Squats, the (F)Utility of Research, Total Knees, and Pain vs. Suffering – Movement Debrief Episode 18

Just in case you missed last night’s Movement Debrief Episode 18, here is a copy of the video and audio for your listening pleasure.

in this debrief, I was stumped!

Andrew from Facebook asked a phenomenal question on the biomechanics of the squat, which led to great discussion on what it means and takes to squat.  Great contributions from Dani and Jonathan to the discussion.

Here were all the topics:

  • How I use research
  • Influences on full knee extension and flexion post-operatively
  • Changing perception of rehab post-total knee arthroplasty
  • The problems with chasing pain
  • Pain vs. suffering
  • What is squatting, what it means, and the biomechanicsIf you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 8:30pm CST.



Here were the links I mentioned tonight

Pain and Stress in a Systems Perspective: Reciprocal Neural, Endocrine and Immune Interactions

On the (f)utility of pain

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Return to Play after a 5th Metatarsal Fracture – Case Report

I was recently featured on my buddy Scott Gray’s podcast,  a great clinician in the Florida area who I have a lot of respect for.

Before we dive into the podcast, let me tell you a bit about why I like this guy so much.

It’s not just because he is a part of the IFAST family.

I’ve been going back to the basics as of late, reviewing concepts such as tissue pathology, anatomy, surgical procedures, and the like.

If there is anyone who has the fundamentals down savagely well, it is Scott Gray.

He put out an Ebook called “The Physical Examination Blueprint”, which you can download by subscribing to his newsletter. Here he details all the essentials on screening your patients.

To me, the most important aspect of patient care is knowing who you can and cannot treat. Stratifying your patients based on who needs to be referred out, and who you can help is essential to providing the best care.

Quite simply, there are few better resources out there that outline how to do this than Scott’s ebook.

In it, he delves into what relevant questions to ask, tests to perform, and establishing a relevant diagnosis. Often underlooked, yet exceptionally important components of the clinical examination.

Again, I cannot recommend Scott’s ebook and site enough. It’s a great resource for many things PT, including many of his eclectic and unique manual therapy techniques. Definitely check this guy out.

Rehabbing a 5th Metatarsal Fracture to High Level Basketball

In this podcast, I outline a case I worked on back when I was in the NBA D League. 

This kid suffered a distal 5th metatarsal fracture with only a couple minutes to spare in a game. It was a brutal injury after one of the worst games in my life that I experienced, namely because we had three guys go down in one game.

Talk about awful.

I outline my entire process and every detail of what I did to get this kid back to high level basketball. A process that started with a fracture and ended with him establishing a franchise rebounding record the last game of the season. Pretty spectacular to say the least.

I feel very fortunate to have worked with such a driven and hardworking guy, and ultimately that was what his success hinged upon. Though minor, it was an honor to be this guy’s guide back to high level performance.

In this podcast, we dive into the following topics:

  • Immediate post-injury rehabilitation
  • Post-surgical care
  • The non-weight bearing phase
  • The weight bearing phase
  • Return to play Criteria
  • Return to performance criteria
  • Acute:chronic workload monitoring

Again, thank you to Scott Gray for featuring me on the podcast. I had a blast doing it.

If you’d like to download this podcast and get my free acute:chronic workload calculator that I used with this patient, subscribe to my newsletter by clicking here or simply fill out the form below.

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The Ultimate Guide to Treating Ankle Sprains

A Humdinger No Doubt


Ankle sprains. Such a bugger to deal with.

Worse than childbirth, as David Butler might say.


Ankle sprains are one of the most common injuries seen in basketball. The cutting, jumping, contact, fatigue, and poor footwear certainly don’t help matters.

Damn near almost every game someone tweaks an ankle.

Treating ankle sprains in-game provides quite a different perspective. Rarely in the clinic do we work with someone immediately post-injury. Instead, we deal with the cumulative effects of delayed treatment: acquired impairments, altered movement strategies, and reduced fitness.

The pressure is lower and the pace is slower.

You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.

I had a problem.

Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.

The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.

It’s a tough business.

The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹.    Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.

