the 
importance of. 

758
00:36:42,840 --> 00:36:46,360
Of eccentric loading and heavy 
loading has shown to be there. 

759
00:36:46,360 --> 00:36:50,240
We know this. 
But to get activity specific 

760
00:36:50,240 --> 00:36:52,680
with it when it comes to 
running, the importance of 

761
00:36:52,680 --> 00:36:55,840
bounding activities during your 
rehab process is going to be 

762
00:36:56,040 --> 00:36:57,800
invaluable. 
You have to include it. 

763
00:36:57,800 --> 00:37:00,520
And I think that that's what 
this realization did for me. 

764
00:37:00,520 --> 00:37:03,600
In my mind was OK, when I'm 
working with somebody who's 

765
00:37:03,600 --> 00:37:06,920
having this going on, we got to,
we got to figure out how to 

766
00:37:06,920 --> 00:37:08,920
incorporate that once we get to 
the point where they can 

767
00:37:08,920 --> 00:37:11,000
tolerate it. 
I think that's a good point. 

768
00:37:11,000 --> 00:37:13,200
We do need to still talk about 
ligament and bone, but I think 

769
00:37:13,200 --> 00:37:18,240
that comment about progression 
of activity for like a criterion

770
00:37:18,240 --> 00:37:21,760
based return to sport is really 
important going oh, there's 

771
00:37:21,760 --> 00:37:24,640
these different things that you 
do need eccentric or heavy slur 

772
00:37:24,640 --> 00:37:27,560
resistance training to build 
stiffness back in the tendon and

773
00:37:27,560 --> 00:37:29,960
the musculoskeletalis unit. 
But then you also have to teach 

774
00:37:29,960 --> 00:37:33,080
it how to do the lengthening and
shortening because it's 

775
00:37:33,280 --> 00:37:35,760
different than a muscle. 
So that's an important thing, 

776
00:37:35,920 --> 00:37:37,160
but we'll talk about that in a 
second. 

777
00:37:38,000 --> 00:37:42,640
I also want to say this about I 
hate to backtrack to muscle but 

778
00:37:42,720 --> 00:37:45,400
I I want to I want to backtrack 
to muscle because I think there 

779
00:37:45,400 --> 00:37:49,640
are a couple muscle related 
injuries or or let me put it 

780
00:37:49,640 --> 00:37:53,520
this way, the muscle that you 
have an injury in May. 

781
00:37:53,920 --> 00:37:56,360
Dictate how long it takes you to
return to running. 

782
00:37:56,360 --> 00:37:59,640
And this is where the Criterion 
based stuff will come in handy 

783
00:37:59,640 --> 00:38:02,160
later. 
But for someone who has a tear 

784
00:38:02,160 --> 00:38:04,800
of their Soleus muscle, it's 
going to be a little bit more 

785
00:38:04,800 --> 00:38:07,840
naggy than someone who has a 
hamstring string to return to 

786
00:38:07,840 --> 00:38:10,920
easy running because of the 
demand and the load that the 

787
00:38:10,920 --> 00:38:13,640
calf carries, regardless of how 
fast you're running in 

788
00:38:13,640 --> 00:38:16,640
comparison to something like the
hamstring or hip flexors or 

789
00:38:16,640 --> 00:38:19,600
something like that. 
So I I think that we're giving 

790
00:38:19,600 --> 00:38:22,840
these time frames, but it does 
matter which tissue, which 

791
00:38:22,840 --> 00:38:25,480
muscles involve. 
Which tendons involved because 

792
00:38:25,480 --> 00:38:28,920
that's when it pertains, 
pertains to return to running 

793
00:38:29,080 --> 00:38:31,880
because it's job when running is
different. 

794
00:38:32,560 --> 00:38:33,920
OK, let's let's keep moving 
forward. 

795
00:38:33,920 --> 00:38:36,120
Let's talk about bone. 
Let's just let's hit bone and 

796
00:38:36,120 --> 00:38:38,640
then and then we'll we'll move 
on to our criteria and stuff. 

797
00:38:38,640 --> 00:38:40,320
So I know I just. 
Talked to Bone? 

798
00:38:40,760 --> 00:38:42,880
No, I think I just talked to 
Rich Willie. 

799
00:38:43,080 --> 00:38:43,920
But. 
All right. 

800
00:38:44,280 --> 00:38:46,520
Yeah, go listen to Rich Willie 
to say it. 

801
00:38:46,720 --> 00:38:48,720
Yeah, exactly. 
So be aware. 

802
00:38:48,720 --> 00:38:53,400
So bone can takes quite a bit of
time and it's not just the 

803
00:38:53,400 --> 00:38:55,920
actual getting through those 
different phases, but it's also 

804
00:38:55,920 --> 00:38:59,920
the fact that that remodeling 
and maturation and are much, 

805
00:39:00,200 --> 00:39:01,920
much longer for bone. 
And there's actually some 

806
00:39:01,920 --> 00:39:05,280
evidence that this stuff can go 
like into multiple years to 

807
00:39:05,280 --> 00:39:08,920
actually heal those who have had
stress fractures and fractures. 

808
00:39:09,720 --> 00:39:13,320
If you jump back into things too
quick, you have a very high risk

809
00:39:13,320 --> 00:39:15,920
of recurrence. 
And so please listen to our talk

810
00:39:15,960 --> 00:39:18,200
with Rich Willie because your 
nutrition is really, really 

811
00:39:18,200 --> 00:39:19,440
important. 
Optimal loading is really 

812
00:39:19,440 --> 00:39:21,680
important because bone also does
respond to load. 

813
00:39:21,840 --> 00:39:24,000
It's very important to 
appropriate load it, but it can 

814
00:39:24,120 --> 00:39:27,760
very easily get overloaded and 
how much stimulus it actually 

815
00:39:27,760 --> 00:39:31,360
takes for the bone to adapt is 
not that much. 

