#675: Eric Cressey, Cressey Sports Performance — Tactical Deep Dive on Back Pain, Movement Diagnosis, Training Principles, Developing Mobility, Building Power, Fascial Manipulation, and Rules for Athletes

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At this altitude, I can run flat out for a half mile before my hands start shaking. And then also. No se cybernetic organism, living tissue over metal indoctors. So Hello, boys and girls, ladies and germs. This is Tim Ferris. Welcome to another episode of the Tim Ferris Show, where it is my job each and every episode.

To deconstruct world class performers from all different disciplines to tease out. The Best practices, the exercises, the influences, the books. etc. that you can apply to your own lives. And my guest today is Eric Cressy. I've known Eric for quite some time. You can find him on Twitter.

At Eric Cressy, C R E S S E Y. Eric Cressy, M A C S C S is president and co-founder of Cressy Sports Performance. With facilities in Palm Beach Gardens, Florida, and Hudson, Massachusetts. He has worked with clients. Ranging from youth sports to the professional and Olympic ranks. But he is best known for his very extensive work with baseball players, more than one hundred professional players. train at CSP each offseason. Eric also serves as director of player health and performance for the New York Yankees.

You may have heard of them. Eric double majored in exercise science and sports and fitness management at the University of New England, and then received his master's degree in kinesiology. with a concentration in exercise science at the University of Connecticut. Cressy has publis books and video resources that have been sold in more than 60 countries. He regularly lectures both nationally and internationally, and his research has been published in the Journal of Strength and Conditioning Research. He serves as a consultant to New Balance. Proteus motion and athletic greens.

Cresty has a blog and free newsletter at his website, EricCressy.com, and has a podcast at Elite Baseball Podcast. dot com. You can find more about his training facilities at CressesportsPerformance.com And on social media, Eric Cressy on Instagram. Twitter and elsewhere. We'll link to all of those in the show notes. at Tim.blog slash podcast. And without further ado, please enjoy

A very practical, a very tactical and wide ranging conversation. With Eric. Cressy.

Eric. Doctor Cressy, nice to see you. You too. Thanks for having me. Absolutely. And I thought we could start with the personal because I feel and this is not my quote, but the intensely Personal is often the most universal.

And the way to lead into that is by reading an email. You sent to me. This was not too long ago, but it led to this conversation on the podcast. Hi Tim. I hope this email finds you well. Wonderful to see your continued success with the podcast. Thank you for that. In particular, I love the section on medical literacy in the recent episode with Peter Atia. It's such an important concept that can go in a number of different directions. But my brain immediately went to the realm of orthopedics.

A few things that I think our must covers include Don't worry guys, this is not gonna be The great American novel. But These are the bullets that got me very excited to have a conversation that I could share with people. I was like, I'm gonna have this conversation anyway. Why don't we share it with folks because I think it'll be incredibly helpful. Number one, incidental findings on musculoskeletal imaging of asymptomatic individuals. We'll explain what that means. Bias slash oversight in radiology.

We'll probably touch on all these three. the medical model potentially not being well equipped to handle non homogenous conditions like low back pain. So the origin of this was my personal experience of having this Escalating low back pain. that led to

X rays, MRIs, and To this point in time, it's been very hard to decipher what is happening. Back to the email. Number four, systemic causes of musculoskeletal pain, in parentheses, vitamin D, prescription meds, etc. Five, the overlooked misunderstood emerging role of the fascial system. Six psychosocial stress and sleep deprivation as they relate to

Injury risk seven new frontiers in biologic stem cell PRP, etc. I wanted to read this email in particular for the clothes. And some phrasing in that. And this is from you. I was always fascinated with a lot of these things, but over the past four years with the Yankees, my access to aha moments has been far greater. It might make for an intriguing episode that would help folks advocate for themselves a bit.

Better. That's self advocation. is is super interesting to me. And I thought we would start with the low back pain because I've learned So much. In the last.

month or two. We can begin anywhere that makes sense. But actually before we get to that, just to establish some bona fides. Because people certainly have heard the bio, but what are some of your PRs? In the deadlift.

Let's just begin there. Personal records. I pulled six sixty at a body weight of one eighty one. Little bit lighter at a at a body weight of one sixty five. So I've I've lifted my fair share of heavy stuff without a really a well targeted long term goal with it in mind. Now without recommending this to other people many years ago because we were introduced something around I don't know two thousand ten, two thousand twelve in that range. You once sent me a video of you doing

Something you would probably not advise to any of your clients, which was trap bar deadlifts. for higs with some ungodly amount of weight for the reps. Do you recall what this might have looked like. I do. I think it was four fifteen for twenty five. And I I made the mistake of doing it Thanksgiving morning and uh absolutely ruined the holiday. I think I had a headache for about four days. So um definitely one of my my more ignorant moments in my youth. On the quest of science, though, right? On the quest of science. I met other people. And the reason I want to bring this up is because there are many theoreticians out there

I am very interested in people who have the academic And research understanding of the literature, but who are also practitioners. And that is certainly you on many different levels. So how should we edge our way into low back pain. Where do you think it makes sense to start?

I think back pain is is fascinating, obviously. It's a It's an all encompassing diagnosis. It covers a lot of different things that that impacts a lot of different people. What's particularly fascinating about it is it's very different. If you're a nine year old kid and you fall off the playground, you you break your forearm, you throw in a cast, it heals up, you're good to go. There's a much more significant level of chronicity that happens with the back pain that we see in the general population. And I think what's to my email's point. And the term non homogenous was one I actually stole from from Dr. Stuart McGill, who's who's great in this. And he he's talked about how the The medical system may not actually be well designed to handle a non-homogenous condition like widely varied. Yes. Or somewhat different. You know, speaking in a you know really, really broad strokes in an athletic population, we tend to see much more extension based low back pain. So we're gonna see in a tennis player

Or a baseball player or soccer player is probably markedly different than what we're gonna see as someone who sat at a computer for thirty years, or a roofer, or a plumber, or a floor who spent a lot of time in flexion. Right bending forward. Correct. And then and then what we have is we have a lot of people that have probably done a little bit of both and created adaptations in both directions. Maybe it's the plumber who goes out and then plays in a erect, you know, basketball league four nights a week or something like that. So everyone presents, I think, with a different history of of activity and symptoms and either successful or, you know, failed treatments that may have intervened in one way or another. Um it often leaves us just in like this situation where you you can't just look at these all the same. Let's maybe segue just for a moment to radiology, which people might Raise an eyebrow. over but let me explain why.

The Event that precipitated me reaching out to you. was getting a radiologist report after an MRI. And I got the report. And

It was right before going to dinner. I was in an Uber. I somehow got a V atts, which I thought was very interesting. I thought it was a fishing attack at first, but it turned out to be legitimate. And there was moderate to severe XYZ, this type of degeneration, that type of degeneration. And as a Lay person, albeit someone who's tried to take time to become somewhat medically literate.

It was a terrifying read from me personally. And the I think it's the impressions slash conclusions section, as you pointed out, was a little strange. Usually there's some type of summary, but it was it effectively just said see above.

And As someone who doesn't read these reports frequently, I just took that at face value that that's how these things And Spoke with you, spoke with Peter Tia.

And Doctor Tia said to me on the phone, he said, Well If I were to show you an MRI of my spine, I think he keeps his images somewhere close to his desk. He said it's a garbage fire, basically. It makes your spine look like a neonate.

But He is, as far as I know, asymptomatic. He does not have any type of low back pain or back pain. How should we think about The use of these tools.

Your experience is not At all. I hate to say it unique, but I think it's very much something that happens every day. And let me preface this by saying I'm I'm not a radiologist. I'm not an orthopedic surgeon. I'm not a doctor in any capacity. I'm a strength additioning coach. So I kind of found this world by accident. I do happen to look at a couple thousand radiology reports every year. It's something that kind of happened by accident just because you started to try to work backwards from the conditions that we were seeing, people who are having pain in various points in their body, and and we want to understand why. This is not to take away from radiologists or doctors at all, because it's a it's an incredibly specialized

you know, approach and it's a huge part of the diagnostic puzzle. But the thing that I would say that's interesting first off is we'll have people that will walk in with a you know with their films and I'll say, Listen, I'm not reading those for you. I people go to school for a decade to understand how to do that. But I can certainly kinda draw maybe some conclusions from some of the things that you see relative to my sample size. So I always try to always illustrate that in our conversations. But the big picture I would say is that it it has to be looked at as as a piece as of the diagnostic puzzle. So really no diagnostic imaging is appropriate without, you know, an accompanying physical exam, a a full like kind of case history as you go through a variety of things. Cause as we kind of alluded to in in that initial email, is like there's a lot of other things that can impact it. And what's really fascinating, maybe this is the place where it gets intriguing for people is there's actually an article that came out in the Lancet in two thousand nine. An exact quote from it that said, lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes. Clinians should refrain from routine immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition. So

We've always been taught the second something gets hurt, you call your doctor, you go and you get an MRI and you get all the answers. And there may absolutely be a a case for that in certain situations. And there may also be times where you get a whole bunch of false positives that can wind up leading you to to bark up the wrong tree. And that happens a lot with spines. How Objective. Are these reports? Yeah, I remember we chat on the phone and I wanna say That you mentioned

Yeah. In some I wouldn't know what to call them studies, perhaps. Experiments that if radiologists were shown photographs Of the patient's faces. That the outcomes differ. Yeah. There was one particular study, and I don't think it's at all reflective of like a a greater conspiracy theory in the radiology community that but if patients pictures were actually shown to the radiologist before reading, they tended to read a little bit more intently. So I think it's like anything else. Radiology is a little bit like fine art and they're ultimately trying to interpret what they see. And sometimes

you can see a little bit more or a little bit less. And sometimes if you see something that's very slight, you might not relate it in a report, whereas other people might document, you know, absolutely everything. And The additional context I would add to that is Number one, I'm used to Duplicats to get a second opinion before

staging any kind of intervention. But I have much more comfort with blood draws and those types of biomarkers. So if I see something that's out of whack, I don't immediately freak out. I think. Okay, if my triglycerides have shot up that significantly, it's probably some type of dietary issue. Maybe I just ate a ton of meat the night before and I had it too late, et cetera.

Or it could be a lab error. And I'll run the test again. And only when you have confirmation would I consider beginning to stage interventions. I have less exposure to MRIs. So it threw me into it. A complete. Tizzy, right? I mean I I really

was scared of this because it seemed also maybe unlike The blood markers. Like something structural I could not. Fix. Potentially without some kind of surgery.

And whether it's objective or not. And I have the number of friends who are radiologists and very, very good at what they do. It's incredibly difficult. Skill to develop.

And That being as it may, the The Aspect of low back pain. that is different from my past injuries because as you know I've had a long list of injuries. If I

Let's just say. Really hurt my shoulder, really hurt my knee. really hurt my ankle. I've done all these things and I get an MRI ultimately. The correlation from image read to pain seems to be

Much. Stronger than with the low back. Whereas with the low back, it's like you have people who might have What appear to be normal images, but they're extremely symptomatic. They've all sorts of Pain showing up.

And vice versa. So how do you begin to Examine. Or fix. Low back pain.

That's very definition of a billion dollar question. I mean, just to speak to some of the things that you just kind of hinted at in terms of actual numbers, there was actually a a landmark study in the New England Journal of Medicine that basically looked at a collection of asymptomatic spines. I believe there were 98 particular subjects. 52% of them had a disc bulge at one level, 27% had a protrusion, and one percent had an extrusion. So eighty two percent of people had something on. And actually thirty eight percent of them had abnormalities at more than one level. Without having it in front of me, your report was markedly more significantly than that. We saw quite a bit of more and That was looking at a relatively unathletic population. And you look at yourself like you've you've got a history in a wide variety of sports. You've tried just about everything. And when I saw yours, I started thinking more of there was actually studying the American Journal of Medicine that came out in 2000 that looked at elite Spanish athletes. And they're actually scoping especially for stress fractures. And what was interesting is they found eight percent of Spanish athletes were affected and only fifty percent of them really demonstrated symptoms. So really you're looking at a scenario where one out of twenty, one out of twenty-five actually had a stress fraction. They had no idea that was there. They saw it a lot in tracking field throwers and rowers and gymnasts and weightlifters.

But when I saw that study. I didn't buy it in an American population just because weightlifting is much more accepted here. We see way more early sports specialization here. We see more rotational sports, hockey, obviously lacrosse, baseball. You know, everything's just played at a much higher level. So and I think that study was also, you know, was done in 23 years ago. So I think right now we are dealing with an epidemic of a lot of young athletes that always have stress fractures taking place. Every time I see an oblique strain on a professional baseball player, there's usually an old stress fracture, you know, listed on the radiology report that they just saw. So for a guy like you, it's a unique look because You know, you have a wide variety of things that could be emerging and and certainly when you got your report read, they they talked about absolutely everything that was on there. Right. And then

I was sitting at dinner trying to concentrate, but My inner voice was going, I think you feel tingling in your low back. I think there's burning in your toes. I think your foot is not much freaking out. Which is unlike me. But it took having a conversation with you just to think about how compartmentalized my reference points are. uh conversation with you to do maybe what in retrospect is obvious, which is send the images to somebody else.

Don't send the report. 'Cause that's the interpretation, but Get a second read. Which is what I'm doing right now. How should we think about

low back pain, whether it's preventative or Diagnosing. We can go in any direction that you think. Make sense. I mean, I I think the first thing I'll say is that we probably have been conditioned to think that it is all the same and it really isn't. You know, what we see in a sedentary population is generally going to be markedly different than what we encounter in our very athletic population, particularly those that utilize strength and additioning on top of sports participation. So it's one thing to just be an Olympic lifter. It's another thing altogether to Olympic lift and then go play you know, soccer or something like that. So I think we have to really understand our population norm for sure.

