Read the conversation below
Dr. Yoni Rosenblatt: Thank you guys for joining the True Sports Physical Therapy Podcast. Awesome conversation with Dr. Dan Pope. Everyone knows who Dr. Dan Pope is, really one of the good guys in our sports physical therapy field, has carved out a niche and a reputation for working with high-level strength and fitness athletes.
Dr. Yoni Rosenblatt: In this conversation he really breaks down how he evaluates specifically knee pain or athletes with knee pain and how he takes them all the way back to what it is they love doing. Dr. Dan really highlights how he increases compliance, how he maximizes his outcomes, and really how he approaches the entire field. It's really a far-reaching conversation. I look forward to your feedback.
Dr. Yoni Rosenblatt: As always you can DM us @TrueSportsPT, or email me directly, Yoni, Y-O-N-I at truesportspt.com. Of course, we're always looking to add to our awesome team of 40 sports physical therapists. We are now throughout the State of Maryland, into Pennsylvania and now into Delaware.
Dr. Yoni Rosenblatt: If you're interested in joining us, please shoot us an email. You can send it directly to me, Yoni at True Sports PT, you can send us your resume and cover letter via DM @truesportspt on Instagram. We can't wait to hear from you. Without further ado, Dr. Dan Pope.
Dr. Yoni Rosenblatt: Welcome into the True Sports Physical Therapy podcast. We got Dr. Dan Pope with us. Everyone knows who Dan Pope is. This guy is a legend in our sports PT world. You guys, the audience, asked to have him on. I'm thrilled to get him on, thrilled to get a little bit of his time.
Dr. Yoni Rosenblatt: And we're gonna switch it up a little bit. Usually, I ask the guest now to just tell us about yourself. In a little bit of a flip, I'm just gonna throw questions at you. We're gonna start with a lightning round so that we can pull some information out and then anything I miss, you fill in afterwards. Ready, Dan?
Dr. Dan Pope: I'm ready.
Dr. Yoni Rosenblatt: Okay, I love it. Where were you born, Dan?
Dr. Dan Pope: Camden, New Jersey. Beautiful vacation spot.
Dr. Yoni Rosenblatt: Beautiful this time of year. Where did you go to undergrad and PT school?
Dr. Dan Pope: Rutgers University, New Jersey, born and raised and educated, undergrad and grad.
Dr. Yoni Rosenblatt: Oh wow. Now, what do you wish your grad program taught you that they didn't?
Dr. Dan Pope: I like my grad program a lot, and I obviously wish they taught me a little bit more about strength and fitness and that type of thing, but they weren't able to. There's too much stuff you have to learn in university, so. I liked it. Good job, guys.
Dr. Yoni Rosenblatt: What do you think Rutgers did better than maybe some of the other universities that you're seeing?
Dr. Dan Pope: Yeah, so it's public, so it's cheaper. I think that's really important. Just because it's so dang expensive for PT education. I thought my orthopedics classes were great. My professor, kept it super simple. We had another staff, Mark Butler, and I got to do a clinical affiliation there, and super smart guy and learned a ton and I loved it.
Dr. Yoni Rosenblatt: We don't hear that enough. That's amazing. I should have gone to Rutgers.
[chuckle]
Dr. Yoni Rosenblatt: That's super cool. Tell me your favorite pathology to treat?
Dr. Dan Pope: Femoroacetabular impingement syndrome.
Dr. Yoni Rosenblatt: Why do you love that?
Dr. Dan Pope: Well, I like a lot of things, so it's tough, but I guess I have a special interest in the hip. I didn't learn a lot about it in PT school, and then I learned a little bit by reading and also kind of watching lectures and people present on it, and it was like an underserved population, still is, more research emerging about it.
Dr. Dan Pope: And then I started to become one of the go-to guys at Champion, which is a little bit hilarious, and I made some connections with some surgeons over my course of time out in Colorado, they were all Philippon trained, so he's like a big wig in the hip arthroscopy world, and they introduced me to some other docs in the Ballston area and I made some good friendships and we just had a lot of referrals, and then I just started treating lots and lots of hips. Pre-op, post-op, just 0kind of a cool population.
Dr. Yoni Rosenblatt: Yeah, absolutely. Ironically, I was in grad school in my ortho coursework, and I had pretty bad groin pain, and here's how poorly it was relayed to me what FAI was. I went to the doc, I'm like, "I have a hernia." They're like, "What? I thought you were in PT school?" I'm like, "No, it's a hernia, I have groin pain. Clearly."