816
00:39:31,360 --> 00:39:33,720
Like it blew my mind to go like,
you know, when you're running, 

817
00:39:33,720 --> 00:39:35,800
only the first few minutes is 
when you actually get bone 

818
00:39:35,800 --> 00:39:37,920
stimulus. 
After that, it's just repetitive

819
00:39:37,920 --> 00:39:42,600
and you can even like overdo it.
So bone healing, typically 

820
00:39:42,600 --> 00:39:46,120
what's said is anywhere from 6 
to 8 weeks up to three to six 

821
00:39:46,120 --> 00:39:50,680
months, if not longer to for 
bone to really, really heal. 

822
00:39:50,680 --> 00:39:53,240
Which is probably why we have a 
really high recurrence rate in 

823
00:39:53,240 --> 00:39:56,240
runners, because people like to 
get back to stuff really quick, 

824
00:39:56,360 --> 00:39:58,160
right? 
I think, I think an important 

825
00:39:58,160 --> 00:40:02,080
part with the bone healing time 
frame too is a lot of the 

826
00:40:02,080 --> 00:40:06,520
research is done regarding like 
full fractures to like 

827
00:40:06,520 --> 00:40:08,920
trabecular bone or whatever. 
Or I may have said the wrong 

828
00:40:08,920 --> 00:40:11,120
thing, but whatever. 
Like to a long bone and having a

829
00:40:11,120 --> 00:40:13,760
fracture and watching the 
healing of that where a stress 

830
00:40:13,760 --> 00:40:16,040
fracture might, might. 
Present a little bit 

831
00:40:16,040 --> 00:40:18,880
differently, but I think the 
minimum you're looking at for a 

832
00:40:18,880 --> 00:40:21,360
fracture of some kind is going 
to be your 6 to 8 weeks. 

833
00:40:21,360 --> 00:40:25,280
And that's assuming that you 
have all of the things needed to

834
00:40:25,280 --> 00:40:28,640
heal well, nutrition, sleep, all
that kind of stuff. 

835
00:40:29,240 --> 00:40:32,120
The other big difference between
like a stress fracture healing 

836
00:40:32,400 --> 00:40:36,640
and a tendon is that the 
recommended pain level for bone 

837
00:40:36,640 --> 00:40:40,480
is 0, whereas the recommended 
pain level that's safe to allow 

838
00:40:40,480 --> 00:40:42,840
healing and tendon might be a 5 
out of 10. 

839
00:40:43,080 --> 00:40:47,080
So depending on what tissue it 
is, you have to change the 

840
00:40:47,080 --> 00:40:51,400
amount of discomfort or pain 
that's allowable during the 

841
00:40:51,400 --> 00:40:54,080
activity. 
So yeah, bone can take a while 

842
00:40:54,080 --> 00:40:56,720
to heal. 
I think returning and I'd say at

843
00:40:56,760 --> 00:40:59,760
a minimum we're looking at six 
weeks of no pain with the 

844
00:40:59,760 --> 00:41:04,800
activity and then slowly finding
a way to come back, whether 

845
00:41:04,800 --> 00:41:07,760
that's through like I have the I
have like the lever system to 

846
00:41:07,760 --> 00:41:10,360
offload a little bit like water 
running. 

847
00:41:10,360 --> 00:41:13,160
There's lots of different ways 
to try to introduce some blown 

848
00:41:13,160 --> 00:41:16,280
to bone without having to go 
full body weight, but we can 

849
00:41:16,280 --> 00:41:20,120
talk about that as we bring in 
the nuance with criterion based 

850
00:41:20,120 --> 00:41:22,720
progression through 
rehabilitation and return to 

851
00:41:22,720 --> 00:41:25,240
running. 
So would you think can you just 

852
00:41:25,240 --> 00:41:29,600
help us again we talked about 
time based return to activities 

853
00:41:29,720 --> 00:41:33,040
based on oh attendance going to 
take three to six months, wait 

854
00:41:33,040 --> 00:41:34,480
till that time and then just go 
do it. 

855
00:41:34,760 --> 00:41:37,600
That doesn't seem to be enough. 
So we want to add in criterion 

856
00:41:37,600 --> 00:41:39,120
based. 
Can you help us understand what 

857
00:41:39,120 --> 00:41:41,960
does it mean to have a criterion
for progression? 

858
00:41:42,200 --> 00:41:44,400
And then how do you 
conceptualize it when it comes 

859
00:41:44,400 --> 00:41:45,560
to rehab? 
Right. 

860
00:41:45,760 --> 00:41:48,440
And I want to encourage people 
that for a lot of these things, 

861
00:41:48,440 --> 00:41:50,920
it's not oh, I have to wait 
until six months when this is 

862
00:41:50,920 --> 00:41:54,880
healed to start this thing, this
is what you do with intolerance 

863
00:41:55,000 --> 00:41:56,400
while you are going through 
this. 

864
00:41:56,400 --> 00:41:59,120
So that doesn't mean, oh, I 
can't run until six months. 

865
00:41:59,120 --> 00:42:01,800
It means, depending on the 
tissue injury, you have things 

866
00:42:01,800 --> 00:42:05,080
you need to be working on to 
prove that you are ready to run 

867
00:42:05,480 --> 00:42:07,640
either by that time or 
beforehand. 

868
00:42:07,640 --> 00:42:10,360
And running can become part of 
your loading program if 

869
00:42:10,360 --> 00:42:12,560
appropriate. 
So don't panic with this. 

870
00:42:13,000 --> 00:42:16,120
So the key is behind this is 
it's not just oh, the tissue's 

871
00:42:16,120 --> 00:42:18,440
healed, you've returned to run. 
There are things that are going 

872
00:42:18,440 --> 00:42:20,520
to happen, right. 
We mentioned in the acute phase 

873
00:42:20,520 --> 00:42:21,920
you have pain and inflammation, 
right. 

874
00:42:21,920 --> 00:42:24,360
If that is too great, you 
shouldn't be running. 