Yeah, I remember you asked me on the phone, you said uh or asked If I thought I was Compression. Sensitive. Flexion sensitive or extension sensitive. Is that right? Yeah, I got a memory. Yeah. And so

Extension, bending backwards like a back bend. Let's just say I'm simplifying this of course. Flexion, like Yoga bending over at the waist, rounding your spine. And then uh compression, which I knew immediately I was gonna be sensitive to because I think the Test, don't do this at home, folks. Work with a professional. This is not medical advice. But was to raise up my heels and kind of a classic heel stomp test. Heel stomp test. And I was like, Nope. I don't even want to do that because I know it's gonna hurt. Those are tough ones because you're our heads weigh more than bowling balls. We're always encountering compression in our daily life. And some of those are some of the most, you know, stubborn cases of back pain. But I think in the in the big picture, you talked about like you know freaking out over an MRI, right? I'm not proud of it. Yeah, but it's but it's like it's like looking at your business, right? And

You had one employee that had a bad day, showed up late for work or something like that, and you immediately like think, Oh my God, my business is falling apart. In reality, it's it's one little entity might be wildly profitable and a million things are going right. So you have to be careful about honing in on one aspect of that diagnostic equation. So I talk a lot more about not just having a medical diagnosis, but also having a movement diagnosis, having an ability to relate how you move to what's actually taking place in the context of your symptoms. So let's talk about that because As always with my very self interested podcast I wanted to have this conversation because I think it'll be very helpful for folks who are trying to navigate This type of non homogenous condition. I just like using big words. And uh

I also wanted you to have a chance to look at my movement to look at my current state to see if you can discern anything about the low back. So what might a movement screen or assessment look like? What are some of the things that you take someone through? The first thing I'll say is it always starts with a

With a conversation. And I think that's really, really overlooked, unfortunately, nowadays because There's one thing I've learned over the course of my career, it's that people always underreport. Even if you look at like facial manipulation, which is a prominent, you know, soft tissue intervention right now. They'll dig deep on, hey, did you break your ankle when you're younger or anything like that. So it can really open some some eyes for you. And I've had uh several times in my career where I've been burnt by by not digging deeper. Or you you look at a guy and it's like yeah I You know, y it just doesn't make sense. And I scaped my I fractured my scapula in a car accident ten years ago. Do you wanna give an example on the prescription med side? Because people might think it's Unrelated so they don't report it. But whether Accutane or something else. Yeah, that is one that we if if there's one we see the most commonly, particularly because of our work with young athletes, is you know see athletes that are taking acne medication and don't necessarily want to report it. It's a sensitive subject, right? And oftentimes you you do a postural screen, they take their shirt off and they have significant

acne that's readily apparent, but you know, some of that stuff can stay in your system for a while and there can be some pronounced, you know, musculoskeletal side effects in terms of joint pain and things like that. So we've seen a number of athletes over the years that have done well if they've gotten away from it, but we've also seen scenarios where they didn't report it. And you know, we floundered with kind of the wrong approaches for three or four months before it finally just came up in conversation. You know, in the general population, certainly there's there's concerns. You guys spoke on your podcast about statin use. You know, some people do have really significant muscle soreness with that. we've seen certain antibiotics that may make people more susceptible to tendon injuries as well. Yeah, that's one that's been discussed for sure. So it just speaks to you always have to dig deeper on it. And people really tend to underreport, you know, pharmacological interventions, they underreport previous musculoskeletal injuries. Um and I think they also underreport What they might not know. Do you know if this person is wildly deficient in vitamin D or they have an adequate magnesium levels? There can be so many different places where things can kinda go off the rails systemically, that I think it's just so important to always start with a conversation and and also get a feel for their history with exercise and in some cases rehabilitation, what's worked What hasn't, what's made you feel better. All right, you you felt great with dry needling, but not with something else. Those are all things that can kind of clue into the

You know, the clinical puzzle, so to speak. Yeah, totally. If somebody's Yeah. Let's just say uh Jiu Jitsu player. And they're constantly in guard. That's gonna be very different from, say, a surfer.

Who spends ninety percent of their time paddling in that extension. So you have the conversation What happens? After that. I always go to a a static postural assessment. And there's a lot of I guess debate over posture and it doesn't perfectly predict injury or lack thereof, but does give us some clues into where people at least start. And then there are

schools of thought that are heavily focused on alignment. The idea being if you're in a good alignment, it's gonna increase the likelihood that you can be in a better position once you actually wind up somewhere else. I look at it it much more as how's gravity working on this body? What are the shapes that they're in? And it starts to give me some clues on hey, if you've got really, really low shoulders, you got this downslope shoulder blade like crazy, And you have anterior shoulder pain. I'm I'm probably thinking that when we get to movement, your you know, your scapular upward rotation, what's taking place when you take your arms overhead, probably is gonna be less than ideal just because you're starting ten yards behind the starting race. The other fly in the ointment for me is that I have Congenital. Transitional vertebra.

Well, I should say uh vertebrae. What is the plural? Vertebrae is the singular, I guess. So I have one transitional segment. Which means For people who may wonder. If you're looking at my lumbar spine, so my lower back. On an M RI from the side.

These segments of the spine should be. I'm simplifying here, but look kind of rectangular and In my case I have one vertebra in the lower back that is more like a wedge. It's like a door wedge.

So I have a lot of lower back. Lordosis, right? I have sway back, basically. I used to have kyphosis, which was that like Yeah. Thankfully fixed that. But that is also another

That's another aspect to this whole thing. Which Has led it to be a problem for decades. It's true for my brother as well. But then whatever it was, twelve weeks ago, suddenly

Everything. Just got put into acceleration mode from a hand perspective. And it's really been mystifying and it it's made me really sympathize for people in chronic pain because I it seems to be such an elusive problem for so many people. So you look at the static. Posture. Mm-hmm.

What comes next? I mean, to your point, everybody's invincible until they're not, right? You know, and I think that's that's a a line I I tend to use quite a bit. But you might have that conversation about hey, I have a congenital variant in some way. Some people we see in the structure are their hips or could be a number of different things, but what you also have to do is have conversations with doctors, with physical therapists to see if

their symptoms actually correlate with where that may take place. And that's something I I should emphasize is that I work as part of a comprehensive team. I have physical therapists one door down and massage therapists and we refer out to a lot of orthos on the regular, but once we've done that postural screen, you know, for me I I will go into a collection of like I guess classic orthopedic range of motion tests. We may do some manual muscle testing. And then we actually get them up and move them around in more general screens, things like overhead squats, overhead lungewalks, pushups, toe touches. Shoulder abduction slash flexion, all these different screens that are I guess collectively general screens. So you want a collection of both general and specific screens that you're not necessarily missing things. I got it. So general screen, but you're also doing specific screens that might relate to the lower back correct assessment. Yeah.

And those are your your gateways, right? In in my world, those are sometimes just the things that I need to know and whether, hey, we need to refer this out. Yeah.'Cause you know you're gonna have people that walk in with low back pain that just they trained like idiots. They either choose the wrong exercises, they call it an idiot. Or they go in the wrong uh they go in the wrong patterns or whatever it is. So they some people just need good coaching and Maybe a little break, maybe they need a discussion about like hey, the the volume in your program is just inappropriate. We need to find some different kind of variability for you. And then other people may kind of scream this is something much more clinical. We need to escalate this. We need we need to get it to the hands of somebody who could do some imaging for it and maybe get a better diagnosis, or we may in house do some kind of test retest where it's, hey, let's do some manual therapy here and let's see if they get some symptomatic resolution. And if we do create some kind of a transient change, whether it's in the context of their range of motion or in their reduction of symptoms, what are some things on the exercise side of things that we can do to follow it up to make those changes stick?

Is there a resource Or a book, anything. That people could check out to become familiar with some of these movement screens. Long time ago I talked about FMS in For our body.

There are probably many other variants of that type of screen. With the understanding that you should work with a professional, are there any other resources you might recommend. Yeah, for sure. And I think the the crewed FMS has done a good job and and the selective functional movement assessment is kind of a little bit more of a clinical add on to that that I think they've done a good job with that. If you walk in and look at our screen, it's really a collection of different philosophies all melded together. So I think my response would probably be very different for people in the health and humor performance industries asking versus like a general population folk. With that said, I know Kelly and and Juliet Starrett in their new book have kind of talked about some stuff. He was a recent guest, just, you know, things that people should be able to accomplish in terms of Activities of day living and task. I do think that's all maybe a a good proactive screen that people could use. Built built to move for people to just finish it. Mm-hmm.

Yeah. So people can start there. Let's continue to go down the rabbit hole of lower back pain. So I'm looking at some research that

I gathered for this conversation. Could you speak to maybe Some of the ingredients in the cocktail that can Produce lower back pain or exacerbate lower back pain. So I have a number of things here. I didn't want to read

them in depth. And maybe you have revised your thinking on this. But I have a whole list of things here. Left AIC, right B C patterning, no idea what that is. Poor motor control and strength of the glutes, poor hip rotation and mobility in general, thoracic spine mobility, et cetera. Are there any usual suspects. that in

Not necessarily sedentary, folks, but let's just make this personal'cause that's the easiest way to have a conversation. You have a former competitive athlete, me. And I've done a fair amount of extension and flexion, but I'd say probably more Flexion. Just from wrestling. Yeah, and so on. And

I have not competed in a long time. But I've continued with the weight training. Mm-hmm. And sometimes more methodical than Other times. What are some of the ingredients that you would want to consider

as part of the cocktail that is Producing the lower back pain. I can't remember when I wrote that, but it's uh good find in the archives. Yeah. I think the big things that I would say is is all those things come back to probably two things. It's loading aberrant patterns. So, you know, in the example of the left AIC, right B C patterning that speaks to the Posture Restoration Institute and they talk about a very predictable pattern of asymmetry, you know, right hips that are shifted out, low right shoulders. And so there can be some compensatory things when we start to to load that. What does that mean? Left AIC? It's just an abbreviation for the pattern that they talk about. I see.

But basically that's the way they define it. And you will see it very commonly. Like if you go to any major league baseball game, you'll see every shortstop standing between pitches, like in the exact same position. They'll be stuck in their right hip with a low right shoulder. And their mindset has always been that we'd rather breathe well and move poorly than move well and not be able to breathe. It's a survival instinct. And yeah, to some degree these patterns that we account for are how we maintain our line of sight and our ability to to breathe the way that we want to. So, you know, these are normal asymmetries, right? We have a heart and we have a vena cave on one side and a liver on the other side. But when we get into trouble is where these things may become excessive and we we load on top of them and we lose the variability that we count on to have long term successful movement. And I think that's what leads kind of to my second point is that when we talk about poor hip rotation, poor thoracic spine mobility. Really where people get into trouble is they sell out for too much movement at one joint. What do you mean by that?

So if you look at how your spine is constructed as an example, look at your lumbar spine. They're they're very big. Vertebral segments. They're really conditioned much more for handling compression. They don't rotate nearly as much. And as you go further up your spine, you have substantially smaller segments that are way more equipped for rotational capacity. And I think that just speaks to our body's wonderful design, is that we need to get a lot of rotation through our hips and a lot of rotation through our mid back or our thoracic spine and certainly our our cervical spine as well. And we don't necessarily have it. Sometimes we go to the wrong places to get it. And that's why some people will wind up with back pain.

What would be some of the wrong places? The lumbar spine in particular. Oh, rotating at the lumbar. Correct. Basically using the molars of the back to rotate. That's exactly it. And you get into trouble when you bang those big segments off of one another, you can wind up with a collection of different issues and You know, Stu McGill has has done some great stuff in his research where he's talked about spine range of motion, particularly lumbar spine range of motion being positively correlated with injury risk. It has to move, but it just can't move to a There is such a thing as hypermobility. Exactly. And I think the challenge that we see sometimes is how people change over the course of time. So you know I talked in that article about poor hip mobility. And we know is that some athletes over the course of time will develop reactive changes in their hip. Now, does poor hip mobility in this context mean hip extension, sort of the freeze frame of the sprinter with one leg behind them, or does it mean something else? I think it can be

All the above. You know, if you look at a lack of hip intern rotation, it seems to be associated with low back pain and golfers. So I think it depends on what your activity is. But I would argue that not having sufficient hip flexion can create problems too. I think it's a joint that obviously has evolved from an evolutionary standpoint from being very, very mobile to being a little bit more stable to support weight bearing. But where we get into trouble is we start to lay down, you know, a lot of bony overgrowth on the acetablum to the socket or on the the head of the femur. And those can create a collection of challenges because you have stiffness that you have a hard time working around. So at the end of the day, it all comes back to we lose variability over the course of time. We lose the ability to go back to what's very foundational for us. So I'd love to chat maybe about thoracic mobility in a second.

Just to do a deep dive on one of these. First I want to say and you can fact check me on this, just for people listening who may suffer from low back pain or back pain, or actually it's a question, what percentage of your super high performing players If you were to take an MRI of their back. Have you got to be able to do it? What would be

viewed as something. Pathological or deterioration. A hundred percent. And the best example I can give you, this is with knees. 2020 study of 115 patients, average age was 44, so 230 total knees. MRI showed abnormalities in 97% of knees. Thirty percent of them had meniscal tears, fifty-seven percent had cartilage abnormalities, forty-six percent had tendon abnormalities, and six percent of them were actually qualifying as high grade tendonopathy. They had some ligament disruptions in there, two percent of them had ACL issues that they didn't even know were there. And so these are 44 year olds, and this wasn't really an athletic population. So you can imagine the wear and tear that takes place from playing any sport at a really high level. And you can do this for every joint in the body. It's it's pretty eye opening.

And When I reached out to Kelly Star at the co author of the most recent built to move you mentioned. About the same MRI read.'Cause I was like, Okay, Defcon five, need to figure this out. Especially before I go travelling internationally and won't have won't have access to much.

And his rough reply. I'm paraphrasing here, but you might recall some of this. He said, You know, all that says is you're a savage who's played sports really intensely. He's like, Guess what? If I sent you a photo of your face from when you were fifteen and then compared it to your face now, you've aged. That's true for your back too. Rub some dirt in it. He's like, it's gonna be fine. Don't forget. And then he sent me a photograph of something that was removed from his knee. I can't remember what it was. And he's like, That's supposed to be flat. And it was just a mangled mess. And he's like, Yeah, now I'm back to Full operating capacity. And just to your point, I think normalizing it a little bit for folks to say hey

This is super common. And it's just part of being human for most. Insignificant, but it's part of the discussion. Another study that I talk about a lot with our athletes. So there was a study of Scandinavian junior basketball players. And this is significant because we're talking about a collection of basketball players in their late teens. Like these are the guys that can recover from anything. I'm in my forties. I can't bounce back from the dumb stuff I used to. They looked at 134 players, 268 tendons. And this is where it gets really fascinating. There's only 19 tendons. So 7% of them actually presented clinically with like a patellar tendonopathy. They said the front of my knee hurts.

And then what they did is they went back and they ultrasounded all 268 tendons. And they found that under ultrasound, 26% of all tendons could be diagnosed with tendonopathy. So they hit the clinical qualifying criteria for a tendon problem. So you can make the argument that for every one we diagnose, there's probably three that get overlooked. And it's probably substantially higher. Both these numbers probably shift as we get older and older. And that to me is just so important is is you almost have to look at your muscular skeletal health as there's a line. It's a symptomatic threshold line. I'm either above it or below it. It's kinda like being right on the fringe of having like a type two diabetes diagnosis. You go for a walk, you watch what you're doing. Exactly. That was a veiled cookies reference. But I think what we look at is Everyone to some degree is probably working right at that threshold. And maybe it's because some of those imaging findings are significant, but it's our job to figure out what can we do with our movement diagnosis? What is it that we see and how they move, whether it's a hip rotation limitation or a lack of scapular upward rotation or poor cervical spine motion, whatever it is, what are the things that we can do in our training interventions?

both in terms of what we do and what we don't do, to keep people below those symptomatic thresholds. And it's not even just an exercise thing. Sometimes it's a You know, we've all had that friend who got dairy out of his life and it changed his life. Or someone that was legitimately intolerant to gluten that had serious problems with that. And so sometimes it's a systemic intervention as much as it is like a true, you know, training or rehabilitation intervention. Just a quick thanks to one of our sponsors and we'll be right back to the show. This episode is brought to you by AG1 by Athletic Greens. I get asked all the time

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One hundred percent satisfied. Learn more. Try it out. Athletic Greens dot com slash Tim. Yeah. So let's take the limited thoracic mobility. Please feel free to fine tune this, but let's just call it

Mid back? Yeah. Just for simplicity, so people. Know what we're talking about. A lot of folks listening spent a lot of time at computers. Probably not getting much rotation.