[chuckle]
Dr. Yoni Rosenblatt: Anyway, clearly FAI. I think, listen, that was a long time ago, so hopefully we've kinda come up to date mostly with what Dan, you've been putting out as to how to treat FAI, but definitely underserved. What's your least favorite pathology to treat?
Dr. Dan Pope: I would say, and I like this too, but it's a little bit frustrating, but I'd say gluteal tendinopathy. And the reason why is I just find it super stubborn, and especially in that post-menopausal population, I have a lot of kind of fit women that are post-menopausal, and they get this kinda lateral hip pain that tends to just stick around and be super stubborn and recalcitrant, regardless of what we do, all the treatments. So that's a tough one. But I do enjoy it too, so there's that.
Dr. Yoni Rosenblatt: Yeah, that sounds like what we used to just throw in the bucket of greater trochanteric bursitis, right? That's what we used to call that. And they're freaking stubborn. How do you start to learn how to beat that? I know that's not the topic of this pod, but how do you start to learn how to be that?
Dr. Dan Pope: Yeah, for sure. Learning. That's a big one. I think Alison Grimaldi is probably the big influence for me. I think she's a big name in the, basically all around the hip, so hamstring, but also gluteus medius tendinopathy. Learned from her, read some of her research, listened to her on some podcasts. Read some more.
Dr. Dan Pope: I know that's one of the big issues that's interesting right now is post-menopausal women have changes in their hormones, right? So one of the things that they're trying right now is hormone replacement therapy. I'm aware of one study anyway that showed a positive effect.
Dr. Dan Pope: So there's potentially some stuff going on there from a hormonal perspective, which is generally not something we think about with tendon issues, but it definitely is. So yeah, just learning, reading. I guess long story.
Dr. Yoni Rosenblatt: It sounds like that's your solution to everything. Tell me if that's your least favorite pathology, although you say you love it. What's the most frustrating thing about being a sports PT, period?
Dr. Dan Pope: Man, I don't know. I like sports PT a lot, so that's actually a little challenging. I guess it's when you know you can't help someone, is tough.
Dr. Yoni Rosenblatt: I'm gonna ask it, Dan. I'm not just throwing softballs out here.
[chuckle]
Dr. Dan Pope: Yeah, line drive straight to my face here.
[chuckle]
Dr. Dan Pope: I would say that it stinks when you can't help someone. That's tough. It's hard to work with in-season athletes that you know they've got a big hamstring strain injury and the chance of them getting back for a big game is maybe not gonna happen. Or big competition or whatever it is.
Dr. Dan Pope: I don't like the idea of having to refer someone to a surgeon when I know that's the best place for them to go. But I'm getting more comfortable with that. I just kind of think about if I was in the patient's shoes and I had a physical therapist say, "You know what? I think you probably need to get this looked at by surgeon." It's not like a feel-good moment for anyone.
Dr. Dan Pope: But the other part is that I think it's you need it. If that's the best thing that the patient can have long-term, I need to tell him to do that.
Dr. Yoni Rosenblatt: Yeah. And that's why we went into this, right? I used to take it as a massive blow to my own ego, like I can help you, but that's... It's just not about that, it's about the person in front of you. So if you can find that surgeon that they need to go to or wherever it is, sometimes it's primary care, sometimes it's just primary care sports or whatever, that goes such a long way, I have found. So I definitely know where you're coming from.
Dr. Yoni Rosenblatt: The last piece of our lightning round. If you're not working out, studying, reading, or probably walking a dog, I don't know, you seem like a dog guy, and you have one hour to yourself. What are you doing, Dan?
Dr. Dan Pope: That's a tough one 'cause I love those things, but I'm a dad. I have a son.
Dr. Yoni Rosenblatt: You have a dog?
Dr. Dan Pope: No dogs.
Dr. Yoni Rosenblatt: Oh. Okay.
Dr. Yoni Rosenblatt: I like dogs. I'm not anti-dog. We just don't have one. But yeah, I have a young son, so spending time with him is probably my favorite thing, spending time with my family. I'm a family guy now, I guess. So that's it, I'd say. [chuckle]
Dr. Yoni Rosenblatt: Okay. Okay, fine. Fair. Good answer. Tell me what we missed in your bio, Dan? Tell us a little bit about your track and just tell your, how you got to where you today.