875
00:42:24,360 --> 00:42:28,200
You need to be able to get that 
under control, not forcibly, but

876
00:42:28,200 --> 00:42:30,760
be able to actually demonstrate,
yeah, the tissue is stable 

877
00:42:30,760 --> 00:42:34,520
enough for me to load 
appropriately with higher level 

878
00:42:34,520 --> 00:42:37,000
activity. 
So that is kind of that first 

879
00:42:37,000 --> 00:42:39,960
stage of of kind of step by step
going, hey, I need to go through

880
00:42:39,960 --> 00:42:42,040
this. 
Then there's also you need to be

881
00:42:42,040 --> 00:42:44,520
able to prove that you have 
decent mobility and movement 

882
00:42:44,520 --> 00:42:46,360
control. 
Meaning, hey, after the 

883
00:42:46,360 --> 00:42:48,800
inflammation has calmed down, do
you actually have the 

884
00:42:48,800 --> 00:42:50,760
appropriate motion to get 
through this? 

885
00:42:50,760 --> 00:42:53,120
So if you're if you sprained 
your ankle, now it's all puffed 

886
00:42:53,120 --> 00:42:55,800
up and super stiff. 
If you don't have any ankle 

887
00:42:55,800 --> 00:42:57,720
motion, any dorsiflexion, how 
are you going to run 

888
00:42:57,720 --> 00:42:59,120
appropriately? 
Or now you're going to be 

889
00:42:59,120 --> 00:43:02,160
compensating and hobbling along 
and it's going to cause other 

890
00:43:02,160 --> 00:43:05,600
issues or reinjure the tissue. 
So that kind of like second part

891
00:43:05,600 --> 00:43:08,520
is going, all right, Do you have
decent postural control? 

892
00:43:08,520 --> 00:43:11,240
Can you control core, for 
example, because that tends to 

893
00:43:11,240 --> 00:43:13,520
load things down lower. 
And then do you have the 

894
00:43:13,520 --> 00:43:16,560
appropriate range of motion for 
the requirements of running 

895
00:43:16,760 --> 00:43:19,880
that's at least 20 to 20 to 30 
degrees of dorsiflexion, at 

896
00:43:19,880 --> 00:43:22,600
least 50 degrees of plantar 
flexion, depending on who you 

897
00:43:22,600 --> 00:43:24,560
ask. 
And that's just the ankle. 

898
00:43:24,560 --> 00:43:26,160
That's not the knee. 
That's not the hip. 

899
00:43:26,480 --> 00:43:28,680
And I'm saying the ankle because
that's what I'm presenting on at

900
00:43:28,680 --> 00:43:30,840
CSM, but I'm just using as an 
example. 

901
00:43:30,880 --> 00:43:33,840
Do you have enough range of 
motion for the tasks that's 

902
00:43:33,840 --> 00:43:35,760
being required? 
So that's Part 2. 

903
00:43:35,760 --> 00:43:37,520
Can you get your range of motion
back? 

904
00:43:37,880 --> 00:43:41,320
Part three is, do you have the 
nerve sensation, also called 

905
00:43:41,320 --> 00:43:44,480
proprioception or kinesthesia, 
to be able to tell where your 

906
00:43:44,480 --> 00:43:46,480
body is? 
When you have pain and 

907
00:43:46,480 --> 00:43:50,080
inflammation, that does inhibit 
your body's sense of awareness 

908
00:43:50,080 --> 00:43:52,880
going where the heck is my foot?
People might notice, like, hey, 

909
00:43:52,880 --> 00:43:54,800
if you sprained your ankle all 
of a sudden, like, why is there 

910
00:43:54,800 --> 00:43:56,520
a delay in me figuring out where
my ankle is? 

911
00:43:56,520 --> 00:43:58,920
Or like, where's my ankle? 
That's a real thing. 

912
00:43:58,920 --> 00:44:01,960
Your brain has kind, somewhat 
lost connections got a little 

913
00:44:01,960 --> 00:44:03,920
bit fuzzy, right? 
There's some protective 

914
00:44:03,920 --> 00:44:06,120
mechanisms there to kind of go, 
hey, can we decrease pain? 

915
00:44:06,120 --> 00:44:09,000
But it's also some of the nerves
need to learn to refire. 

916
00:44:09,000 --> 00:44:11,880
So there's proprioceptive stuff.
That's why your PT or persons 

917
00:44:11,880 --> 00:44:16,120
having you stand on one leg do 
like, eyes closed, trying to get

918
00:44:16,120 --> 00:44:17,960
your nerve sensations back. 
Really important because if 

919
00:44:17,960 --> 00:44:19,880
you're going to run something, 
you better have a good idea 

920
00:44:19,880 --> 00:44:21,800
where your feet are. 
Or else you're going to be 

921
00:44:21,800 --> 00:44:23,760
slamming to the ground and who 
knows what's going to happen. 

922
00:44:23,760 --> 00:44:27,120
So that's kind of the next stage
of going, OK, am I ready to 

923
00:44:27,120 --> 00:44:29,920
return safely to run? 
The next thing is, do you 

924
00:44:29,920 --> 00:44:33,040
actually have the coordination 
and muscle performance to run 

925
00:44:33,080 --> 00:44:36,040
right? 
Running requires a high level of

926
00:44:36,040 --> 00:44:38,080
force. 
It is a series of single leg 

927
00:44:38,080 --> 00:44:40,160
hops, and that's not just 
something to mess around with. 

928
00:44:40,360 --> 00:44:42,920
That requires a lot of calf 
strength, a lot of quad 

929
00:44:42,920 --> 00:44:45,480
strength, eccentric hamstring 
strength, and a good amount of 

930
00:44:45,480 --> 00:44:47,160
hip strength at different 
phases. 

931
00:44:47,520 --> 00:44:49,600
You don't want to be missing one
of those because then you're 

932
00:44:49,600 --> 00:44:51,840
going to be compensating and you
might either re injure the 

933
00:44:51,840 --> 00:44:54,280
tissue as you because you're 
going to ask it to do too much 

934
00:44:54,280 --> 00:44:56,760
because it doesn't have the 
capacity to handle it or you're 

935
00:44:56,760 --> 00:44:58,520
going to load something else as 
you compensate. 