What would the training look like if you diagnose someone with very poor thoracic Mobility. What might some of the training look like to address that? The first thing is I would say make sure that you're separating static posture from movement proficiency. And we see very different things in an athletic population versus a desk bound population. And a despound population

You're obviously gonna see people similar to older adults who acquire a you know more of a hunchback posture, that kyphosis. In athletic population, we actually see a lot of very flat thoracic spines. We see people who are almost like in a military posture from extending and rotating so much. And that actually creates a scenario where we need to do a lot more reaching and rounding and rotating to drive flexion. So in in my baseball guys, we spend a lot of time talking about that. Could you say that one more time? Talking about what? Yes, so we're talking about the upper back. You know, I think the assumption is that everybody is very kyphotic, meaning that we have like that classic S curve where we round up top and then we arch further down. And that's how we're built, but we can acquire different positions in different places, right? So if you sit at a computer all that, you're gonna more than likely reaffirm that it's gonna get significantly worse.

In an athletic population, what's interesting is athletes extend, they rotate, they actually arch their upper back so much that they move in the exact opposite direction, and they actually lose the convex, concave relationship between the rib cage and the scapula. So in our baseball world, we actually do the exact opposite in many cases of what we'll do with a lot of our people. Or maybe the folks you're referring to, the folks that sit at a computer a lot. Well let's take the computer folks just because that's gonna be the majority. Yeah. What might you prescribe?

In that situation. I think the number one thing that I'm looking for is I'm looking at that upper back posture. as an avenue through which I can create movement and in particular rotation. Historically speaking, if you're really rounded through your upper back, it's not going to rotate very well. If you just look at the way that the segments kind of sit on each other. Try to do a pyrouette while you're bent over the waist. Exactly. So you know I think the challenge is a lot of people go to the gym and they do things that reaffirm it. They ride the bike, they bench press, they do a lot of things that just just kind of support that existing posture. So do a whole bunch of cycling to exactly reinforce the computer posture. And then on top of that, they may select exercises that don't allow them to safely get out of that posture. So classic example is The guy that sits like that at a computer all day and he goes to the gym, he tries to overhead press and his shoulder starts to bark at him. There's nothing inherently wrong with overhead pressing, but he might not have the proficiency to even get enough thoracic extension to safely get overhead. Yeah. Just quick side note, one of my very close friends

Has this habit. proportions are a little unusual. Former world Championship level kickboxer. But the way he

historically has worked at his computer is Kinda slouching back on a couch so his head is really create forward. And he was totally fine. Until he wasn't, where he went from that posture for like eight hours to playing a game of tennis after work.

Did a couple serves. And then had two plus years of Horrifying neck pain. Just bending the paperclip into sort of rangers of motion where you don't have and think about what happened. Is that's just is robbing Peter to pay Paul, right? If your upper back doesn't move

Something else has to pay the price. Maybe it's his cervical spine that was put into positions that were less than ideal. A lot of times we see a scapula that just doesn't sit flush with the ribcage the way that it should. So let's say you have somebody who has developed a bit of the quasimoto. Back. Yeah. Where do you start?

The first thing I that I'm gonna try to do is I'm gonna try to safely give them movement variability. So things like, you know, the old kind of adage of pull twice as much as you push. There may be some merit to it in that population. I get on board that. When I'm doing my pulling, I'm actually doing a lot of stuff that's probably unilateral. So one arm at a time. And the reason I would do that is I want to be reaching with the opposite arm. So I wanna kinda bring everything back to almost ambulation, like that reciprocal action that takes place during the gate cycle. Could you give an example of pulling and then pushing Or extending those. So think of like a cable row where you just do it one arm at a time in the standing position. And if you're rowing with the right arm, you would actually be reaching forward with the left. So you're actually in the process, you're not just moving your shoulder blade on your ribcage. What you're actually doing is you're teaching your thoracic spine to rotate a little bit more. So we we find ourselves trying to attack rotation. I think more and more across the board with our clients just because it is the thing that seems to go away. Even people that live through a full range of motion and live what we think are really varied lives, like you you look at them and they they often lose T spine mobility, they lose hip rotation over the course of time. Maybe that's just where life takes us. You know, we don't run as fast, we don't, you know, do as many athletic things into our forties. But it's been impactful for folks.

Yeah, so T spine that's thoracic, folks. What are some other tools or exercises that you might consider for somebody who's Mostly deskbound. Which is a lot of people, including me, right now, I would say. Like even if you are training every day.

It's like okay, well you have I think you've written before, it's like you have two hours to get it right and like another sixteen to twenty hours to get it wrong. Absolutely. What might you Inject into the program. Yeah. first thing I would say is amplitude. And maybe I I got ahead of myself by talking about the rose because that's a that's a loaded movement, right? I think probably what's more important and when we look at like the long term successful folks that really do make significant changes not just to their posture, but probably more importantly to their movement quality. It's using the warm ups to actually impart some kind of favorable change to the way people move. So instead of just getting your body temperature up riding the bike for five minutes, the play is more often than not to find ways to expose yourself to new movement patterns. So for some of the folks, there may be like an element of

self-myofas release, whether that's using a lacros ball or an acu mobility ball or foam rolling or something to that effect. And then following it up, we may do some positional breathing just to kind of teach different ways that they can get expansion through their rib cage, which can help them to optimize some of their mobility through their T spine for sure. And then following it up with larger amplitude movements. When I say amplitude, I mean add range of motion, stuff that you don't get. in your daily life. We look at people that work on factory lines that do the same thing over and over again. They they wind up with these pattern overload things, but if we give them exposure to more significant ranges of motion. They do substantially better. And and it's probably something that's mediated through the the fascial system. We look at all these fascial chains in our body, everything starts at our hands, our feet, and our head. And if we're really stuck in a small amplitude movement for an extended period of time. Meaning shorter range of movement. Correct. Yeah, exactly. And you know, Thomas Myers, who's the author of Anatomy Trains, I distinctly remember of

conversation with him. He spoke at a a conference back in 2009. You know, at the end of the conference, I remember chatting with him and he said, you know, we probably know about 25% of what we need to know about the fascial system. And he listed off, you know, a few different things that he thought were really important for fascial fitness. And really the biggest things were multi-joint movements and be patient. Those are the two things that he emphasized over and over again. And I mean, I have twenty eight year old daughters and a four year old. And they do everything imaginable. One of'em like sits upside down while she's reading. Every walk across the living room has to include a cartwheel. They are craving movement variability in every aspect of their life.

And over the course of time we just lose that. Whether it's long car rides or you know, different things that we do, like You didn't see my cartwheels after the cookies last night. Exactly. You know, I I think sometimes a loss of athletic participation, right? It's very structured in our world from up until age eighteen in many cases. And then people, you know, they go off to college, they get jobs, whatever it is, and Unless you're joining like a men's soccer league every, you know, Saturday afternoon or something like that. It's not there. And I do think there's something to be said about folks trying not to lose that amplitude in their lives. And we even see it in higher level sports. I work in baseball, and you know, if you're a starting pitcher, you want every pitch to look exactly the same. Where you get into trouble is when there's deviations and hitters see it differently. So there's an unyielding level of specificity in the baseball world that needs to be, I guess, supported by training that adds varied range of motion to people's daily lives.

Let's expand on the fascial manipulation and then I think uh I might want to come back to Exercises. Yeah. Just to paint a picture for actionable stuff that people might consider. You talked about the row. But other examples of Increasing range of motion amplitude. So we could do that in either order. Do you want to hit that first or would you want to go straight to

Fashion. matters. Let's talk the exercise stuff since we're we're kind of touching on a little bit. You know, and I think another thing that's really, really helpful is Anything that that allows your your shoulder blade to move freely in space. So you think about if I have you go in and do a bench press. You lay on your back, your shoulder blades are kind of tugged down underneath you. And in fact, the way that we coach high level benching is pinch your scaps down and back. In the real world, when you reach your shoulder blade actually has to move around your ribcage. It effectively delivers your arm. That comes from thoracic rotation. So the upper back rotates, which moves the rib cage, the scapula moves on the ribcage, then the arm moves. And when we're stuck down on a bench, it's not

necessarily a truly functional movement. And it might be great for aesthetics and it might be great because you you know you like to bench press. That's all ex arms aren't practical in all things it is. So I whenever possible, I try to emphasize things like push ups. Cable presses. I love landmine presses. So let's talk about these push-ups. Are you talking Getting into more of a hollow back position or just a flat position? I prefer the hollowed back position. Well, I call them yoga push ups. Some people call them push ups to downward dog, but I think those are great options for driving some scapular upward rotation and and really I kinda hinted at that convex concave relationship of the scap and the rib cage. That's so important to really reaffirm. What were the other two that you mentioned? Any kind of cable process where you're in the standing position?

Maybe pressing away from a cable column and some of the same ideas of opposite arm reach can be really helpful. I got it. Alternating arms. Yeah, exactly. And so it'd be sort of like a We got this right. Unilateral. hammer. Press. But with cables. Something like that. And then the the landmine was the last one. What is that? Uh landmine. Imagine a barbell stuck in a corner. They they actually have you know that's an overhead. Correct. Yeah, and it it is and it isn't. It's interesting. You'll see a lot of people that can't handle overhead pressing and they do great with landmine options. And you can do so many different variations on it.

And is the landmine from uh half kneeling position. You can go half kneeling, split stance, standing. We'll do step throughs, we'll do rotational ones. There's a couple different attachments that you can use. Tons of stuff. I mean quick Google search will we'll find you a million things on Instagram and on YouTube. For better or for worse, right? What what are the benefits of landmine presses. I think above all else it's the free scapula pressing. Your shoulder blade is able to move freely, whereas it's not locked to a bench like you would with a bench press. But I think Beyond that, there's something to be said about it. It's almost like a calculated way to get some axial loading. You know, some of the same thing. Yeah. So when we deadlift, when we squat, there's a significant amount of load that goes through our spine. And some people don't handle that. really, really well. And I'd argue you're probably a guy like that right now and you may be one of those. Yeah, you probably could could landmine press. I know for me personally, I don't handle really, really heavy overhead pressing great with my own shoulder history, but

Actually my low back that bothers me with the overhead pressure more than my shoulders. Even though I had my left shoulder completely reconstructed My shoulders are still better than that's it's sometimes where you have to look deeper as you look back at the injury history is you know, maybe there's a mobility restriction, a loss of thoracic rotation from, you know, wearing a sling after a surgery. These are all things that you have to unpack, but landmines are are awesome. We use them with our general pop folks, with our with our athletes a ton. It's just kinda like a It's a moderated overhead press is the way I would look at it. So definitely a important tool in the in the training toolbox. Do you use weighted exercises like chop and lift with cables or some variant of that? Yeah. We do those quite a bit, both chops and lifts. We throw medballs a ton. We use something called the Proteus, which is a a cool technology. kind of purely concentric that allows you to train some of those patterns in a fluid way. Why is that meaningful? So for folks who may wonder Please correct me if I'm getting this wrong, but if you imagine doing a bicep curl, because most people know what a curl is, the concentric would be the positive portion when you're lifting the weight, the eccentric would be the lowering of the weight where you're sort of lengthening the overlap of the fibers. Why is the concentric focus helpful?

I think it's important in part because you can do more of it. You can do a high volume of concentric work and it won't necessarily make you sore. So it can be advantageous for athletes who are in season. But there are, you know, scenarios in our daily lives where we do have kind of purely concentric stuff. Think of like, you know, lifting a couch to help your friend move to a to a new apartment or something like that. Or just Yeah, things that we do with medball, if you look at like some of the athletic activities that we encounter, like you know, kicking a soccer ball is largely a concentric motion. There's gonna be some elements of deceleration sports, there's a ton of concentric moment. Yeah, but it's you know there is a high velocity component. So when you throw a baseball, there's actually a ton of deceleration taking place throughout the entire system. But it is a concentric dominant sport. So I'm just going and training the opposite direction. Doesn't necessarily match up from like a pure loading and velocity standpoint. Okay, so I feel like we've checked the tick box of a number of exercises that people might

Find helpful. Of course, with the help of a professional. Fasha. Mm-hmm. Let's talk about it. Yeah, there's a lot to talk about. There is. And probably get some death threats from people that listen. People are crazy out there. It's wild.

Yes, people are it's religion, politics and the fascial system are kinda like uh three big things. I saw you posted the the picture of some cupping that you had recently and You got eviscerated for lack of better term. Yeah. And then I followed it up with saying this is the Rorschach test for people on the internet with strong opinions. Because I didn't even provide any context, right? People didn't even ask what I was using it for. But the Conviction and the rage. Was impressive.

So Maybe you could just start from the basics and Explain. What fascia. Is.

And then we can go from there. The the best way I can describe it is all the first time I ever sat on a surgery. I sat on an elbow surgery. And for those you don't know, Tommy John surgery is a most you know, kind of storied surgery in the baseball world. It's a tiny ligament on the inside of the elbow and it's a limiter, right? It's subjected to crazy high stresses at super high velocities and the the fastest motion all of sports, which is the baseball throw. And what basically happens is that ligament when it's ruptured needs to be repaired. So basically They'll

you know, basically take a graft either from your forearm or from your leg and they'll use it to take a tendon and make a ligament. But what happens is they have to do an incision on the inside of your elbow. So they open you up. And when you open it up, you're you're expecting to see this pristine anatomy chart the first time you're there. We all took exercise physiology, anatomy, all that stuff. And I even had gross anatomy during my undergraduate experience. I spent a much time with cadavers, and it still didn't prepare me for this. But they have muscles, they have tendons, they have bones, they have ligaments, they have nerves. That's the stuff you expect to see. But when they actually cut that elbow open for the first time, you're like Holy cow, what is all this stuff? It's the fascist intermuscular septum in it. And a ligament is intramuscular septum. Exactly. Yeah, I'm throwing big words out here. I need to slow this down. So you go all the way down. I'm gonna use it correctly tomorrow. I can't wait. Yeah. And

What you're looking at very quickly is like there's a lot of stuff to get through because a ligament to connects bone to bone. So you see all these different layers. It's like what is all this stuff in the way that wasn't in any of these anatomy charts. And visually what does it look like? Is it kinda like spider webs? That's a great way to describe it. Yeah. And the hard part is when when I got gross anatomy, a lot of it had been cut away. because they were teaching you muscle, you know, we were the exercise science students, the med students and the OTs and the athletic trainers, they all got it before we did. So we we missed out on all that. The hard part about that world though is it's very, very important in terms of as we're learning kind of how it both restricts or optimizes mobility, how it helps us to transfer force. And the best way I can describe it is we've all seen that freaky athletic high jumper who just doesn't look very strong, but jumps out of the gym. We see baseball players. In our world, there's a couple of guys that throw a hundred miles an hour that weighed, you know, hundred sixty, hundred and seventy pounds. It just doesn't make sense. These are very fascially driven athletes. They're not producing high levels of force with classic muscular strength. If you looked at like a Mark Maguire back in the day, Maguire's a very strong guy. It looked like the ball just sat on his bat for a while and he muscled it out of the park. And then you look at other guys who had just freakish bat speed that, you know, were very elastic in nature.