Here’s how. Continue reading “The Ultimate Guide to Treating Ankle Sprains”

How to Design Your Learning Program

Thanks Buddy

The other day I was texting with a friend and writer I respect dearly, Seth Oberst, and he asked me an excellent question regarding the reading process:

How do you determine what you read next though? ~Seth Oberst

I answered him then, though it felt brief and inadequate. His question inspired me to reflect on how I design my learning process.

Though I’ve mentioned my learning philosophy, it may be fruitful to delve into the details. Seth, I hope I don’t let you down. Continue reading “How to Design Your Learning Program”

The Sensitive Nervous System Chapter XIII: Research and Neurodynamics: Is Neurodynamics Worthy of Scientific Merit?

This is a summary of Chapter XIII of “The Sensitive Nervous System” by David Butler.


Research has demonstrated that often evidenced-based medicine is low on the list for why clinicians choose a particular treatment. From an ethical standpoint, it is important to consider evidence. This chapter is very short so I will just provide the highlights that I got from it.

Appraising a New Theory or Approach

There are six criteria that a new theory should be evaluated by:

1)      Support from anatomical and physiological evidence.

2)      Designed for a specific population.

3)      Studies from peer-reviewed journals.

4)      Include a well-designed randomized controlled trial or single experiment.

5)      Present potential side effects.

6)      Proponents discuss and are open to limitations.


Here are some definitions of different ways research measures agreement.

–          Cohen’s Kappa: Measures nominal data reliability.

  • >0.75 is excellent agreement.
  • 0.40-0.75 is fair to good.
  • <0.40 is poor.

–          Pearson product movement correlation: Measures interval/ratio data.

–          ICC: Measures continuous data.

  • The closer to 1, the better.


There are also many different validity types defined throughout this chapter. The first two are proven through logic and have the least evidence support.

–          Construct Validity: Valid relative to a theoretical foundation.

–          Content Validity: Can I use this measure to make an inference?

The next two are higher up on the evidence support hierarchy.

–          Convergent Validity: The test shows a correlation between two variables.

–          Discriminant Validity: The test shows a low correlation between two variables.

Lastly, these are criterion-based tests that infer similar results compared to an established test.

–          Concurrent Validity: the compared tests are performed at the same time.

–          Predictive Validity: The tests are compared at different dates.

If only EBP were as exciting as evidence-based law.

The Sensitive Nervous System Chapter VI: Clinicians and Their Decisions

This is a summary of Chapter VI of “The Sensitive Nervous System” by David Butler.


All approaches (Maitland, Mckenzie, Mulligan) have myths. The common bond between them all is pain. Today we will look at building a clinical framework with pain as the cornerstone.

Evidence-Based Medicine (EBM)

EBM is defined as a conscientious, explicit, and judicious use of current best evidence in making patient care decisions. This concept is not merely reading researches articles, but it combines scientific evidence and clinical expertise. You have to know when to apply what.

For manual therapists everywhere, this creates issues and unease.

1)      Decision making moves toward an external body.

2)      Evidence suggests manual therapy improvements are more psychosocial than physical.

3)      A disconnect between researcher and clinician.

  1. The researcher thinks: “What does this work contribute to the literature?”
  2. The clinician thinks: “What does this work do for my patient?”
Likely not aligning OA on AA.

The movement towards outcome-based therapy per EBM is also problematic for several reasons.

1)      Clinicians begin to think statistical analysis becomes greater than any other form of knowledge rather than complimentary.

2)      Research doesn’t take into account the inherent uncertainty and subjectivity in a clinical encounter.

3)      Good evidence can lead to bad practice if applied in uncaring and unappealing environments.

4)      Outcomes may be coming out too quickly, leading to research development stopping in certain areas.

Butler’s thoughts are summed up very nicely when he states it would be a sad day if meta-analyses have the final say instead of exposing clinical errors. However, the self-scrutiny and analysis is a good thing as long as it stops short of reducing clinician self-confidence. For confidence is what allows us to practice in uncertainty and maximize the placebo effect, our most powerful pain reliever. The uncertain conditions which we practice in are what Butler terms the Grey Zone. These typify most syndromes in which underlying pathoanatomy and physiology is unknown.