936
00:44:58,520 --> 00:45:02,600
So making sure you have adequate
strength either in other areas 

937
00:45:02,880 --> 00:45:05,640
and in the tissue to tolerate 
what you're going to ask is kind

938
00:45:05,640 --> 00:45:09,080
of that next step going, hey, 
can you produce enough force and

939
00:45:09,080 --> 00:45:12,800
can you control it? 
Then can you be able to handle 

940
00:45:12,800 --> 00:45:17,200
the higher level loads like 
plyometrics or the hopping 

941
00:45:17,200 --> 00:45:18,840
required? 
So it's not just how much force 

942
00:45:18,840 --> 00:45:22,640
can your muscle produce, but how
quickly and how long you can do 

943
00:45:22,640 --> 00:45:24,640
that. 
And there's also the final level

944
00:45:24,640 --> 00:45:27,960
of, hey, I know we talked about 
the variability and in running, 

945
00:45:27,960 --> 00:45:30,320
but running is a skill. 
It's not just you don't just 

946
00:45:30,320 --> 00:45:32,840
throw yourself out there. 
You kind of need to learn to 

947
00:45:32,840 --> 00:45:35,800
figure out what mechanics work 
for you in a way that doesn't. 

948
00:45:36,120 --> 00:45:38,560
Potentially overload the tissue.
And I'm not saying change your 

949
00:45:38,560 --> 00:45:40,720
running form, but running is a 
skill. 

950
00:45:40,960 --> 00:45:43,360
You need to work on it. 
Once you have all those other 

951
00:45:43,360 --> 00:45:46,160
things set, then you need to be 
able to prove, hey, I'm working 

952
00:45:46,160 --> 00:45:48,560
on the ability to run. 
Whether it's can I tolerate 

953
00:45:48,560 --> 00:45:51,200
running for 5 minutes and then I
need to take a two-minute walk, 

954
00:45:51,480 --> 00:45:55,360
5 S on the run walk method. 
But you need to the final stage 

955
00:45:55,360 --> 00:45:58,360
is going, how do I use running 
as my rehab. 

956
00:45:58,360 --> 00:46:00,880
And that means you have to ease 
into it and use running as a 

957
00:46:00,880 --> 00:46:03,120
loading program. 
Which means don't go run your 

958
00:46:03,120 --> 00:46:05,720
marathon you planned. 
It means you need to ease into 

959
00:46:05,720 --> 00:46:08,320
this. 
So that's kind of this is called

960
00:46:08,320 --> 00:46:11,200
the pyramid of rehab kind of 
looking through these things and

961
00:46:11,200 --> 00:46:13,720
we'll dive into maybe a couple 
of what those things look. 

962
00:46:13,720 --> 00:46:16,120
But anything I think you think I
missed. 

963
00:46:16,400 --> 00:46:19,520
No, I think that's a good 
progression where you're going 

964
00:46:19,520 --> 00:46:23,880
from kind of these manage the 
manage the thing at hand and the

965
00:46:23,880 --> 00:46:26,840
symptoms and moving towards now 
let's increase the requirement 

966
00:46:26,840 --> 00:46:30,440
of motion, let's increase the 
requirement of body awareness. 

967
00:46:30,440 --> 00:46:34,240
Let's increase how well the 
motor units and the muscles and 

968
00:46:34,240 --> 00:46:37,000
your body can move through 
certain functional movements 

969
00:46:37,000 --> 00:46:38,560
with the right muscle 
performance. 

970
00:46:38,760 --> 00:46:42,400
And then work on the specific 
skill, the this, this pyramid, 

971
00:46:42,400 --> 00:46:45,640
the functional rehab pyramid, Is
this from what you're presenting

972
00:46:45,640 --> 00:46:50,200
at CSM and is it something that 
you've created or is it from an 

973
00:46:50,200 --> 00:46:53,800
another source here? 
It's it's from a friend of mine,

974
00:46:53,800 --> 00:46:56,160
Michael doctor Michael Jean 
Faber, who is kind of the 

975
00:46:56,240 --> 00:46:57,920
masterbind behind our 
presentation. 

976
00:46:57,920 --> 00:47:01,520
But this is kind of combined. 
After a systematic review we did

977
00:47:01,520 --> 00:47:05,080
on trying to figure out if there
was good criteria for return to 

978
00:47:05,080 --> 00:47:07,160
sport after foot and ankle 
injury, we found it was 

979
00:47:07,160 --> 00:47:09,320
terrible. 
So something that we kind of 

980
00:47:09,320 --> 00:47:12,640
started and he ran with. 
And there's there's lots of 

981
00:47:12,640 --> 00:47:15,600
different other sources, but 
this specific one that I'm 

982
00:47:15,600 --> 00:47:17,440
referencing I have didn't go 
through the whole thing is 

983
00:47:17,440 --> 00:47:19,400
something that he kind of came 
up with. 

984
00:47:19,400 --> 00:47:22,440
But others have also come up 
with something fairly similar. 

985
00:47:22,960 --> 00:47:25,200
It's great. 
It's a it's a really nice 

986
00:47:25,200 --> 00:47:27,200
resource. 
Especially again, I think for 

987
00:47:27,360 --> 00:47:30,800
those who are helping people 
progress through rehab as 

988
00:47:30,800 --> 00:47:33,760
physical therapist, it's a 
really nice matrix. 

989
00:47:33,800 --> 00:47:37,080
But when we think about how does
this pertain to return to 

990
00:47:37,080 --> 00:47:39,840
running, how can we know? 
So you, you know, you mentioned 

991
00:47:39,840 --> 00:47:41,720
a couple things. 
Do I have the right mobility? 

992
00:47:41,720 --> 00:47:43,360
Do I have the right muscle 
performance? 

993
00:47:43,360 --> 00:47:44,840
Do I have the right functional 
movements? 

994
00:47:45,120 --> 00:47:48,040
How can we as runners in our 
houses? 

995
00:47:48,320 --> 00:47:52,200
What sort of criterion can we 
meet to know, Hey, I'm ready to 

996
00:47:52,200 --> 00:47:55,760
return to running and obviously 
this is going to differ 

997
00:47:56,000 --> 00:47:59,720
depending on the condition, but 
what are some some types of 

998
00:47:59,720 --> 00:48:02,000
tests that you can that you 
consider? 

999
00:48:02,640 --> 00:48:04,960
And this is where we talk about 
criteria instead of just going. 