Dan Paf is a great coach. He talks about mechanically and fascially driven athletes. Our fascially driven athletes largely use this kind of connective tissue matrix. to really effectively transfer force. And I think you can fine tune it, much like a whip, you know, some people are really, really good at one activity. I'm a guy who was good at picking up heavy things off the floor, but I wasn't a great overhead presser. So I think we get what we train and the fascial system is probably one reason why. What are This is wading into dangerous territory, but misconceptions about the fascial system or Some of the

most interesting modalities of manipulating the fascial system that you've seen good outcomes from. with your athlete. Yeah, full disclosure, I am not a massage therapist or a physist or even athletic trainer. So it's outside of my scope of practice to actually do manual therapy. But just what you've seen. I'm fortunate to work with some really, really good ones. My business partner Shane in Florida is phenomenal is see some really high profile athletes and on a regular basis I see people that walk out of his office Shocked at how good they feel. And I think What do we have in our toolkit? It could be a number of different things. It could be a very focal approach, like a dry needling. You know, kind of centers on trigger points and things like that. And dry needling for people who don't recognize it. Number one, I don't think you can find practitioners in all states. I think it's Yeah, there's some limitation. But dry needling, is it fair to say that

Same tools of acupuncture, but instead of Meridians, you're I'd be very careful. And not. I tread as uh this entire conversation we're treading is the um so that would be a more focal east of exercise physiology. And then certainly, you know, there are things that are focal with respect to like classic pen and stretch techniques and things like that. Pin and stretch, so this is pinning something down, pressing into it. Yeah, and then stretching it. Yeah, and then obviously. Would ART fit into that? ART is is is certainly a a focal approach. Right, active release technique. Absolutely, which is, you know, had great success in certain populations. And then certainly you have more diffuse approaches that might cover a larger surface area, something like an instrument assisted approach where they might scrape along the entire length of your hamstrings, something like classic massage, which tends to cover a lot more square footage and then and cupping could kind of go in both directions. You can cup and drag, you can throw a cup on one spot. So there's a lot of different

Ways that you can impact the fascial system. I'd say the biggest misconception about it is that it doesn't work. I mean, that's my personal opinion. I think there'll be some folks from the paint science community that will have really strong disagreements. My mindset has always been if it's been on cave paintings for five thousand years, massage probably has its place and we're just figuring out why it works. I don't think I'd be able to walk if I didn't have regular soft tissue work. Yeah. It's it you know, it's it's a challenging thing to study for sure.

I do think that the academic world is doing a better job of actually starting to learn more about how different fascial layers glide on one another. We're actually starting to get some of the technology that can kind of see how things change pre and post treatment. At the end of the day, we haven't necessarily elucidated exactly why it works. And it's it's probably not even my place to say, but we are big bags of water. And probably what's happening with fascial interventions is that we're changing the way that fluids move so that folks do have better gliding of tissues that are adjacent to one another. I don't think we're mechanically breaking down scar tissue. Maybe we're stimulating the nervous system in a unique way that translately reduces the risk of fat threat and maybe creates this short term opportunity for us to put in the right exercise interventions for motor learning. And that's the stuff that I think that's missed. Some people might not have a good experience of manual therapy, either because they work on the wrong places, they do the wrong approach. Or what I see more commonly is they get that transient reduction in symptoms. And what they don't do is follow it up with the right interventions to make the changes stick. So they feel good for ten or twelve hours and then the next day they they go right back to hurting. But I can say for All of my interactions with athletes, you know, the success of our business, manual therapy has been a very important inclusion.

Part of the reason that I've traveled to where we're recording today is to do multiple sessions with someone. Who focuses on Fascial manipulation. And I won't name names, but I was introduced to this Person by a friend.

PhD in neuroscience who Thought she had. Effectively permanent injury or disabilities related to multiple child births. And nothing.

even reduce the symptoms. And I recognize this as an anecdote, but She was completely transformed after Two or three sessions.

And You know, I try to wear a skeptical but not cynical hat. Also recognizing it's easy to throw the baby out with the bathwater. Sometimes think you might agree, like some of these amazing

Soft tissue workers may be very good at getting clinical outcomes, but they may not. even themselves understand the exact mechanisms by which they're getting these outcomes. But One thing that I did notice. immediately was improved range of motion in my ankles. I've had a lot of lower leg injuries.

And in the last two weeks after Getting them. Pulverized, basically. It's incredible to notice on a daily basis how much more range of motion I have. And I certainly need to strengthen into those New ranges.

But I'm excited to see where it goes and I'm sure we'll get lots of strong opinions on the internet. Where does it make sense to go? Next, we could talk about fascia. We could talk about Low back.

More if we wanted. Could you talk to the role of the glutes? With respect to Low back pain or lack thereof. Yeah, for sure. And I think the whole glut amnesia thing maybe has been a little overdone. I tend to look at them as part of a comprehensive system. I mean that we live in a population that's lost a lot of hip extension. The ability to obvious get your upper leg behind your body. And we don't have adequate hip extension.

We go somewhere else to substitute for it. So Two big things happen. When that's the case, you either get too much motion through your blow back, so you get lumbar extension instead of hip extension. We tend to see that particularly if you see like fatiguing runners, you know, as time goes on, they just kinda keep arching their back more and more. And you also have kind of the way that the joint itself is controlled where your glutes are really, really important is They kind of terminally extend your hip. They give you that last 10 degrees of hip extension that are so important. And what happens is when they don't really do their job at terminal hip extension, you get a very hamstrings dominant pattern. And a lot of people, because of the way the hamstrings attach in your pelvis, will actually wind up with like an irritation in the front of the hip. So sometimes, you know, if the glutes don't do their job, it's not just the back pain aspect of things, but it's also a function of people.

kind of wind up beating up on the front side of the joint. That could be that could be an issue for me. Yeah. I look at it very much the the glutes are kind of your rotator cuff of your hip. I think less about activate the glutes, activate the glutes, and I think more about how do we clean up our hip extension patterns so that they're actually taking place in the right place. But the glutes are you know, it's a buzzword, you know, it's it's certainly something that I think has gotten some good momentum. For better or for worse in kind of the exercise community.

But I I look much more at How does it fit into the big picture, particularly because we just talked about fascial system. probably less about individual muscles and more about how comprehensive movements are controlled in a reasonably tight window. Where does

And you could define terms here, but where does This is the leading question. Strengthening the posterior chain. Fit into This is the same. Posterior chain hamstring glutes.

Yeah, Doctor Magnus, and and to some degree the lower back. Like all these things are vitally important. Stuff on the back, you're right. Yeah, everything on the back side of the body. I mean I think just in general we know that we're stronger in hinging patterns. If we're looking at functional carry over to the real world and our ability to attack what life stresses. I think Peter did a great job in his in his recent book just talking about the need to be be strong and to hip hedges. Do you need to deadlift eight hundred pounds? No. But in general these are high cross sectional area muscles that probably have a lot more of an ability to to help us. And most people are going to be stronger in a hinge pattern than they are in a squat pattern. So it's probably the most biomechanically efficient way for most people to accomplish various lifting tasks, whether it's something that's significant in the gym or something that's as simple as picking up a bag of groceries or a kid. What are your go to exercises. If you can only pick two or three, let's just say.

for the strengthening of the posterior chain and that hinging action. Where would you go? Without a failure, uh looking at a deadlift. And deadlift is a broad Categorization. You might have a trap bar deadlift or a kettlebell deadlift, something that In those realms are going to be a little bit easier to teach. A lot of people go right to the straight bar and some people just are not biomechanically set up to be successful with that. So we don't necessarily go to that.

Things like kettlebell swings, if you're ready for the patterning and the higher velocity, I think a lot of people need to train power as much as they need to train strength. particularly as we age and that's a a low impact alternative to going out and sprinting or jumping that, you know, isn't gonna leave an Achilles on the floor. So I I think kettlebell swings probably have some merit in that discussion. certainly various hip thrust opportunities have have come about in the industry from you know wide variety of exercise selections there. I think, you know, some people probably do better with them than others, but I do think there's a place for it. Anything in in those worlds are good. Single leg RDLs as well, it's kinda like a Romanian deadlift. Yeah, something underneath that deadlift umbrella. But there at the end of the day, most of them are gonna be deadlift derivatives. Same thing with a kettlebell swing. It's it's a deadlift that you just execute quickly. Why is power

Important as we age in addition to strength. And maybe you could differentiate the two. So really think of power as just strength with a time component. It's how quickly we can apply force. And you'll see Powerlifting is really not powerful. It's slow movement. Yeah, limbic lifting should be called power. Most of the athletes you see on T V are are really, really powerful. The guys that are running fast and jumping high. That's

kind of a in person demonstration of power. But I think where power is tricky, we we do know that it tends to detrain fastest strength, aerobic capacity. They they actually stick around pretty well. Assuming you're not like a crazy high level of those things, you can probably train it if you're in an intermediate to slightly advanced stage. You can probably train it once every thirty days and it's gonna power. No, I'm talking about strength and aerobic capacity. On the power side of things, it it seems like they it starts to detrain in as little as five to seven days. So it's very important to actually challenge it. And where it becomes vitally important as we age is, you know, this is the stuff that protects you when you're older and you want to avoid falls. And when we know that, you know, you fracture your hip. It's For a lot of people, it's honestly a death sentence as terrible as it sounds. because you know, it markedly impacts your mobility. We know that the the cognitive decline after a you know a loss of ambulation is is really substantial. So we see a lot of people that just tend to spiral after falls, being honest, my my own father passed away a couple years ago after he fell down our several cellar steps and and fractured his clavicle.

And it was very interesting, maybe in the context of the orthopedic relationship to systemic factors. He kind of went through multi system failure. He was unhealthy, but a clavicle fracture on a fall really kind of like pushed him over the edge on it. Would training power have helped that? Probably not. But I think for a lot of people that, you know, wind up with hip fractures and things like that, we have to be very mindful of how power could potentially have prevent it. So first I'm sorry to hear. That's the same. And second

Could you give an example of what type of power training might be incorporated. to help mitigate the risk of a fall. For instance. It sounds terrible to say. Any kind of sprinting.

You know, and I'm not saying go out at age eighty and sprint. But we do see people in those ages that play tennis regularly, that are involved in things that are that are higher velocity that involve change of direction. So I think a lot of it is remain athletic into age. So what'll we do with folks? We'll we'll throw medballs And for people who may not get that so medicine balls, right? Weighted balls that you're sort of throwing against a wall or on the floor. Exactly. relatively low risk for folks. can be really helpful, but I I think people sometimes overlook how much they do.

My grandmother is ninety nine years old and she still golfs. That's her version of power training and she's you know, she's got two new hips and one knee and and she's been doing great with the Robocop on the golf course. Exactly. So I I think that's vitally important. If you don't use it, you lose it and it's a function of a lot of things. That's mobility, that's strength, but power is probably the the most important of the bunch when we talk about aging. Everyone's gonna get stiff as they age, but you don't want to be stiff and weak slash slow. So before we Delve back into the weeds. I thought we would take just a little breather. And

Talk about it. Box. Because of the rapid fire questions that I had sent over Before we met up. You had highlighted a few.

Mm-hmm. Unpacking. So let's begin. With What is the book or what are the books that you have gift? Often before.

I'm gonna give you Two. Because there are kind of categories to it. I'd say the first one underneath this. Health and human performance realm.

Diagnosis and treatment of movement impairment syndromes. The Shirley Sarman book that I I think is landmark. It's I mean it's decades old. Super impactful, kinda reads like stereo instructions, so you're gonna go through a a page at a time, but Starman is is still a practicing physical therapist. I watch you in St. Louis.

You know where I think that one impacted me the most. is we'd always had this very pathology driven model of movement where it was like, all right, you have biceps tendinitis. Here's what we're gonna do to treat it. We're gonna do ultrasound on the biceps and you're gonna do this, this, and this. And it changed the perspective from that medical diagnosis to a to a movement diagnosis. Instead, we started saying, All right, you have scapular downward rotation syndrome. And someone that's in this position from a movement standpoint could have a lab strain, they could have biceps tendinopathy, they could have a rotator cuff irritation. So it made us realize that one movement issue could create a number of different pathologies versus going and, you know, having a diagnosis of biceps tendinitis could come from a collection of different things. So it got us thinking a lot differently about that. So that's one that I've I've recommended and gifted, you know, quite a bit over the years.

In a different category. Chip and Dan Heath's books across the board. Are excellent. I think the longer I'm in this industry, the more I realize that it's all about closing the gap between what I know and what I implement. I think so much of their stuff is behavioral nature, understanding what makes people tick and you know how to get them to buy into different things. I think Dan Heath's latest book upstream was really, really good just in the concept of thinking about What are the things that are upstream in terms of our athlete success? Well, it's sleep, it's nutrition, it's taking care of these higher level concepts before we even get into the nuances of the particular exercise that we're giving them and things like that. And to be honest, but Peter Tia's latest book, which I just finished last week.

is probably gonna trend in that direction. Some of the stuff that's meant for longevity still optimizes performance for athletes. You'd be shocked at how many. seemingly healthy thirty year old professional athletes have absolutely horrific blood work that really needs to be addressed and And I think that's something that could be a good one too. So I actually just got that from my mom. So nice. Um th three categories, I guess, there.

Yeah, I got it from my dad as well. Just a quick side note of trivia. So the Heath brothers with made to stick, I think it was. Forever ago. had the speaking session Right before me in March of two thousand seven.

when I gave my very first presentation ever about the then forthcoming four hour work week. Wow. So they were right before me. I was a nobody and they were the nicest guys. They're great. They're just fantastic humans. Their stuff reads awesome. Decisive is another really good book. I actually gift that to a number of different athletes who have been drafted, who have tried to decide between signing and going to college and just outlines the decision making process really well. So good stuff across the board. We'll probably return back to some of these rapid fire questions, but Now that we gave everyone a Scooby Snack.