Dr. Dan Pope: Yeah, for sure. I feel like this story is more and more common nowadays, but I kind of started my personal training journey in undergraduate. I was always the guy who loved strength, loved fitness, love wellness. I was a guy that would bring rusty chains into my local gym to try to do Westside Barbell methods, dynamic efforts.
Dr. Dan Pope: I would leave rust all over floor. One of the chains is probably 15 pounds, the other one was like 25. Grunt and scream with my friends in the gym, loving every second of it. Right? So it just naturally led me to doing more personal training, because it really is, that's passion.
Dr. Dan Pope: When I graduated, I started to find that working as a personal trainer I'd have a ton of clients that had pain. And it was tough because I wanted them get better, I wanted to learn more about why they were getting hurt, and I would send them to some local physical therapists and I would get the typical like, "Oh gosh, you know, your patient got hurt because you're dead lifting with them."
Dr. Dan Pope: Or, "Your patient got hurt because you're doing kettlebell swings." Or your patient got hurt because you're doing overhead press. Those are dangerous." And that was a terrible relationship with the physical therapist because basically my clients, they would all leave me. [chuckle] Because they think I was doing dangerous stuff.
Dr. Dan Pope: And in my mind I was like, "This makes no sense. Exercise is good for you. We know exercise is good for you. Strength training is good for, there's a myriad of benefits. This can't be the right answer." So it kinda led me to start to learn more about physical therapy and get interest from it.
Dr. Dan Pope: And actually a lot of strength coaches and trainers out there that do a phenomenal job with pain and injury, but I had a big ego and still do at this point and I wanted to be the best in terms of working with my clientele that had pain and try to help them out, and my thought was, "What is a profession that spends the most time working with injuries?" And that was physical therapy.
Dr. Dan Pope: So it was kind of a next natural step to go to physical therapy school, and during physical therapy school, I continued working as a personal trainer. When I graduated, I did the same. When I went to PT school, the goal was never that I wanted to be a regular physical therapist, I really just wanted the knowledge so I could do better working with kinda strength and fitness clientele.
Dr. Dan Pope: So when I graduated, I did start working full-time as a physical therapist along with personal training, but I started to build a niche working in strength and fitness. So at the time mostly CrossFit, but also powerlifting, Olympic weightlifting, just weight training, strength in general, runners, and I just kind of fulfilled that niche there to try to help those folks out, because at the time it was a very underserved population.
Dr. Dan Pope: I think what's good is that that switched. So I think if you still go to the average physical therapist and you're an athlete, right, especially if you're a barbell athlete, the physical therapist will probably be a little bit confused about how to help you, just because they're not really aware of that sport, but I think in general, it's gotten a lot better. But that's a niche that I found myself in, that's my true love and passion.
Dr. Yoni Rosenblatt: What year did you start? What year did you make that switch from strength coach to PT?
Dr. Dan Pope: I graduated in 2013. 2008 to 2010, I worked full-time as a strength coach, personal trainer. Then I went to PT school, worked at the trainer throughout there. And then when I graduated, I started full-time as a therapist and worked part-time as a CrossFit coach. And then I gave up CrossFit coaching a few years ago, 'cause I was doing way too much. [chuckle] Not that they don't like it.
Dr. Yoni Rosenblatt: No, I can imagine. That timeline sounds familiar. I graduated in '08. Dude, we didn't, PTs didn't know crap about barbells. It wasn't until I found Supple Leopard and Kelly Starrett was I like, "You know what? PTs can actually treat athletes. Or here's the Bible." 'Cause it just wasn't out there. So I think, and you're probably one of the reasons, that we've come a long way, holy cow, to think about in a short time.
Dr. Dan Pope: Thank you. Geez. [chuckle]
Dr. Yoni Rosenblatt: Yeah, high praise. High praise. And I throw compliments around like manhole covers. So it's not often.
[chuckle]
Dr. Yoni Rosenblatt: But I think you have been a big piece of that, and that's what gets us fired up to treat, and that's what gets the audience, that's why they're like, "Get Dan Pope on." So I wanna pull your knowledge when much as possible for this audience, okay?
Dr. Yoni Rosenblatt: So you already have a long-standing course out on just knee rehabilitation, intro to the knee. So I wanted to pick your brain along that, whether it be patellar tendonitis, quad tendonitis, meniscal, whatever it is. What does your knee evaluation look like?