1000
00:48:04,960 --> 00:48:07,360
I have this number of minutes 
going, hey, there's kind of some

1001
00:48:07,360 --> 00:48:09,600
standards. 
And none of these tests, by the 

1002
00:48:09,600 --> 00:48:11,240
way, by themselves are 
effective. 

1003
00:48:11,600 --> 00:48:14,480
All the current literature on 
return to sport, be it running, 

1004
00:48:14,480 --> 00:48:16,840
be it post ACL repair, be it any
of this stuff. 

1005
00:48:17,160 --> 00:48:19,800
There's no single test that 
tells you you need a battery of 

1006
00:48:19,800 --> 00:48:21,760
tests, because each test is 
going to measure something 

1007
00:48:21,760 --> 00:48:23,920
different. 
Also be here with where with 

1008
00:48:23,920 --> 00:48:27,480
what I and we say it's going to 
change depending on where the 

1009
00:48:27,480 --> 00:48:30,480
tissue injury is and what it is,
as Nathan mentioned, right? 

1010
00:48:30,480 --> 00:48:32,520
If you have a bone stress injury
and you're doing stuff, even if 

1011
00:48:32,520 --> 00:48:36,320
you can do it very well, but you
have pain, absolutely not, 

1012
00:48:36,320 --> 00:48:37,640
you're not ready to return, 
right? 

1013
00:48:37,880 --> 00:48:40,560
Versus a tendon, you might have 
a little bit of pain because 

1014
00:48:40,560 --> 00:48:42,600
actually there's some good 
evidence that a little pain with

1015
00:48:42,600 --> 00:48:46,600
loading is actually completely 
normal, if not sometimes a good 

1016
00:48:46,600 --> 00:48:49,040
thing, right. 
So depending on who you ask, so 

1017
00:48:49,040 --> 00:48:52,440
this is going to vary a lot. 
But what I might suggest just a 

1018
00:48:52,440 --> 00:48:54,760
couple tests that might be 
helpful. 

1019
00:48:54,960 --> 00:48:58,280
One of the classic ones to begin
with right just do you have 

1020
00:48:58,280 --> 00:49:00,560
ankle range of motion? 
Can you bend? 

1021
00:49:00,680 --> 00:49:03,960
Super easy one. 
Hey, if you really basic I 

1022
00:49:03,960 --> 00:49:06,640
forgot why am I forgetting the 
the functional movement screen 

1023
00:49:06,640 --> 00:49:08,880
right. 
Can you just do a squat? 

1024
00:49:08,920 --> 00:49:10,720
OK it can. 
Your knee. 

1025
00:49:10,840 --> 00:49:13,320
I know people don't always like 
this but can your knee get over 

1026
00:49:13,320 --> 00:49:15,400
your toes? 
How much ankle dorsiflexion do 

1027
00:49:15,400 --> 00:49:17,680
you have? 
There's also a lunge like wall 

1028
00:49:17,680 --> 00:49:20,440
test you can use but. 
The criterion for that gets a 

1029
00:49:20,440 --> 00:49:23,040
little fancy, and I would, I was
just, hey, do you have enough 

1030
00:49:23,040 --> 00:49:25,200
ankle dorsiflexion? 
Can you squat and get your knees

1031
00:49:25,200 --> 00:49:28,200
over your toes If you can't do 
that without your heels coming 

1032
00:49:28,240 --> 00:49:29,760
up, right, without your heels 
coming off? 

1033
00:49:29,920 --> 00:49:32,360
If you can't do that, it might 
be a good thing to work on. 

1034
00:49:32,360 --> 00:49:35,200
Not everyone can do that, but 
that might be one thing to go. 

1035
00:49:35,200 --> 00:49:37,560
Hey, do I have enough 
dorsiflexion, knee and hip 

1036
00:49:37,560 --> 00:49:40,600
mobility to actually get there? 
And I'm not saying squat like 

1037
00:49:40,760 --> 00:49:42,720
butt to the ground. 
I'm just saying, can you do some

1038
00:49:42,720 --> 00:49:45,560
of the basics? 
That's like an early Hey, can I 

1039
00:49:45,560 --> 00:49:47,240
do this without too many 
symptoms? 

1040
00:49:47,600 --> 00:49:50,960
Another thing that you might 
want to consider is hey how many

1041
00:49:50,960 --> 00:49:53,840
calf raises that can I do 
because your calf is the most 

1042
00:49:54,000 --> 00:49:56,480
one of the most important 
muscles for propulsion, running 

1043
00:49:56,840 --> 00:50:00,600
specifically as that Nathan 
Menton soleus, how many single 

1044
00:50:00,600 --> 00:50:03,400
leg calf raises can I do? 
And this is again not a strength

1045
00:50:03,400 --> 00:50:06,200
test, this is much more of an 
endurance and capacity tests. 

1046
00:50:06,280 --> 00:50:07,760
There's some interesting 
research on that. 

1047
00:50:08,000 --> 00:50:12,320
But can you get 20 to 25 single 
leg heel raises with good range 

1048
00:50:12,320 --> 00:50:13,880
of motion? 
Not these tiny little quick 

1049
00:50:13,880 --> 00:50:16,400
ones. 
Can you do this and get through 

1050
00:50:16,600 --> 00:50:19,680
at least 25 on each side? 
I've heard different criteria of

1051
00:50:19,680 --> 00:50:23,280
doing like 5 by 25 or 5 by 30 to
actually demonstrate this. 

1052
00:50:23,280 --> 00:50:27,040
But typically I'll just go, hey,
can you just demonstrate basic 

1053
00:50:27,560 --> 00:50:31,520
muscle capacity of the calf to 
be able to handle some of the 

1054
00:50:31,520 --> 00:50:33,520
stuff You look like you want to 
say something? 

1055
00:50:33,880 --> 00:50:36,280
Yeah, what I have people do with
that one just to make sure that 

1056
00:50:36,280 --> 00:50:39,000
you can be consistent with 
yourself and not just what I 

1057
00:50:39,000 --> 00:50:40,080
say. 
Like, don't you don't want to 

1058
00:50:40,080 --> 00:50:42,600
jackhammer your way through calf
raises? 