Let's Go. Back to Something you mentioned earlier. You did mention medical diagnosis versus movement diagnosis.

And feel free to get into this any way that makes sense. But could you expand on movement diagnosis what you mean by that? For sure. And that is a in many ways a derivative of of Sarman's work that we just talked about. I'll speak to maybe my own example. I was a a tennis player in high school. Got recruited to play. I was a as many coaches are, I was a fantastically mediocre athlete. I was I was all stayed in the state of Maine. Problem is there's only about a million people and not a lot of people play tennis. So you know, upside was probably division three tennis, but I dealt with a lot of shoulder issues that ultimately kind of limited me from going on and playing college tennis. And this started, you know, my junior in high school and really It w it was present all the way through my college years as I kind of walked away from tennis. I I worked at a a club and strung rackets and gave lessons and things like that, but in reality it was something that really plagued me for a good five, six years. To the point that I was in pretty significant pain.

Actually in the summer between my undergraduate experience in my the start of grad school. I was diagnosed I had an undersurface cuff tear, which is a really common diagnosis. It's internal impingement, really something you see all the time in in a throwing population. It's basically a instead of in a classic like general population rotator cuff irritation, you'll see tearing on the top side, so the burstal side. I had an articular sided tear. So the undersurfied from serving? That's exactly what it is. It's that big externally rotated abducted serve. You see it in baseball players, swimmers, tennis players. And I went through physical therapy and I didn't get better. I'd gone through multiple courses of it. And so I went off to grad school in the fall of two thousand three thinking I was gonna have surgery over winter break. I was gonna, you know, suck it up for a few months. I was gonna have surgery the day I got back from break, you know, be in a sling for a couple of weeks and then hopefully go back and do the spring semester.

Was it a complete tear, partial tear? It was a partial tear, which to be honest, if you look at the research, sometimes are the most stubborn because they're most painful. Yeah. A lot of people, you know, I've seen Achilles or patella ruptures where people have no pain once they finally rupture, it's when they've got like a a partial tear that's more painful. Um maybe not very highly functional, but So I went off to college or to grad school in the in the fall of two thousand three, expecting to have surgery in three months and decided, you know what, I'm gonna just try to figure this out in my own. I'm gonna be a a guinea pig in the I guess in the to Tim Ferris way. I'm gonna experiment. So I Completely redesigned my training program, took out a lot of stuff, added some new stuff, and and just as significantly I found actually a a good ART guy down the street. How did you make those decisions? I had nothing left to lose. And and a lot of it was just self education.

reading what was out there and and again, this is two thousand three, so The internet now it wasn't as easy back then to kinda dig deep. So it was a lot more asking questions and Sure enough, got a got a good ART down the street. And First time I had somebody dig a thumb in my subscapularis, like pretty much changed my life. Yeah, I had bruised armpits and all that stuff. But um I rem I'll never forget Halloween Day, two thousand and three, I I called my my surgeon's office and I canceled the surgeon. I was completely asymptomatic. No.

How would you weight the factors that led to that? Was the ART Subscap release. A revelation were there other things. I think it was a lot of it. As I look back I wanted to know what were the shortcomings that defined my experience in physical therapy. Why didn't I get better? How could I have reengineered it differently? I think the first thing I'll say is I it was a classic kind of insurance driven physical therapy model. I was one of

Six patients at a time. Some of them were grandmother rotator cuff repairs, some of them maybe gymnast with stress fracture. That was a twenty two year old athletic guy who had shoulder pain and needed to learn. And so there was probably an element of like the exercises just not being done correctly with not enough eyes on me. So I think that was the first one. Second as I implied I really had no manual therapy. It was not a hands-on experience. For me, that was particularly important. I had a pretty significant athletic background and I'm sure I'd been accumulating a lot of gunk in my armpit, as I implied, and they didn't touch my neck. And just in reality, it was it could have been reengineered markedly different. But I think the biggest thing for me is there was no counseling about what else I was doing. That wasn't necessarily with respect to sleep or hydration. Yeah.

Incompleteness of the intake. the variables were not controlled enough. I might have come in and done all the exercises great. And it didn't matter because the training that I was doing on my own, maybe my activity patterns in both work and in training were just not ideal. So it made me realize that when we actually wanted to eventually design this system at Crusy Sports Performance, like one of the things that we needed to do was build out a team where everybody was rolling in the right direction, that there was no stone that was left unturned. And that when I see people who have failed rehab like I do, Often it's one of those things. They didn't have anybody put their hands on'em, or they've been giving

other exercises they thought would be helpful and they've been doing them completely incorrectly. So I kinda have my checklist that I go through. I certain exercises that are in almost every rotator cuff pain patient's programs and we come and we look at them and 75% of the time they're just not being done correctly, even because they weren't taught or they weren't being supervised. And it's to some degree, maybe it's a flawed business model. It's maybe some of the challenges with insurance driven physical therapy, but it's not really rehab unless you're doing the exercise correctly. So I I hate it when people say I I failed rehab. It's like no, sometimes rehab failed you. You were trying and you just didn't get the right coaching cue or the right intervention that you needed. Totally. And I should say, and this might seem obvious to everyone, but The worst case is not that you don't get better, you can also get worse. And I think about a partial labrum tear. that you know among my dozens of other injuries I had about

Two years ago? from getting back into snowboarding and just getting hyper aggressive immediately'cause I'm an idiot. And uh Long story short, it was misdiagnosed. And then I was given exercises that had a really strong kind of P N F internal rotation aspect and it just made it so much worse for weeks until I was able to say, Wait a second.

We see that a lot in the baseball world. And baseball players, if you think about what external rotation is, imagine what a baseball pitcher has to do to throw. It's like to really lay their arm back. They have freakish external rotation. But we actually see in the throwing shoulders something called retroversion. And it's actually an adaptation that takes place when kids are playing catch in the backyard at age eight, nine, and they actually warp their growth plates. And they acquire more shoulder layback. And it's advantageous. It helps you to throw hard and actually probably spares the elbow a little bit. But what we see is they actually present with less internal rotation on their throwing shoulder than they do on their non-throwing shoulder. And so it's in normal asymmetry. And what we'll sometimes see in clinicians that don't see a lot of baseball pitchers. they all of a sudden get their eyes on this like, oh my gosh, we got to stretch them into internal rotation because they're you're asymmetrical. And we'll actually see scenarios where the rehabilitation has created other challenges, whether it's a posterior capsule tear or irritation of the cuff. So it what it really speaks to for me is that

rehab in general is getting more and more Nuanced and niche. for lack of a better term, and and we started dealing with this baseball population, we quickly realized that It was a very underserved population. It was either, Hey, here's the football program or here's the rehab program, don't lift heavy or just do the football program. And we realized that you could push guys pretty hard if you understand their unique demands and the way that the game challenged them and what subtle intricacies that you may need to be put in from a exercise selection coaching standpoint. But we also saw

that the game was changing dramatically. There were way more specialization with younger kids playing baseball year round. The massive increase in fastball velocity that's still taking place. The average major league player, you know, gained twenty two pounds. twelve percent increase from 188 pounds to two hundred ten pounds from nineteen ninety to two thousand ten. The game is just played at these insanely high speeds. So if you have like a generic

program and you have maybe doctors that don't see a lot of baseball players and all those things, it you're not going to be very well conditioned for it. Yeah. Yeah, man. Sports sports evolve quickly. You know, you look at MMA or you look at tennis. We were talking about this before we got started recording just the average heights. It's incredible. You don't see many Michael Chang's playing professional tennis anymore. Freaky athletic, but these guys are monsters now. They're much, much bigger. Hit the ball down at you. Yeah. Um average basketball velocity in the major leagues climbs

every single year. And if you look at like my experience, we founded our facility in two thousand seven. If you were a left handed pitcher who was throwing ninety one to ninety two miles an hour, you were a first round pick. Nowadays. You see guys consistently throwing a hundred miles an hour. Some of those kids can't even get drafted. It's incredible how much it's changed. That's incredible. So let's tie Your personal experience. with your own issues when you're younger, say twenty two.

your personalization of your own program, having these breakthroughs with, say, the hands on with with ART. Which is is really remarkable on a whole lot of levels, I encourage people to check it out. My official release. More broadly speaking also. And if you have a kink for BDSM where you're not sure where to find a convenient dungeon, let's say, you can get the subscap manipulation to get your fix,'cause it fucking hurts. It's very unpleasant. You can get some like Iliakis if you really want to double down or uh so has work at while you're at it. Let's tie your personal story in

back into the broader question of movement diagnosis. I think the challenge then becomes I look back and I can see how I moved poorly. That's the challenge to me is that I was treated as a rotator cuff. patient when I should have been treated as here are the things that are I didn't posteriorly tilt my scapula well. I didn't upwardly rotate well. I had poor end range rotator cuff control. So I think what it speaks to is that if we're talking about

Medical advocacy being the overarching theme of our discussion. Meaning enabling people to navigate more effectively. Yeah. And I think when the conversation was initially happening, it was talking about, hey, our parents are aging, how do you advocate for your parents when they're getting medical care and you're having to make a lot of these hard, I guess, conversations take place. But I think there is a need for it on the orthopedic side of things. How do you advocate for yourself as a patient when your shoulder's barking at you? And I I think for me, I I always come back to like you have to do a lot of questioning. You have to ask to make sure like how specialized is my issue. Yeah in the baseball world. We had a teenage athlete.

This is two thousand eight or so, right after we opened up. And he had significant medial elbow symptoms, pain on the inside of his elbow with throwing. And Super stubborn, had been to a doctor, MRI was clean, clean in quotes always, which I never literally loved as a as a term, but kept having issues. And he was just he went to a general ortho. And long story short, he found his way. Yeah, and long story short, found his way to an elbow specialist, which is not a super common specialty, and more importantly, was an orthopedic. Oh, but especially with an affiliation with a major league baseball team. So he's used to seeing these all the time and he quickly diagnosed them with with a subluxating ulnar nerve. Some percentage of the population has an ulnar nerve that kind of goes back and forth over the metal epochondy. So your funny bone kind of moves depending on position. And the challenge is when you throw a baseball and you go from flexion to extension. it'll flare that nerve up. So you're really predisposed to nerve irritation. Plucking the base base guitar strength. The kid lost a year and a half and it wound up being an on a nerve transposition. It was a pretty quick surgery and he he came back, played college baseball, but looking back on that, I was like, I never wanted to

not be an advocate for an athlete because I didn't know. So for me, that was really important is we needed to be very, very specialized in our particular realm, which, you know, was baseball and it eventually morphed into shoulders, elbows, neck for all overhead athletes. So we see, you know, tennis players, swimmers. And sure enough, probably six or twelve months after that, We had another Baseball player who came in and I had really kind of immersed myself in in all the research and things like that. And kid came in with a really mundane shoulder. Radiology report. You had an MRI. He had a little bit of posterior label fraying, which is literally a hundred percent of major league baseball players. They all have fraying in their posterior shoulder. Like I looked at this kid's MRI and like

If I was a major league team, I'd give you 150 million without a problem with this MRI. And there was a doctor that wanted to do surgery on it just because he had some symptoms. I was like, let's Pump the brakes. Let's actually rehab this, but they treated the MRI instead of the kid in front of him. He Literally did like four weeks of PT, did a good return to throwing program. We went on and played four years of college baseball and never had shoulder issues again. So I I look back on that and that year was very transformative that I needed to be an advocate for my athletes because they didn't know, much like I didn't know when I was younger. And really the quest over the last, you know, 15 years has been how do we continue to build out. our team at our facility, but also the network of people to whom we can refer just because as the game is getting more specialized, we need to be more specialized in who cares for our people. In the service of helping people to advocate for themselves.

The intent being, of course, in this conversation, not to say do what I do, because I have an unusual network. Right. I can call you. I can call Kelly Starrett. I can call various specialists. You brought up questions. Asking questions. Are there any particular questions? And you could pick a condition. Let it could be a shoulder, but Could be a lower back. Something orthopedic, or

Potentially recipe. What are some of the Tools or questions. You might recommend to folks who are hoping to become better advocates for themselves first. And then maybe we talk about parents later.

First and foremost, it's asking around to who's had favorable experiences with different physicians. Obviously, Bedside Manor plays into this tremendously. You want to make sure that you you're dealing with a surgeon who is accessible. If things don't go well, Things like that. So you know, we try to really align ourselves with people who have great bedside manner and we've been really fortunate to have some really strong relationships in that realm. So I think that's important. How do you find those doctors if you're not a correct? It's it's it's obviously it's conversations. And I'm not sure that reading patient reviews online is great because you always tend to get just the really bad ones are the people that take the time to write it up. But I think asking people in your network who have been to these folks, particularly if there's a geographic component. Hey, I I live in Oklahoma and I need to see someone who's within 30 minutes of me. So that's the first thing. The second thing I would I would say is How specialized is it?

It's one thing if you break your leg. That happens all the time. People are are pretty well equipped to handle that. When you have this very Odd collection of symptoms, something that's unique. Things like a thoracic outlet syndrome is a is a more specialized thing. Basically your your thoracic outlet is you know, based where all the nerves and blood vessels of your upper extremity start up at your neck. And it can be effectively clamped off at at multiple different points. So it can become a hard diagnosis when you see numbness and tingling in the fingers and you don't know whether it's at the neck, at the shoulder, at the elbow, all these different things. So that's a harder diagnosis that's much more specialized. So I think you have to be aware of

The more complex it is, the more you might need to travel. The one thing that I actually talk about the most is when we're talking about rehabilitation specialists, I think it's always important to make sure you do some digging on what's the model that's employed in this rehabilitation realm. Is it a lot of one on one, hands on? Is it one person supervising eight patients at the same time? Is there a manual therapy component to it? Do you have experience working in these specific post-operative cases or with this? Something like an Achilles rupture is a is a pretty specialized injury. Just someone who's done shoulder rehab all the time isn't necessarily gonna be able to handle someone who's had a a post op Achilles. So you have to be mindful of how specialized the actual rehabilitation may be. I think that's big. And then kind of building out that, you can always just scrutinize a resume. I think that goes a long way. I always worry when it's like

Bob Smith is a chiropractor that does this. He likes long walks on the beach, has a wife and and two dogs. And and you read their bio and like there's no substance. When I read a bio for someone I can refer to, I think I match with that guy a hinge. I'm just kidding. What I always want is I want a I want someone who's got like a a number of different skill sets in their toolbox because if you're a carpenter who only has a hammer, everything starts looking like a nail. Yeah. So you're looking for some people that can delve into different methodologies to try to help get you better. Yeah. Totally. Tell me if this is a decent heuristic to use. My bias has always been

to work with practitioners. I'm using that deliberately pretty broadly. Yeah. Whether they're soft tissue Folks or surgeons or Otherwise who work with a lot of currently competitive athletes just because

Please feel free to rip this apart, but my feeling is with Sedentary folks there may not be a clear pass fail. So it's harder to get an accurate read of whether the surgery delivered what it intended to deliver in terms of outcomes, but with athletes If they are saying And

Iron Man triathlete and they're having trouble running because of X with their right leg. And the promise is we will fix your right leg so you can get back to running. That is very simple to, in a sense, figure out from a pass fail perspective, like are they able to run and compete or not? And I just like

Maybe the simplicity of that. Any thoughts on that? The simplicity in identifying those people, yes, the complexity and what it takes. it probably makes it a useful approach is a key consideration. So I'd say is there's There's being asymptomatic.