Screaming with confidence. Just think how much serotonin drips from his patient's mouths when he explains pain to them.
Screaming with confidence. Just think how much serotonin drips from his patient’s mouths when he explains pain to them.

Clinical Reasoning Science

Clinical reasoning involves the merging of three areas: science, current therapies, and the clinician-patient relationship.

3 prongs

Butler also suggests that we need to shy away from thinking damaged structures and move towards movement dysfunction. We must realize that movement sensitivity does not involve the tissues only, but is a process that involves changes at a chemical and cellular level. When a movement becomes sensitive, changes occur in the ion channel, neurotransmitters, and nervous system. These changes are driven biopsychosocially.

Following this process, central processes are very much active in all types of pain. For example, acute pain depends on peripherally activated central processes. We must also look at recurrent pain, which is actually a chronic, central process as opposed frequent acute injuries.

Does that mean we need to be psychologists?


We must treat faulty movement patterns, but that does not mean we cannot take aspects from psychology, namely…

Butler on Experience

There are two types of clinicians.

1)      One who has 20 years of experience in 20 years.

2)      One who has 20 years of experience in 1 year of practice.

How do we become the latter?

  • Reason
  • Learn
  • Experiment with management techniques.
  • Remain open.
  • Be aware of the outcomes movement.
  • Read widely
Don’t know who said it, but live every day as if it were your last, but read as if you will live forever.

Pain in the Clinical Reasoning Model

Step 1: Consider what pain is.

Pain is an unpleasant, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Step 2: Differentiate class vs. source.

For example, patient x’s pain fits a peripheral neuropathic pain class, with the source being an L4-5 nerve root.

Step 3: Know your pain mechanisms. (3 types)

  • Input: Nociceptive, peripheral neuropathic pain (Entrapment outside dorsal or ventral horn, nerve root, peripheral nerve).
  • Processing: CNS plasticity changes, cognitive influences.
  • Output: Sympathetic, immune, and endocrine systems, potentially consciousness as well.

Step 4: Classify in terms of dysfunction.

  • General physical function/dysfunction: The patient’s main problems.
  • Specific physical function/dysfunction: Problems found by clinician that are related to patient’s problems.
  • Mental/psychological function/dysfunction: What the patient thinks/feels about his/her injury, the clinician, the treatment, and society’s approach to his/her disability. Distress fits in here.
Could be a mobility problem, could be a stability problem, but most likely a distress problem.

Step 5: Make sense of dysfunction

One needs to determine if the dysfunction is maladaptive or adaptive. For example, limping after a sprained ankle would be an adaptive response to allow for tissue healing. Limping for the same sprained ankle 25 years later would be considered maladaptive. Often too we must realize that we accumulate dysfunction over time, and minor findings may not be relevant to a person’s complaints.

Step 6: Find your sources

In terms of dysfunction and mechanisms. You need to know where you would fire a magic bullet if you have it. This could be a particular manual therapy or even explaining pain to reduce the fear of movement.

Step 7: Know your contributing factors

This can include any factor related to the predisposition, development, and maintenance of a problem. These factors can include psychosocial, genetics, anthropometrics, and ergonomics.

Step 8: Determine Prognosis

Prefer function over pain.

Step 9: Know precautions

Do no harm is first and foremost. When thinking manual therapy, use the least amount of force for maximum gain.

Step 10: Management

Realize and be comfortable knowing that chronic pain is something we may never cure, but it is something we can manage.

The Reasoning Process: Key Points

Reasoning is an evolving process throughout the treatment course that starts broad and moves toward refinement. This path occurs via the information gained from the patient assessment coupled with the clinician’s knowledge, understanding, and previous experience.

Most important, we must keep the patient as part of the reasoning process. Their hypothesis of their problem affects all reasoning categories and will alter as assessment and management proceed.

The intervention provided will affect the evolving concept of the problem, and the placebo effect can occur anywhere in the process. With that in mind, be mindful of any errors made during.

Without the patient front and center our work means nothing.