1059
00:50:42,800 --> 00:50:45,400
I have people put on a metronome
at 60 beats per second. 

1060
00:50:45,800 --> 00:50:49,360
Wow, Wow, 60 beats per minute, 
60 beats per second. 

1061
00:50:49,360 --> 00:50:51,200
I don't know. 
Whatever. 60 beats per. 

1062
00:50:51,200 --> 00:50:53,840
Minute, even the hummingbirds 
are going Dang, I can't do that.

1063
00:50:53,840 --> 00:50:57,520
I'm just kidding. 
And you go to the, to the, you 

1064
00:50:57,520 --> 00:51:03,400
go up, down, up, up, down to the
60 beats per minute. 

1065
00:51:04,160 --> 00:51:05,720
And that's a good way to slow 
yourself down. 

1066
00:51:05,720 --> 00:51:07,800
So so far you've kind of said 
you want to make sure you have 

1067
00:51:07,800 --> 00:51:10,880
mobility and you can check that 
through that deep squat, making 

1068
00:51:10,880 --> 00:51:14,040
sure your heels can stay down or
just, you know, go into, like 

1069
00:51:14,040 --> 00:51:16,000
you said that wall test. 
You can kind of just slide your 

1070
00:51:16,000 --> 00:51:18,000
foot away from the wall and see 
if you can keep your heel down 

1071
00:51:18,000 --> 00:51:21,080
and touch your knee to the wall.
So you got mobility check there.

1072
00:51:21,240 --> 00:51:25,160
You've got one idea of a calf 
heel raise test for muscle. 

1073
00:51:25,280 --> 00:51:27,760
I kind of went a little. 
I kind of went a little ahead on

1074
00:51:27,760 --> 00:51:30,200
the pyramid on that one you did 
that was a little bit further 

1075
00:51:30,200 --> 00:51:31,680
up. 
The one in between would be kind

1076
00:51:31,680 --> 00:51:34,720
of that proprioception, yeah. 
And what do you got for that? 

1077
00:51:34,960 --> 00:51:39,080
Yeah, so a common one is, hey, 
can you balance on each leg and 

1078
00:51:39,080 --> 00:51:41,600
can you close your eyes and hold
that for a decent amount of 

1079
00:51:41,600 --> 00:51:43,720
time? 
So I've typically heard this be 

1080
00:51:43,720 --> 00:51:46,040
at least 10 seconds, But if I'm 
going to really determine 

1081
00:51:46,040 --> 00:51:48,680
somebody's ready, I want to see 
can you hold on and not fall 

1082
00:51:48,680 --> 00:51:52,560
over without holding on anything
with your eyes closed for at 

1083
00:51:52,560 --> 00:51:54,120
least 30 seconds? 
Right. 

1084
00:51:54,280 --> 00:51:56,160
You don't have to be standing 
completely still. 

1085
00:51:56,160 --> 00:51:58,120
A little bit of motion is 
totally normal because that 

1086
00:51:58,120 --> 00:51:59,320
tells you you're adjusting. 
But. 

1087
00:51:59,760 --> 00:52:01,720
That's kind of how, you know, 
hey, if you take out your vision

1088
00:52:01,720 --> 00:52:03,560
because people like to cheat, 
you got a lot of different 

1089
00:52:03,560 --> 00:52:06,640
proprioceptive centers, your 
inner ear, your eyes, and all 

1090
00:52:06,640 --> 00:52:08,760
the ligaments and the nerves 
that go through all the tissues 

1091
00:52:09,040 --> 00:52:11,600
through your extremities. 
But if you can do a single leg 

1092
00:52:11,600 --> 00:52:13,880
balance test with your eyes 
closed for 30 seconds, that 

1093
00:52:13,880 --> 00:52:16,400
might demonstrate that, hey, you
might have enough proprioceptive

1094
00:52:16,400 --> 00:52:20,400
stuff or capacity to handle 
moving on to the next level, 

1095
00:52:20,480 --> 00:52:22,000
right? 
And I know that would be 

1096
00:52:22,000 --> 00:52:23,960
probably like doing some single 
leg calf raises. 

1097
00:52:24,920 --> 00:52:26,040
Yeah. 
I'm supposed to check the order 

1098
00:52:26,600 --> 00:52:27,840
and then you have the calf 
raises. 

1099
00:52:27,840 --> 00:52:31,880
Another one I would add into the
muscle kind of endurance type 

1100
00:52:31,920 --> 00:52:35,360
would be a single leg sit to 
stand from a standard chair and 

1101
00:52:35,360 --> 00:52:37,200
do in. 
And again there's no standard 

1102
00:52:37,200 --> 00:52:39,360
number so I can't. 
I'm going to tell you what I do 

1103
00:52:39,360 --> 00:52:42,040
with people. 
I have them do at least seven 

1104
00:52:42,200 --> 00:52:44,920
where they have good control 
single leg on each leg. 

1105
00:52:44,920 --> 00:52:47,760
They've that they're able to 
control all the way up and all 

1106
00:52:47,760 --> 00:52:49,680
the way down. 
They're not plopping down that 

1107
00:52:49,680 --> 00:52:52,400
and that will get instead of the
calf that's looking at more quad

1108
00:52:52,400 --> 00:52:54,800
hamstring glute complex on a 
single leg. 

1109
00:52:55,520 --> 00:52:57,840
I have to say I've also really 
enjoyed use. 

1110
00:52:57,880 --> 00:53:00,160
So the previous ones I was 
taught was used in the single 

1111
00:53:00,160 --> 00:53:03,720
leg squat test to be able to do 
at least ten with good control, 

1112
00:53:03,920 --> 00:53:08,520
good alignment of the trunk, hip
or trunk, pelvis, hip, knee and 

1113
00:53:08,520 --> 00:53:10,400
ankle. 
But I got to say the same thing.

1114
00:53:10,400 --> 00:53:13,280
I really enjoyed more of the sit
to stand with a single leg 

1115
00:53:13,280 --> 00:53:17,040
because it requires a lot more 
strength and really power if you

1116
00:53:17,040 --> 00:53:18,960
do it for time. 
You're trying to see how quickly

1117
00:53:18,960 --> 00:53:22,000
I can do it to get up from that 
seated position. 