There's return to play. And then the return to performance. Those are three very different things. Like a surgeon can make you asymptomatic. And you can lose all of your range of motion. and not be able to return to play. If you're a recreational tennis player and you can't get your arm up, you're not gonna be able to serve. And then it's another thing altogether to get back to return to performance. And I and I think when you deal with

clinicians who are used to dealing with those higher level athletes. That's their outcome measure is return to performance. When you talk to major league baseball doctors, it's can you come back and pitch in the big leagues and throw ninety eight miles an hour anymore or not? And you know, it's not just the surgeon, it's not just the physical therapist, it's the entire team because you can you can do a lot of things wrong along the way. So I do think the standard of care is probably higher when you're dealing with those competitive athletes. And there's also just a mindfulness to timelines is that hey, we can't just mess around. We want to be proactive with this. So I think it's useful. I would never pull the rug out from underneath people that haven't worked in that population, you know, if they've proven themselves clinically and you know, they really care'cause there's there's absolutely a need for that. But yeah, it probably gives you a little bit more Mindfulness to how

People look at the injury too. treating them like an athlete, not just like a patient. I think that's probably important. Yeah, I've found That If you're in any decent sized city or close to a decent sized city, you don't have to find someone from the Yankees who can give you a referral to their favorite ortho.

the chances are there's some sports team that outperforms relative to other sports team. It could be high school, it could be a college team. And it would be relatively trivial to reach out to say a coach and be like when your players have problems with X. Where do you go? Do you have anyone you you like to send people to? Yep. And

At least I've found that too. Maybe I'm biased. I probably am biased just as a former athlete, but I I really have found that beneficial and not maybe as intimidating or as difficult as people might think, which is not to totally minimize folks who don't specialize in athletes, but it's a pretty straightforward shorthand. What else should we talk about relative to movement diagnosis? And one thing that came to mind for me. Which I'll just throw out there in case it takes us somewhere is there's a difference between

Understanding the structure or structural abnormalities and then the function. And like the patterning that someone uses coming back to that book recommendation. Yeah. But what else can you say about movement diagnosis and how perhaps people Listening. Can think about

More of that type of web technology. So the first thing I would say is is that you know movement diagnosis doesn't necessarily just need to be under the I guess original algorithms that Sarmon outlined in that book, which I think are excellent. We still utilize day to day, but I think what it does is it gives rise to this thought process of there's so many other things that go into it. I'll give you the example. We often see in an athletic population like a scapular depression. Their shoulder blades sit very low. Like as we're talking about this, like you have down slope shoulders. It's really something we see a lot. People have deadlifted, Olympic lifted, thrown a baseball, done anything imaginable in an extension and rotation sport athlete, particularly if they've combined it with a lot of strength conditioning. So sometimes we see, you know, shoulder pain in that population because they just get stuck.

So far down in scapular depression, their shoulder blades sit so low that they they can't possibly get their arms overhead. Safely. So we teach them better patterning, we adjust their exercise selection, um, to drive more movement of the shoulder blades to get their arms overhead. We do overhead carries and we teach them what better movements are. We Yeah, we do soft tissue work on the lats, all these different things that allow them to move better. But if that same person goes and just does a bunch of farmer's walk at the end of the session, it can become a problem.

Can you say a little more about it. Psychic Farmers Walk just taking heavy, heavy weights. Right. So basically just uh not undoing the good work that you've done, but doing something that's reinforces. Exactly. Just brings us right back to it. And that's something that I think that happens a lot. And certainly there are times when That's non modifiable in the context of hey, I play football for a living and I have a concussion, I still need to run into people. Some things like that are are very, very challenging. We're talking about the training initiatives that a lot of people either use to support their athletic participation or what people use for their fitness initiatives. Those are very modifiable. So I think we need to be mindful of always being willing to adjust the program and the avenue. So we we have some athletes, honestly, that have that predisposition that I just talked about, and they don't deadlift, they don't farmers walk, they don't do walking lunges. We do a lot of stuff in the front squat position. Maybe we use a safety squat bar on their back. We can find different ways to load them that won't interfere with our ability

to create optimal movement. So often it's not just about what you do, it's about what you decide not to do. And that's often the hardest part is sometimes you have to counsel athletes from something that they might really enjoy. Are there any particular exercises that you think are remarkably. Overestimated. overpopular. Like if you could just wave a magic wand and remove a handful of exercises, anything make that list.

I really I've always hesitated to contraindicate exercises. I think I tend to contraindicate people for exercises more often. I mean everyone rule it out. I do think there's kind of an interesting trend now of a lot of people who are well into middle age who have lost movement capacity. They've gotten into a lot of like Olympic lifting and gymnastics training and We forget that most really high level gymnasts do that from a young age. They they build our stuff and they and they hold on to it over an extended period of time. They don't pick it up after they've already had like one rotator cuff repair and spent twenty five years at a desk. So I do think that's an area where we need to be really, really cognizant of. Let's use a case that's right in front of us. So got this weird lower back thing. Any exercises you'd be like, Yeah.

Maybe for the next one. X period of time. Yeah. I mean I strike these from the record for you. Yeah, I think, you know, for the most part, if you're looking at some of the blanket statements, particularly based on some of the things you've told me, I and I haven't looked at you yet, but it doesn't sound like maybe bilateral loading is your best friend. It does seem like uh some single leg initiative. Not my best friend. Yeah, compression in kind of positions that don't allow you to bail out very well. that you know kind of two legged stuff is probably not your best friend. And some people just don't do well with it. I think we see kind of your classic flat spines. They generally tend to be people that are more susceptible to discogenic issues and they they don't handle compression really well. So when I see a plumber spine, I'm probably not thinking it's gonna be an eight hundred pound deadlifter coming in So when you examine me later, this will be shortly after we wrap recording.

What type of movement diagnoses What are some examples of movement you'd move me through? So like I said, we'll start with some static posture stuff and I would get a look at just standing looking. Yeah, and that stuff just to stare at you and judge you. Um but then actually we'll do some table based assessments and not just because I'm table based meaning I lay down. Correct. So I'd look at hip and internal and external rotation, collection of different things like that. And one of the things you want to look at for something like that is you might have a wildly stiff hip that just doesn't move and your spine's paying the price. So we kind of look at some of that. And then actually from a functional standpoint, probably look at a toe touch pattern, assuming it's not too problematic.

Look at some squat patterns as well. I'm big on measuring infrasternal angle. Um say that again. Infracternal angle. Um yeah, a lot to unpack there. That's a lengthy podcast, but What is that? Just to break just think of the angle at the bottom of your ribcage. You have some people that are very wide and some people that are very narrow. When you have a wide infrasternal angle, they tend to be very kind of hingy in their squats. They're they're built for toe touches versus a a narrow infrasternal angle will usually be a very, very good squat pattern. They may struggle to hinge and it kind of creates this little like I put it underneath the postural, I guess, measures, but it gives us a little bit of a glimpse into how people may move. So there's a there's an emerging school of thought that I think is really profound in that regard. So The what was the term again?

Infrasternal angle. So a large infrasternal angle. Could I translate that to wide ribcage? Or is that not wide versus narrow, yeah. So yeah. And credit to Bill Hartman. Bill has done some wonderful stuff in terms of bringing this to the forefront. I think I have a large external. I would say generally speaking, people who are biased towards being really, really strong, like weightlifters, powerlifters, NFL linebackers, running backs. They're often your wide. Folks.

I think when you look a lot more at like some of your really like your high jumpers, some of your six foot three hundred sixty pound pitchers who throw ninety five miles an hour, they generally tend to be narrow. There's just different ways to get jobs done. And sometimes people will uh will get into bad patterns just because they get a little bit too adhered to the the things that come naturally good to them. So Let's just say if since people may be familiar with this movement, in the case of a squat, you'll have me

Perform. A few different variations of the squat. What will that look like? And then what will you be looking for? We'll look at a little test, retest on it. So I I usually will do an overhead squat, um, as kind of like a gateway to it. Holding my arms overhead. Yeah, correct. So generally try to keep you in a non kind of compensated position. In other words, like won't let you turn your toes way out and go to an ultra wide stand. So we just want to see what unpacks and what's great, you can kind of I joke if you look for everything, you see nothing. So we can see everything from shoulder mobility to upper back mobility to how well you hinge through your hips to whether you have adequate dorsa flexion really through your ankles, and also just how you position your center of mass. We can also look, you know, do you shift to one side or the other? You mentioned a you know leg length asymmetry, you, you know, we talked about potentially there being like a bony block and a hip. All those things are stuff that we need to kind of keep in mind. So and then we'll do some modifiers, right? If it doesn't look good, then we're probably gonna go and we're gonna try some like a counterbalance where you don't have your hands up overhead, see if the pattern improves.

Then we'll just kinda like work shop it in the sense that, you know, you you screen out whether it was was it terrible because the ankles didn't move. Did you fall over just because you can't reposition your center of mass effectively. All those things are are on the table. Yeah, you're mentioning the Forty five year olds like me getting into gymnastics strength training, which I actually am a huge fan of, but if you talk to the people who really know what they're doing, like coach Chris Summer. He advocates people taking their time. Yes. with the connective tissue remodeling. Yeah.

Uh I think humans and maybe especially Americans are pretty bad at heeding that. But you you see also, and you mention this same thing in some say later in life. Olympic lifters who begin, they just don't have that dorsiflexion, right? The flexibility in the ankles. Which a lot of these competitors have developed from a pretty young age. And then they have all these compensations.

above the ankles that create just mayhem. Yeah. Biomechanically. I never have loved the term injury prone. I would say there's injury predisposed. And I think they're very different things. Like injury predisposed is the guy that rolled his ankle in high school and didn't do anything about it. And all of a sudden he's got, you know, way more dorsiflexion on one side than the other. And he just kind of becomes this helicopter pattern of movement where everything is kind of rotating in the wrong places. So I think those are the things that we need to be really mindful of. And if you're a fifty year old man getting into Olympic lifting, you're more predisposed to injury than someone who's 15. It's not to say it can't be done. You know, you never want to discourage people from their goals. It's just that the onboarding has to be a little bit different. Yeah. It is incredible to see what some of these young athletes are doing. And maybe it's just more visible to me. I don't Olympic lift these days, but I subscribe to

Wanna count on Instagram hook grip. And they have these competition shots. You just see these I mean in my mind kids are like eighteen, nineteen. Just clean and jerking, four hundred and eighty, four hundred and ninety pounds. It's It's wild. I think in general we're we're in an interesting transitional time for young athletes. I think a lot of this conversation centered around like self medical action, people on here who are, you know, listening because they're hip hurtts or something like that. But like advocacy for your kids is a is a really big thing is the the model is changing dramatically. Like when I grew up

We played multiple sports. We played a wide variety of sports until my mom, you know, yelled out to to come in for dinner. And now we have kids that are Legitimately Playing baseball you're on, playing soccer you're round, and they're they're not getting that. broad foundation, that rich proprioceptive environment. And I I think orthopedically I know for a fact we're paying the price for it in the baseball community because it's the most specialized game. It's the highest velocity movement and the shoulder internally rotates at seven thousand degrees per second. Um but we're also gonna pay the price when these guys are

thirty five years old and getting shoulder replacements and things like that. It just it just seems like in general youth sports are are really headed in a negative direction. And why what I do, I I I in my eyes, I feel is so important. You have a lot of career stability. Maybe maybe not as good as the the hip surgeons, but yeah. Oh God. Yeah, or the dialysis manufacturer. Maybe this will go nowhere, but I'll bring it up. I've read that you're a fan of the expression Get long, get strong, train hard. That's a good one. Fair to say? Yeah, it's a great it's a Charlie Weingroff line. Okay. What does this mean?

So get long, right? Is create a transient or more permanent change to range of motion. Maybe that's Some positional breathing that gets you fifteen degrees of hip and turn rotation. Maybe it's some soft tissue work that gets you some shoulder flexion. There's all these different things.

And I'll backtrack to that in a second, but get long, get strong. Go ahead and do some exercises that make that change stick. So all right, we're gonna do a thoracic spine mobility drill to get some length, and I'm gonna do a kettlebell arm bar just to to help kind of hold it under load and then train hard. Now I'm gonna do quite a bit of volume with ample load to make my brain, my body perceive it as normal. So that I hold those patterns. Like that's what good training really does. And here's the problem. We can all agree on what a good lunge is and what's probably an excessive amount of exercise. So the get strong and train hard, everybody's probably 99% in the same bucket on It's the get long part. People love to argue about whether one discipline is better than the other, love to argue about whether manual therapy works.

It's incredible. They argue about whether positional breathing is lame and boring and I think people just like to fight on the internet. But that's the challenge is we get so caught up as an industry arguing about the minutiae of how to create a transient change in range of motion that we lose sight of the fact that we we agree on the other two factors. Ninety nine percent of the time. So how frequently let's just say for yourself, right? Because you clearly still train. What does get long look like for you? As an example.

For me, it's historically been make the most of my warm ups. If I take care of those, whether it's some self-mile fashion release, like getting on a foam roll or doing some of that stuff. And for me, it's much more targeted. I'm not gonna spend a lot of time on on an area that I don't think needs it, but I'll I'll use an acumability ball on my neck a little bit just because my neck gets a little gumped up. Then I'll follow it up with a more thorough warm up, which is usually one to two positional breathing exercise and then I'd say seven or eight exercises that are more long chain compound movements. What do you mean by long chain? Yeah, so it's things that involve multiple joints. So if you do like a Spider Man with hip lift and overhead reach, something like that. And some people call it world's greatest. Like those are things that get you a wide variety of movements across multiple planes of motion. Those are great. And then after that, I'm honestly, I'm doing something that's reasonably powerful. Maybe it's throw some med balls or do a set of kettlebell swings. That's in the warm up or after the kind of like an extended warm up is the way I look at it.