Dr. Dan Pope: Yeah, for sure. I think this is pretty similar to most other evaluations. I'm always telling folks you need to be looking out for red flags. And maybe it's a yellow flag, I'm not sure we'd call some of these things. But it's not like we're looking for cancer of the knee necessarily, but we are looking for, does this person need to be referred out for something else that's going on? Is this an ACL tear? Do we have some sort of repairable meniscus tear that needs to be seen by a surgeon? Maybe get that opinion.
Dr. Dan Pope: But largely, I start off by looking at the knee. Well, I mean really it's subjective. So you're getting a lot of information about how this person got hurt in the first place. If it is one of these, "Alright, I need to maybe refer out," you're looking at probably something that was more acute in nature.
Dr. Dan Pope: I was skiing, I twisted my knee, I felt a pop. It got swollen. I went down to the bottom of the mountain and then they looked at my knee and told me I need to get some imaging. Maybe it's a soccer injury, it's twisting. Or I was doing let's say a box jump and twisted. Or I was in the bottom of a squat, I felt a pop and it was really swollen. Right?
Dr. Dan Pope: So I think you're getting most of the information from that subjective. If you have someone who has, let's say, a gradual onset of pain, kinda hurts behind the kneecap, hurts with deep squatting, I'm already thinking more like patellofemoral pain. Or based on where they're pointing, [chuckle] of their symptoms. Is it right on the quad tendon? Is it right on the patellar tendon? So on the side of the joint, back of the joint.
Dr. Dan Pope: So you get a lot of information just subjectively asking people what's going on, and then from there I'm usually looking at any swelling. Left to right, so looking at different, left to right. And looking at range of motion, if someone is limited with extension or flexion, I'm starting to think maybe you have some joint pathology there.
Dr. Dan Pope: Again, I'm asking questions about symptom location, so is it on the side, the front. Start poking around. Joint line tenderness, anything funky going on there. If I start to suspect there is some sort of meniscus pathology, I may start doing some special tests from that perspective.
Dr. Yoni Rosenblatt: What do you really rely on?
Dr. Dan Pope: Well, I'd say for more meniscus, I'd say range of motion is good, joint line tenderness is pretty good. Standard McMurrays. Thessaly is kinda hit or miss I'd say for that. Lachman test for ACL. Varus-valgus testing, generally speaking. Those are kind of my ligaments test. Sag sign. You know?
Dr. Yoni Rosenblatt: Yeah, okay. Gotcha. Now, going along a little bit more of that chronic presentation. They start telling... 'Cause you probably see this more in that strength and fitness population. What questions are you asking to tease out where you're taking that evaluation?
Dr. Dan Pope: Yeah, for sure. I think a big one, so if it's someone who's in strength and fitness, I'm pretty sure they're not dealing with something that's traumatic and they need to go to the doctor right away. In odd cases, someone will potentially tear the meniscus in the bottom of a squat. Or maybe with a box jump going wrong and they twist their knee or something, and they're dealing with some sort of tibiofemoral pathology.
Dr. Dan Pope: But largely, I think the bulk of folks you'll see in the gym that have knee pain are dealing with some sort of patellofemoral pain, far and away, and you will see some quad or patellar tendinopathy. Generally speaking, patellar tendinopathy is more common than quad tendinopathy, although this is an anecdote.
Dr. Dan Pope: I tend to see a lot of quad tendinopathy. I see a lot of folks that have pain above the kneecap, hurts with squatting or lunging or step-ups. I think far and away, I'm starting to ask questions about what aggravates this. 'Cause that's gonna give me more information about how to treat. So it's...
Dr. Dan Pope: In terms of diagnosis, we get super fancy, but really at the end the day, I wanna get at what is causing this person pain, what are their goals, how can we as quickly as possible get them back to exercise and target them with the best exercise that are gonna help get them back to training based on where they're at in terms of irritability, aggravation, strength, all of that stuff.
Dr. Dan Pope: So what movements hurt you? Alright, squat. What percentage of... Are you on rep max? What kind of squat do you use? Just start digging more into their training programming and which movements bother them. That's kind of my next step, I guess.
Dr. Yoni Rosenblatt: And I think one of the reasons as I hear you talk about it, that's gonna help you with that athlete in front you is you definitely speak their language. So when you start talking about those, whether it be CrossFit-specific movement or if you're talking to a sport...
Dr. Yoni Rosenblatt: Actually, one of our therapists here is a lacrosse guru, Dr. Tim Stone, and he said, first question he asks a lacrosse athlete that walks in, say it's for knee or whatever it is, like, "Hey, what positions do you play? Oh, awesome. Does it bother you when you... " And he'll throw out a lacrosse term.