1118
00:53:22,000 --> 00:53:24,480
So I also really like the single
leg sit to stand. 

1119
00:53:25,160 --> 00:53:27,440
As another measure of going, 
hey, can you use seven of these 

1120
00:53:27,680 --> 00:53:30,440
seven to 10 with good form and 
good alignment. 

1121
00:53:30,440 --> 00:53:32,480
Doesn't mean you have to have 
perfect alignment, but you have 

1122
00:53:32,480 --> 00:53:34,640
good control over it. 
Is a really great kind of 

1123
00:53:34,640 --> 00:53:37,320
somewhat strength test of the 
lower extremity. 

1124
00:53:37,320 --> 00:53:41,120
Gets trunk, hip, pelvis, knee, 
ankle. 

1125
00:53:41,120 --> 00:53:43,200
But definitely agree with that. 
Great. 

1126
00:53:43,800 --> 00:53:45,120
And then what would you put 
last? 

1127
00:53:45,120 --> 00:53:49,600
I I know what I do with my kind 
of one of my closest to return, 

1128
00:53:49,960 --> 00:53:51,560
but but what do you what do you 
do? 

1129
00:53:52,280 --> 00:53:54,680
I have a couple of variations on
this that I've experimented with

1130
00:53:54,680 --> 00:53:57,320
over the years, but I would say 
in general the biggest thing is 

1131
00:53:57,320 --> 00:54:00,920
being able to do single leg hops
and not just one. 

1132
00:54:01,240 --> 00:54:04,240
By the way, because running is a
series of them, not just one, 

1133
00:54:04,240 --> 00:54:06,720
that you can start out with a 
single leg hop, like single leg 

1134
00:54:06,720 --> 00:54:09,000
hop for distance or modified 
single leg hops. 

1135
00:54:09,360 --> 00:54:12,640
But you've got to be able to do 
repeated single leg hops in some

1136
00:54:12,640 --> 00:54:15,640
manner to demonstrate that yes, 
you were able to handle the 

1137
00:54:15,640 --> 00:54:19,000
plammetric and power demands 
that come with running. 

1138
00:54:19,200 --> 00:54:21,520
And I usually have people do 
about 20 again. 

1139
00:54:22,320 --> 00:54:23,920
Again, no magic behind this 
number. 

1140
00:54:24,000 --> 00:54:27,040
It's not studied, it's not 
perfect, but 25 gives us a good 

1141
00:54:27,040 --> 00:54:31,640
idea of how irritable are any 
tissues that are healing and can

1142
00:54:31,640 --> 00:54:34,320
you control that and actually 
and go on one leg. 

1143
00:54:35,160 --> 00:54:38,640
One thing, go ahead. 
I will also say that quality is 

1144
00:54:38,640 --> 00:54:41,240
also important. 
So this is something that I'm 

1145
00:54:41,240 --> 00:54:43,080
learning as I'm studying 
tendons, especially the 

1146
00:54:43,080 --> 00:54:46,160
Achilles. 
It's not just boom, up, boom, 

1147
00:54:46,160 --> 00:54:48,640
like like come out, down and 
land. 

1148
00:54:48,760 --> 00:54:51,360
As Nathan mentioned earlier, we 
both talked about it's getting 

1149
00:54:51,360 --> 00:54:55,560
that elastic like recoil of 
being able to get up and then 

1150
00:54:55,560 --> 00:54:58,600
actually bounce off the ground, 
not just sit. 

1151
00:54:59,040 --> 00:55:01,720
And come back off because if you
want the 10, especially if 

1152
00:55:01,720 --> 00:55:04,600
you're doing 10 rehab, if you 
really want those tendons to 

1153
00:55:04,600 --> 00:55:07,520
function the way you you they're
supposed to, you got to have 

1154
00:55:07,520 --> 00:55:10,480
very quick elastic recoil. 
That means your ground contact 

1155
00:55:10,480 --> 00:55:12,880
time or the amount of times on 
the ground has to be super 

1156
00:55:12,880 --> 00:55:15,800
quick. 
And that can be a really I will 

1157
00:55:15,800 --> 00:55:18,440
give a little interesting thing 
of what I'm seeing with the 

1158
00:55:18,440 --> 00:55:20,360
Achillesenopathy and the mouse 
is what I'm studying. 

1159
00:55:20,600 --> 00:55:23,560
That is a very that seems to be 
a very good indicator. 

1160
00:55:24,080 --> 00:55:27,800
They haven't done not finalized 
stats yet, but their ground 

1161
00:55:27,800 --> 00:55:30,920
contact time is something that 
is really interesting and can be

1162
00:55:30,920 --> 00:55:34,240
very telling about Achilles 
tendinopathy and their readiness

1163
00:55:34,240 --> 00:55:36,400
to return to sport. 
Yeah, that's interesting. 

1164
00:55:36,400 --> 00:55:37,400
So. 
Quality. 

1165
00:55:37,640 --> 00:55:39,800
Not just how many. 
Just like we're talking about 

1166
00:55:40,040 --> 00:55:43,160
the quality of your abilities, 
not just how much time. 

1167
00:55:43,680 --> 00:55:46,480
Is very similar with some of the
the single leg hop tests as 

1168
00:55:46,480 --> 00:55:48,640
well. 
One thing I do want to say about

1169
00:55:48,760 --> 00:55:51,640
these you know kind of what 
we're giving are like, oh Are 

1170
00:55:51,640 --> 00:55:54,000
you ready to go back to running 
maybe try these things and see 

1171
00:55:54,000 --> 00:55:57,120
if you're ready. 
None of these are complete and 

1172
00:55:57,120 --> 00:55:59,360
none of them are actually 
completely necessary. 

1173
00:55:59,360 --> 00:56:04,120
For example I I'm coaching a 
runner who has she she got 

1174
00:56:04,120 --> 00:56:08,160
diagnosed in the last two years 
with episodic ataxia and so for 

1175
00:56:08,160 --> 00:56:10,880
her to stand on a single leg 
with her eyes closed isn't going

1176
00:56:10,880 --> 00:56:14,040
to happen that and that isn't a 
requirement for her to run. 