Maybe you sprint, maybe you jump something along those lines. I just think it's a good way to kind of like get your body temperature up and solidify some of that stuff. And then then we're gonna go and I'm gonna lift and and I generally lift. Four days a week and all condition a couple of days a week as well. How long does your warm up? Take it. Um I would say it depends.

Full disclosure, like I I'd probably be a lot better off if I followed my own advice better, but I'd say it's bare minimum ten to twelve minutes. I think the older I've gotten, the more I've realized that that needs to be extended. And I probably do better when there are targeted mobility initiatives between sessions as well. I don't think anybody at forty has ever regretted doing more mobility exercises in their their twenties and thirties. So that would be my advice is even if you don't think you need it, you need it. Yeah. I remember chatting with Kelly about this. And maybe it was a profile piece that I read. He was working with some NFL team and he was

Talking to the guys and You know the guys in there. Let's just say earlier mid twenties. We're kind of like listening to music, daydreaming, not paying attention. He's talking about warm-ups and so on. And every single player who's a veteran who's been there for a while is paying complete attention. It's incredible. I I never recognized it, honestly. It was very impactful for me. I had my my first orthopedic surgery. I had a meniscus repair. I had kind of ignored some posterior medial knee pain in my uh my left knee for a long time and I actually finished it off, believe it or not, Christmas Eve 2020. I was re-racking a weight. I went to pivot and I caught it just right. Heard a pop and didn't think anything of it, kinda finished my lift and the next

You know. hour later I could barely move it. But what was fascinating about it to me was that I had the surgery a couple weeks later and two weeks non weight bearing, two weeks partial weight bearing. And what blew my mind was how quickly I lost motion. And my I was taking care of the knee motion, but my inability to kind of move side to side. my adductor. So groin tightness was more significant. You just notice I lost some shoulder mobility during my time on crutches. It was just very eye opening that, you know, for me at the time I I was thirty nine.

It was not a uh you know, something that should procedure I should not have deteriorated that quickly. I don't feel like I mean, I kept my fitness up and I'm I was able to work out. I was hopping around on one leg and doing what I could, but it was it was extremely eye opening to me that that motion can be lost that quickly. even if you're paying attention to the particular joint where you had surgery and being very mindful of that. So I always try to counsel people on like the downstream effects of some of those. orthopedic interventions. They're not just necessarily fixing a shoulder or an elbow in many cases. Your neck might get cranky from wearing that sling. So just be mindful of all the different places where you could lose motion. Like if you're in a sling for four to six weeks, there's not a whole lot of arm swing happening during your gaze cycle. So it could have some other impacts. Well I remember.

Getting my shoulder reconstructed. This fantastic surgeon in SoCal. Yeah. It was recommended by I think he was recommended by Scott Mendelssohn, actually. Famous power lifter.

Bench is thousand and something pounds. Literally. It's not just an embellishment. And I remember paying so much attention to the rehab being really meticulous on the left arm, but not really feeling like I had marching instructions in retrospect for the other arm. I was compensating

Of course, using my right arm in this case that was Had not been using my right arm in this case that had not received surgery for everything. And I ended up developing all of these issues. With the right shoulder. Yeah.

And the other thing too is even during your rehab, the crossover effect, there's there's research that shows that all right, let's say you have left shoulder surgery, you're in a sling. Assuming we do it without obviously setting you back, there are things that we can do for your right side. They won't do anything to minimize the atrophy that might take place on a shoulder side. But from a pure neurological standpoint, we can do some stuff to preserve the strength aspect of it too. So we always train the non injured side in our post surgery athletes. Um I train my right leg a ton while my left leg was on the men and the crossover effect is a real thing. So I'm gonna drag us into the some deep water here. And Feel free to interject or deflect or take us somewhere else, but

I'm just gonna read a few things and then you can modify. So This is in the context of I think it was an interview on Nick Grantham dot com. Wow.

Yeah, from some time ago. But the discussion was around creating bulletproof athletes, and I think that was the wording from Nick. So we have ten points. related to what would make or or could help make a bulletproof athlete. And I know this is a throwback, so I'll hand this over to you. But let me just read these first, if that's okay with you. Let's do it. And then You can update, modify as needed. So

Number one. Adequate hip mobility, we've spoken about this a bit. Number two, stability of the lumbar spine, scapuli and glenohumeral joint. Number three, posterior chain strength and normal firing patterns. We spoke a little bit about that. Four, loads of posterior chain strength. Five, more pulling than pushing. So more deadlifts, rows, pull ups, etcetera. Than pushing squats. Benches, overhead pressing. Six, greater attention to single leg movements. Seven, prioritization of soft tissue work in the form of foam rolling, ART, and massage.

Eight attitude. Then a parentheses being afraid when you're under a bar is a recipe for injury. Nine adequate delading periods, ten, attention to daily posture. You have one to two hours per day to train. And twenty two to twenty three to screw it up in your daily life. So that's what we have. Is there anything that you would modify here, add to this, maybe change because you've

adapted your thinking since this was Put on the internet. I think the first thing I would say is Some of that stuff is really just a plan on some of the joint by joint approach that Greg Cook and and Mike Boyle to their credit kind of put out there is that you have certain joints that are more Condition for mobility, things like the shoulder, right? Obviously have a a lot of motion. We need to drive more motor control. We use the term stability. I'm not sure it's the a great way to describe it. And we have other

Joints that obviously are. you know, more built on hey, they need to be really, really sturdy, like a knee, right? It's a hinge, it's load bearing, all that stuff. So a lot of this is just, hey, preserve what they're meant to do, either be mobile or be be more stable. So I think I would definitely adhere to all those different things. I think the probably the stuff I I might backtrack a little bit from is the more pulling than pushing. I think for you know your general population folks, people who sit too much, that's still probably the case. I think in our athletic populations I've gotten away from thinking of as just pushing and thinking it more now as reaching things to drive more rotational capacity and some of that stuff. But I think on the other stuff, there's some good reminders in there, the attitude aspect of it, where I commented being afraid when you're under a bar is a recipe for injury. I I actually see this a lot.

You know where you see it the most in the weight room is people who don't take their warm up seriously. Can't tell you how many times. Or people that just like jump right to two twenty five on the bar and stuff like that. You always take the bar, you always take your first forty five. If you look at most powerless thing gyms, it's always plate, quarter, plate, quarter, forty five, twenty five, all the way up. So could you explain that just for people who may not have

a view into this. So if we're talking about That would apply to deadlifting as well. Yeah, for sure. Okay. So You've trained in some facilities where people are pulling. What? From the floor. What would you say? A thousand. Yeah. So pulling incredible

Weight from the floor. I mean not not routinely, but yeah. Seven hundred, eight hundred regularly. So what might their warm up sequence look. Yeah. We don't have to go through all of them. I think at that level you're gonna see guys for me personally, if I'm in a deadlift six hundred, it's gonna be usually one thirty five, two twenty five, three fifteen. And once I've hit three fifteen, I'm gonna go twenty fives all the way along. So it'd be three fifteen, three sixty five, four oh five, four fifty five, four ninety five. There's a pretty significant build up to it. You don't just go and throw it on there. And it's usually your first exercise of the day. So there's an extra need for it, but you see so many people that just don't know how to kind of flip the switch and tap into the level of stiffness it takes to move that kind of weight. It's no different than having like a major league baseball pitcher go out and throw their first ball at ninety five miles an hour. It's like no, the first couple of throws are really, really gradual and you build up your long toss. So I see a lot of people that just don't have the right mindset.

to really be handling heavyweights and it's probably even worse than when I actually probably gave this interview just because there's more distractions. I mean this might have been like two thousand ten. Um and here we are now people are checking Instagram between us sets and things like that. So there's probably even more of a recipe for people just getting hurt because they aren't locked in. Yeah. Well, let's hop back into the Scooby Snack category for a moment. What is the worst advice or terrible advice that you hear or see? Being given out.

Often. In your world. Just bad advice. I'm gonna throw one out there that might be a little controversial is um follow your passion. Actually I've never loved that advice in our field. Or really any field. You know, if you if you look back like when I was dealing with all these shoulder issues as an athlete, I was passionate about fantasy sports and you know stuff like that. There was no livelihood to be made at that time. So I think what I did really well early in my career was without even knowing it, built some career capital to steal a a Cal Newport term.

What do you mean by that? Just marketable skills. You know, skills that would eventually serve me without even knowing when I was going through shoulder rehab and and all this shoulder stuff. Like I was actually working much more with basketball and soccer athletes during my grad degree at the University of Connecticut. It just so happened that some of the first athletes I worked with in the private sector were baseball players. And because I had had all these shoulder issues and dealt with them myself. I think I identified a really underserved population even more than I otherwise would have. Would that have been the case if I had spent My entire undergraduate year. boozing and and not doing anything. I I didn't do that. Instead I I worked, I experimented, I was in the gym every single day, and I was annoying people that I knew were a lot smarter than me. So I I never loved the idea of

people following their passion. I think you you follow your marketable skill and eventually as Newport was the book was Be So Good They Can't Ignor You. He talked a lot about being able to redeem those eventually for other things. Maybe it's more compensation, maybe it's a better work life balance, more autonomy, whatever it may be. Too often. In our industry, everybody has these very similar resumes. Everyone has an exercise science degree. Everybody has a letter recommendation from their academic supervisor and their high school volleyball coach or whatever it is. And very rarely are they heavily differentiated. And in my world, I'm like, I want to know what's weird about you. And you know, do you speak Spanish? Do you, you know, have experience with particular technology? Not that it's necessarily about being passionate. You're talking about hiring.

Yeah, for sure. When I talk to young coaches in this field, I'm always like figure out what you can do to be differentiated. And very rarely does following your passion get you there. Cause everybody in my field You have to remember most people wind up in this world'cause they like to exercise or they were former athletes that wanted to stay competitive, but it's not a differentiator. It's just something that they're passionate about. And I think you quickly realize when you you open a training facility that some days it's not much different than, you know, running a restaurant or a you know an accounting firm or something like that. So I think where I've been served well is I always tried to actually develop skills that could in one way or another make me differentiated in the marketplace.

Makes a whole lot of sense. Passion does not automatically equal differentiated. For sure. You still need to have it, but still need to have it. It's not the most important, I'd say. What have you changed your mind about? In the last few years. And why? I'll give you two. The first one I would say is isometrics. And I think For those who who don't know, isometric is really just a muscular activation where there's no change in length. So if I had Tim holding the bottom of a split squat for 30 seconds, that would be an isometric hold.

And I always thought that hey, the loading isn't significant enough. I'm not sure this really has its place. And we started to see more benefit, I think, with respect to really hypermobile athletes, people who are really, really loose jointed, giving them time to own positions really helpful. But what really took me to the next level is um Dr. Keith Barr's research is excellent. He's looked a lot at the favorable impacts of isometric holds on on tendon health, particularly with respect to Achilles and patellar tendons and it just seems like the biochemical response to isometric loading is really, really good. And it it does things that we don't get from concentric or eccentric. Do you have any idea why that is? That's a lot of what his research has has kind of postulated, but it seems like thirty seconds is kind of like a minimum threshold. So We've seen some really, really awesome changes in some of those chronic Pateller teninopathy people, chronic Achilles teninopathy people, where we even use it proactively, like start of the off season, we want to do some more isometric loading for people as we prepare them for their off season sprint programs and things like that. So I think that's powerful. And I think the next step is how do we translate that to maybe tendons that aren't as easily measured. So the example would be like you can touch your patellar tendon, you can touch your Achilles tendon. It's really hard to say like all right, I want to get in on my

super spinatus tendon. And we know in a in a baseball world like some of those get pretty banged up over the course of time. Is there something that we can do to favorably impact tendons that maybe aren't as easy to isolate? So I do think that's kind of like an exciting frontier and you know, credit to Keith and his lab for doing some great work. So that'd be the first one. I think the second one is hanging. In general, I was kind of out on hanging for a long time, even though it's Very evolutionary, if you really think about it. It makes it like holding onto a pull up bar and just hanging. Yeah. And I think

Maybe my bias came because we see a lot of really hypermobile, loose jointed folks in the baseball world. And they can just get in really, really bad positions. So when they hang, you usually see like elbow hypere extension. You see like a ball that's like flying out of the socket in the shoulder. And so I really didn't like the idea of doing a lot of it with them. But I quickly came to realize is if you have any athlete that has like Any element of stiffness, things like that, it does seem to really make a big, big difference. So particularly when you integrate hanging with correct breathing, understanding how to inhale and exhale correctly, where you actually can manipulate how you're you're pressurizing the rib cage, that has been, I think, a big difference maker for us, particularly with how people are very dense through their lats. And you get your arms overhead, you hang, you get some reduction in tone there. And you can also delo it. There's nothing that says you have to hang with your full body weight. You can, you know, put your feet on a box and you know, cut fifty percent of your body weight out. So I'd say if I had to change if I have I've changed in TO ARES over the last couple of years, isometrics and and utilizing more hanging variations. So quick

Side notes. One. This is maybe neither here nor there. Bruce Lee, huge fan of isometrics. And he was really a sort of high neural drive. Connective tissue. Guy with a lot of what he did. And then the second

Is A Question about the hanging, what might a protocol look like for your athletes? How long are they doing it and then what is the correct breathing? I'd say for me.

I'm generally integrating on the warm up, particularly in someone who's really limited in shoulder flexion. So their ability to get their arm overhead. So I I'll generally program it for breaths. So I might only have them do five breaths. And again, usually it'll be like a Like a lat inhibition hangs, we might not have, you know, full percentage of their body weight, but you know, we have other variations that are just like hanging, they're all they're ultimately distraction exercises for the upper extremity that are effectively taking the rib cage away from the pelvis, right? So you're getting some wing through. quadratus lumborum and lat and long head of the triceps, all these different muscles that kind of all run in that same path. So Five breaths and it might be an inhale to the count of three and an exhale to the count of six. So you're talking about these taking close to a minute. So that's why you know full body weight might not be necessary. How we cue their breathing will will kind of be impacted by some of the infrasternal angle stuff that I talked about a little bit or maybe a really forceful exhale for like a wide ISA that that really needs to learn to kind of close ISA's infrasternal angle. Sorry, versus like a narrow, it might be more like an inhale through the nose and try to expand your rib cage to the sides and then

When you exhale, think of like fogging up the mirror versus like blowing out the birthday candles. So subtleties that we would obviously coach in different positions and we might use that more in one than the other, but yeah, definitely just some different ways that we'll attack it. Amazing. Well Eric, I mean we have a million different things we could talk about. I don't know since you mentioned the book

Upstream. From Dan Heath was it? Dan was the one that wrote that one, correct? Yeah, Dan Heath. Would you like to speak to some of the upstream variables that people might want to pay attention to in your world? A couple of big ones. I would say first.

Don't specialize young. I mean that's a message for Both. the parents on this podcast, but also I think People who

maybe losing athletic initiatives in their life, like try to find a way to do a wide variety of movements well into adulthood. So that's certainly an upstream activity because it's much easier to do a little bit and maintain mobility than it is to lose it and try to get it back. Mm-hmm. It takes a lot more work. I think obviously sleep, nutrition, and and regular movement are are very, very big. Certainly there are times when supplementation can make a big difference. We know that, you know, vitamin D deficiency. seems to have some pretty big relationships to musculoskeletal health as well. I think in the big picture of movement, if we're gonna look underneath that umbrella. Just pause for anybody wondering, that is my dog Molly timing her extremely loud water intake perfectly with whenever I'm recording. Man's best friend, I'm a big fan. Yeah. But I think underneath the movement umbrella Optimizing rotation seems to be the one that's really, really big. And I think we get really, really kind of stuck in this sagittal plane world. Everything is very strange. So uh the sagittal plane would be straight ahead plane. So forward and back. You know, so if you're a pane of glass like going through the deck, that's a that's a sagittal plane movement.

You know, a frontal plane would be side to side, so like a lateral lunge or like a s a shuffle to the side. And then the transverse plane is I think where people get in trouble. That's rotational. So imagine, you know, rotating through a med ball or the rotation that takes place during a golf swing or tennis, baseball swing, something like that. Yeah. And I think in general people lose rotational capacity. But it's actually vitally important. We use it probably a lot more than we could have possibly recognized. That's something that we need to be really, really mindful of for sure. I'd say watch for anything that snowballs for you, right? Like if you had a non-ideal pattern and then you go and you throw five hundred pounds on your back and try to back squat. Bad idea. Yeah, loading bad patterns generally magnifies it, but I would even argue that load doesn't just have to be weight on a barbell, right? Load could be going out running full speed when you're Your hips barking at you or you have, you know, an Achilles tendinopathy or something to that effect. Um, anytime you start to load dysfunctional patterns.

I use that term very loosely because we're still, I think, in an industry unable to perfectly define what that is, but you know, pushing through pain generally doesn't end really, really well. And then the last one I'll say this is it kind of an interesting methodology one that I might be starting an entirely new discussion as we work to wrap up, but I think you always want to know why you're stretching something. So don't just stretch something because it's tight. Stretch because you have an actual rationale for doing so. But if you add motor control, if you add the if you look to add good stiffness to a situation, you'll almost never go wrong. But you can make yourself a lot worse if you stretch the wrong thing. Could you give an example of A rationale and adding stiffness. Let's talk about tight hamstrings, because that's probably the tightness that we encounter the absolute most. So your hamstrings can be tight for a lot of reasons. It could be tight because the muscles are actually fundamentally short. It would be really, really hard for that to happen just because they cross multiple joints. They extend the hip.

They flex the knee like you you just don't live in that position to actually be short enough. So More often than not, what we see in the hamstrings is actually a protective tension. Our pelvis is really tipped forward, our hamstrings. posteriorly tilt the pelvis. So they're firing on all cylinders in in many of our really you know, kind of active extension bias athletes to kind of prevent and debilitating low back pain. So that tone is there for a reason. So if we stretch it out, sometimes we leave them transiently unstable in a little bit of a position of exposure. Likewise you could have hamstrings tension because you blew out a disc in your low back, you have some kind of nerve tension, maybe you pulled a hammy and the

There's just like a an element of that the tissue not just realigning the right way. So it's kind of dense and fibrotic and nasty. So when we just go and we stretch aggressively, we're not always taking into account what could cause that. Conversely You add some stability to the system. So in the case of like a protective tension, maybe you give them a little bit of core control, you give them some glucation, teach them how to posteriorly tilt their pelvis, and all of a sudden that tension kind of can resolve. So I'm always mindful of don't just stretch something because you think you need to stretch because you know exactly why it needs to be stretched. And more importantly, look to add Good stiffness, motor control. somewhere else. And this is why some people go to yoga class and feel amazing.

And then every once in a while you get someone that just feels way worse when they left. They probably stretched out some protective tension or they they hung out on on a structure that didn't want to be hung out on. How would you suggest people Learn more about this. the reasons for stretching versus not stretching.

How to sort of forensically analyze what they're experiencing to determine they should stretch or not. Are there any researchers, exercise physios? Or otherwise. Who's thinking you respect on This

And the actionable items for folks. I think this is why it's it's important to have like good practitioners helping you. I think in general. We can probably both agree, like You need a contract written up, you go to a lawyer. You know, you need an MRI done, you go to a doctor, you need your taxes done, you go to an accountant. But anybody who's ever walked into a commercial gym will kind of see that people tend to throw a bunch of poop on the wall to see what sticks when it comes to exercise and and scary because you screw up your taxes, there's a way out of it. You screw up your body, you you might have a lifetime of pain. So I I do think in general escalating things to qualified professionals as helpful. That's very hard because it's a low barrier to entry industry.

We could go on online and get your dog certified as a personal trainer this afternoon if we wanted to. And I think that is a problem is that licensure really isn't a thing. So there are some kind of fly by night operations that are challenging. So that's a great question. I'd have to really stew on it because I think it's such a multifaceted discussion that we really need to dig in on. Let's talk a little bit about Separating the charlatans. from the legitimate practitioners. What are some questions people might look for Elements. Things that are lacking or present. There would be

Not necessarily definitive. But Possibly indicative of Good or bad. So for instance.

For me when people ask me about various facilitators or researchers who are conducting clinical trials related to say psychedelic combat. The best people on almost all of the universities, certainly, will have comprehensive medical intake. And so what I tell people is look, I recognize that saying Just say no to drugs.

May not. work. Like just abstain is not necessarily going to Convince everyone, so for those people who are gonna try to self navigate. At the very least. Anyone you consider working with should

without your prompting take you through a very comprehensive medical intake. Mm-hmm. Just as one example. What prescription medications are you taking? Yeah as one example. What are Perhaps some of the things people can look for or look out for with respect to the good and bad players. Or the trip wires. Yeah. Yeah. You know one that that always blows me away? I'll go on the road here and there. and work at it at random gym. And I'm always amazed when I walk into a gym and they don't have you sign a waiver.

That just to me is a sign that There could be so many other things that are going on there that that just like that's the most buttoned up thing you can possibly do is that if if they're missing that checklist. Because when you do that, that's your emergency contact info. You know, so if if you walk into a random gym in I don't know in the middle of Kansas or whatever to get a workout in and you know, you're not filling that stuff up, you're a diabetic and you know, you collapse in the middle of your session. They should have all of your information on file so that they can call your, you know, emergency contact and find out, Oh, he's he's a diabetic. That's the first thing that you tell the ambulance when they arrive. All those things. So I'm always astounded that that happens. And I I think often that's because you know, it's usually like a sixteen year old kid at the desk and you know, there's your standards aren't held, but then you have to ask yourself, all right, has this equipment been serviced correctly? Are these bands broken?

Is this cable gonna snap while I'm working out? Like those are you know some of the very realistic, you know, kinda challenges. Those are legitimate concerns too. I've seen some horrifying videos of people working on Pulley systems and the cables just snap. Because they're not maintained. Yeah, having run facilities. We have that. It's all very itemized in terms of how often we check it and

I want to know that anytime something goes on that we have like immediate contact info for everyone. So that's, you know, I I think that's maybe not where you're going with it. It was more with respect to the professionalism aspect. That's super helpful. But I do think I mean the certification is obviously like a minimum threshold for working with people. And like I talked about earlier with practitioners, you want to look at people that have been exposed to a wide variety of philosophies. I think that's helpful understanding like what a typical session looks like. If it's like all right, they come in, they ride the bike for five minutes and then we leg press and, you know, do pec deck flies and stuff like that. It's probably not someone that's gonna be an ideal fit for like teaching you how to move better. So, you know, when I see people that have a little bit more movement competency emphasis to this, that's important. And I think it's vitally important to consider too, like the people that are probably listening to this podcast are not gonna be the um the one percent that are trying to like compete as bodybuilders or, you know, in some cases be you know, high high level powerlifters. We're talking about folks who are looking to to exercise to improve their quality of life and to reduce the incidence of pain and all these different things. So you want someone that has a little bit more of a a movement competency. So I look for things in that realm, like an an awareness of, you know, how we can actually optimize movement quality.

So not to invite you to put your foot in a bear trap, but I will Any certifications that you find more compelling than others if someone's looking for someone to help them with the types of things that were discussing in this conversation. In a word, no. And that's a sad commentary on industry. And I think it's really, really hard because

So many people have kind of flocked to that world. Don't get me wrong, there's stuff the NSCA has obviously been been looked at as like kind of the gold standard, the CSCS. And you know, I do think that's a critical threshold because it at least verifies that your first aid and CPR certified and you know, you have some awareness of how to design a training facility and some of those things. But I think if you talk to most people that are having success in this industry and they're they're coming back, they're saying that most of what I learned, I learned on the fly. I didn't learn it from my certification. I didn't even learn that much from my undergraduate exercise science degree in many cases. And then and I think that's challenging. I do think there's some people that have have put out certifications that tend to be very specialized in various ways on a wide variety of topics. But I don't know that there is one certification out there that really heavily differentiates really well. I think Mike Boyle's done a great job with the certified functional strength coach certification. People that are that are doing that are certainly like a above the the basic threshold. Mike Robertson certification is excellent as well, but I'm still not sure that certification is enough in our industry to like really uphold this really high standard because you

You can do it in a day. You can't do med school in a day. My wife is actually an optometrist. And she always has remarked about this. She's like, you know, she did four years of undergraduate school, was a biochemistry major, four years of optometry school. And then she went to a a one year residency in Corney and contact lens. And she's like, I spent nine years on eyes. And like people in your industry go to a weekend certification and they get a whole body. Like is Pretty eye opener for lack of the pun, but it's something that I think we need to be better on. It it's good for motivated people that want to make a difference because it is a low barrier entry, but it's it's also bad for unmotivated people that wanna enter an industry that can

profoundly impacts people's lives really quickly too. Yeah, totally. Eric, we can keep going for hours. Is there anything else that we have perhaps omitted, or I'll take the blame for that, that I have omitted. That would make sense to talk about.

And There are many notes in front of me. We could talk about Any number of things. I think you've done a wonderful job. Which is expected in light of of how long you've been doing this. So I I think probably the the best place we can finish is me thanking you because you've done a a great service to the

to the body of knowledge by supporting so many different initiatives in this realm for a long time. So I I commend you for all of your great work. Oh thanks, Eric. Well I I really appreciate that. And I think we're maybe We could try to wrap up. That's very kind of you to say. And Looking forward to Getting unbroken. I do periodically.

Smash Humpty Dumpty into a million pieces and then he needs to be put back together again. Let me Read a name. And maybe this will be A good place.

To begin to wrap up. Maybe not. We can decide. So B in quotation marks, is it Bridgesh Patel? Oh yeah. What did you learn from this person? Who is that?

In my so funny story, I got accepted to the University of Connecticut graduate school. early in the summer of two thousand three. And I went to UConn not knowing what I really wanted to do underneath this kinesiology umbrella. I thought maybe I wanted to get into research and all that stuff. And it was just when I had started doing some writing in the kind of like an online medium. And uh Brajesh at the time was a graduate assistant strength edition coach at the University of Connecticut. And what Brajesh did was he actually read a couple of my articles. And so I got to campus. We had some graduate classes together. He had several teams at UConn that were underneath his umbrella and he said, Hey man, if you ever want to

Come in and coach, like or just observe. Just say the word. He's like, all right, awesome. He's like, all right, men's baseball is at five thirty a.m. tomorrow morning. I look back and he was million percent like testing me. And sure enough, I you know I got up at five. I showed up and I watched it and it l it literally changed my career in that moment because I saw the way that he commanded a room. I saw that the way that the players bought into everything he said. In that moment I got I got completely hooked on string conditioning. And you know, at the time I was taking organic chemistry for the class of like

Two hundred fifty undergraduates and I saw what Burjesh did. And not that his his focus on movement competency and things like that. It was just a different way of training people, but also a different way of Impacting athletes, which I thought was great. What made him different or notable for you and how he interacted with his athletes or commanded their attention.

I think the biggest thing was how he could be two different people in the best way possible. You know, there's the old saying they don't care how much you know until they know how much you care. And in with Brajesh, he could be very business like and in front of a crowd when you need to be very organized and locked in and and control a room so that everything could happen efficiently. But then I also saw the relationships that he had on the side, how he knew literally everything there was to know about every athlete. He clearly grasped them on a personal level and things like that. Interesting, we only got probably six months together. He actually moved on and took a job at the College of the Holy Cross and actually just won a national championship with Quinnipiac in in hockey. But looking back, like that was the reason I went into strength additioning instead of something else underneath that umbrella. And I was very lucky to have very good mentors at UConn, him and Tina Murray, who's now with the Pittsburgh Penguins, and Chris West and under the soccer umbrella and Andrew Hootie, who's back at UConn. There were just some some amazing coaches that really, really helped me out there. Is there

Looking forward. Anything in particular that you would be excited to work on in the next handful of years? That maybe you're not working on now. Or it could be an extension of something you're working on. So baseball's in a challenging place right now. As we've we talked about a little earlier, you know, average fastball velocity has has surged. Like there is very much this injury epidemic in baseball. And I think the challenging thing is that we hear about it at the major league level.

And the stakes are the highest. But we're realizing more and more most of the athletes are very broken at young levels. I look at radiology report after radiology report on eighteen year old elbows and so many kids are are blowing out at young ages and they're they're broken before they even know they're broken and they just they get to higher levels and that's when they eventually start to kinda hit a wall. So I think really The big picture is what excites me the most is how do we favorably impact what's happening. on the youth side of things to make sure that the next generation of really talented players are are healthy because we're getting to a point where sports medicine really can't keep up with

You have six year old kids that are throwing a hundred miles an hour. That never happened in the past. So I think big picture, it's the interaction between sports science, sports medicine, strength conditioning, biomechanics, mental skills. It's how all those different pieces fit together. It's a lot of the stuff I'm kind of tasked with on a daily basis in my role. So that's what's really exciting is how do we make this better for the next generation. Eric, thank you so much for the time. I always enjoy

our conversations and People can find you. In many different places. So Cressy SportsPerformance dot com.

Just to remind people on the spelling, that's C R E S S E Y Eric Cressy dot com. And we'll link to all the social as well. Are you more active on any particular social than any others? I'd say probably Twitter and Instagram. Okay. So Twitter is at Eric Cressy. And Instagram also. At Eric Cressy. Thank you so much for taking the time. Thanks for having me. This was a lot of fun. I really, really appreciate it.

And I can't wait to get hands on and to everybody listening. You can find show notes, links to everything we discussed. As usual at Tim.blog slash podcast. That includes transcripts and so on. And until next time. Be just a little bit kinder than is necessary to others and to yourself. And as always, thanks.

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