1177
00:56:14,040 --> 00:56:16,400
She has goals with her running 
and we're working on those 

1178
00:56:16,400 --> 00:56:19,480
things and it we relate it back 
to her needs based on her 

1179
00:56:19,480 --> 00:56:23,600
specific condition. 
But I I use that example to say 

1180
00:56:23,720 --> 00:56:28,320
these are not exclusive saying 
they're if you can't do these 

1181
00:56:28,320 --> 00:56:31,200
then you are not allowed to run.
They're not they're not that 

1182
00:56:31,200 --> 00:56:33,840
they're not that good hate to 
say it we are giving some ideas 

1183
00:56:33,840 --> 00:56:36,240
but they're not that good. 
It's also not comprehensive. 

1184
00:56:36,440 --> 00:56:39,040
Just because you can do these 
things means you should run. 

1185
00:56:39,200 --> 00:56:41,400
So it's but it's very much 
incomplete. 

1186
00:56:41,400 --> 00:56:44,880
But it is a starting point and 
it hits some of that pyramid 

1187
00:56:44,880 --> 00:56:48,880
that Matt was talking about to 
be able to rehabilitate an 

1188
00:56:48,880 --> 00:56:51,800
injury and just trying to check 
some of those things easy on 

1189
00:56:51,800 --> 00:56:53,320
your own. 
We're obviously biased. 

1190
00:56:53,320 --> 00:56:55,480
We're PTS. 
We think PTS are pretty cool. 

1191
00:56:55,600 --> 00:56:57,920
If there's APT who can be 
tracking these things for you, 

1192
00:56:58,800 --> 00:57:00,920
all the better. 
Because I know I am not 

1193
00:57:00,920 --> 00:57:05,200
objective with myself ever. 
And so I need APT when I am 

1194
00:57:05,200 --> 00:57:07,480
rehabbing. 
I need a coach when I'm training

1195
00:57:07,720 --> 00:57:11,040
because I like to have somebody.
He's actually honest with me 

1196
00:57:11,080 --> 00:57:12,400
because I'm not honest with 
myself. 

1197
00:57:13,280 --> 00:57:14,680
That's why I made the comment 
earlier. 

1198
00:57:14,680 --> 00:57:18,000
You bring up a great point that 
it's not just one test. 

1199
00:57:18,000 --> 00:57:20,840
Even if you look at the 
literature, there's not a lot of

1200
00:57:20,840 --> 00:57:24,400
stuff on like when do you know 
when to return to running. 

1201
00:57:24,400 --> 00:57:27,720
Like there's some decent stuff 
on like post ACL replacement, 

1202
00:57:27,720 --> 00:57:30,600
but a lot of other injuries, not
so much because we really don't 

1203
00:57:30,600 --> 00:57:31,920
know. 
Nobody's done the research on 

1204
00:57:31,920 --> 00:57:33,680
that. 
But what we do know is one 

1205
00:57:33,680 --> 00:57:38,080
single test is not indicative of
your ability to or not to run. 

1206
00:57:38,440 --> 00:57:40,400
It's just some ideas going. 
You know what? 

1207
00:57:40,680 --> 00:57:42,360
These are some of the things 
required of running. 

1208
00:57:42,360 --> 00:57:46,080
It might be helpful for you to 
work on these just to make sure 

1209
00:57:46,080 --> 00:57:48,360
your return to run goes a little
bit better. 

1210
00:57:48,360 --> 00:57:51,800
These might be good things. 
It's also more fun that if you 

1211
00:57:51,800 --> 00:57:54,520
are waiting to return running 
like well, I know I need this 

1212
00:57:54,520 --> 00:57:57,560
much time to heal. 
Why not work on your capacity to

1213
00:57:57,560 --> 00:58:00,400
be able to do that so that when 
you do return to run, these 

1214
00:58:00,400 --> 00:58:02,920
things might be able to help you
stay a little bit more injury 

1215
00:58:02,920 --> 00:58:04,600
free. 
But we also don't have great 

1216
00:58:04,600 --> 00:58:06,480
evidence on that to be honest. 
This is more. 

1217
00:58:07,000 --> 00:58:09,560
Theoretical. 
Just being honest, Yep, we're 

1218
00:58:09,560 --> 00:58:10,840
not there yet. 
That's OK. 

1219
00:58:10,840 --> 00:58:12,680
And we're working on that start.
That's where we're going to 

1220
00:58:12,680 --> 00:58:16,080
start. 
So we clearly are almost at the 

1221
00:58:16,080 --> 00:58:17,680
top of the hour of this 
recording. 

1222
00:58:17,680 --> 00:58:20,040
And so we're not going to be 
going specifically into 

1223
00:58:20,040 --> 00:58:23,160
posterior tibialis tendon 
issues. 

1224
00:58:23,480 --> 00:58:26,960
So we will save those questions 
for the day where we can circle 

1225
00:58:26,960 --> 00:58:30,120
back to that condition. 
So if you submitted a question, 

1226
00:58:30,120 --> 00:58:33,480
thank you for doing that. 
We will you know we have them 

1227
00:58:33,480 --> 00:58:37,000
saved and so we'll come back to 
those or we'll gather them again

1228
00:58:37,040 --> 00:58:40,640
if we if we lose them. 
But the the the plan will be 

1229
00:58:40,640 --> 00:58:43,840
someday to circle back to that. 
But this was a I had a lot of 

1230
00:58:43,840 --> 00:58:47,960
fun hearing your thoughts on 
this topic of what does it mean 

1231
00:58:47,960 --> 00:58:50,640
for a tissue to go through its 
healing time frame and what can 

1232
00:58:50,640 --> 00:58:53,200
we start thinking about for 
return to learn criteria. 

1233
00:58:53,480 --> 00:58:56,800
And we will continue these 
conversations with specific 

1234
00:58:56,800 --> 00:58:59,600
tissues in the future, but hope 
you have a great night or a 

1235
00:58:59,600 --> 00:59:00,480
great day everybody.