Dr. Yoni Rosenblatt: Because you just wanna get that connection. I would assume the same thing transpires in that strength and fitness world, right?
Dr. Dan Pope: Yeah, it's huge. I'm a huge rapport guy, I think that's enormous. So usually when people are coming in, they're being referred from someone else within the fitness world, so usually I just start talking about that, talk about things that are going on, current events. "How is the CrossFit Open? Are you're watching this? You take a look at this athlete." And it puts people at ease.
Dr. Dan Pope: I think it's huge, especially where I'm at as a cash-based physical therapist, because if people don't like you, they can just leave. Right? And your outcomes are terrible if people don't stick around. [chuckle]
Dr. Yoni Rosenblatt: By the way, even if you're taking insurance, 'cause I take insurance, they could still leave, Dan.
Dr. Dan Pope: Yeah, that's true. They could just go down the street, right?
Dr. Yoni Rosenblatt: It's not like we're holding 'em. But okay, good point. Now, if it's more chronic and you're thinking patellar tendonitis, quad tendonitis, where do you take it from there if that's a diagnosis in your head?
Dr. Dan Pope: Yeah, for sure. So I guess I'm thinking about which exercise would be most beneficial. So if you're dealing with like patellar tendinopathy, quad tendinopathy, I wanna give them exercises that are evidence-based, so we wanna try to strengthen the quad for the most part, but I also wanna make those exercises as specific as possible to the patient's goals, right?
Dr. Dan Pope: So it depends on the individual. So if let's say you have an Olympic weightlifter with a quad tendinopathy. Some athletes will blow through their pain and they keep training and they don't stop at all, and it just bothers them all the time, and some athletes will stop all of their training.
Dr. Dan Pope: So I think the first step is to figure out where they're at in terms of irritability, and then try to give them some guidelines on what's okay to push and what's not okay to push. We'll go out in the gym, we try to load them up a little bit with different exercises, and we try to keep their training as similar as possible to what their current training plan is supposed to be, without aggravating the area and allowing them keep working towards their goals.
Dr. Dan Pope: Oftentimes we don't have to change a ton. So if I have an athlete that has, I don't know, a quad tendinopathy and they're tolerating squatting fairly well, but it just hurts when they get above like 85%, 90%, or their one rep max, then we might just stick around 80% for a while, and for the Olympic lifts, maybe we're cautious with heavy heavy cleans, but oftentimes, let's say the snatch feels fine just because it's not as much load.
Dr. Dan Pope: So we only really have to modify heavy squats, maybe heavy cleans maybe, and the rest of their training is kind of exactly the same. Right? And then from there, I try to give some additional accessory exercises to help target the tendon. And there's lots of options, but I'd say like a heel tap is a big one. Single single-legged squat and a slam board, very evidence-based exercise. I love those a lot.
Dr. Dan Pope: I love adding a terminal knee extension to it, so a band behind the back of the knee, pumping that thing up is phenomenal. Some more research coming out about blood flow restriction training, which I think is great adjunct to the rest of their training. We could pop that in as an accessory exercise and choose some quad exercise with it, it could be squatting, lunging, step-ups. And then really trying to give them a well-rounded program on top of that, is usually how I would go about it.
Dr. Yoni Rosenblatt: This is why great PTs need to be great strength coaches, right? You've gotta be able to look at that entire program and figure out where they are, like you said, what their goals are, but what they've currently been doing and loading.
Dr. Yoni Rosenblatt: I wanna back up, 'cause this is a great example, let's get a little bit into those weeds. If the patient or the athlete doesn't know that it's a given percentage of their one rep max that is causing their quad tendonitis or pain, how do you tease that out in the clinic?
Dr. Dan Pope: Just a lot of questions. Usually patients will tell me that. I had someone with back pain the other day and it's funny 'cause I have a student right now, and this confuses the heck out of students, right?
Dr. Dan Pope: So patient comes, low back pain. They go through the entire process, A-Z, examination, zero special tests with everything, no pain, toe touch back extension, slump, everything is negative, but one of the pieces of information the person leaves in subjective is that, "My back hurts when I get to five rep max and higher."
Dr. Dan Pope: So you have someone that's not very irritable at all, right, and essentially they can tolerate everything in their daily life, and you have a student that has a hard time working with that person just because they have to really push to provoke that pain.
Dr. Dan Pope: So usually the patient will talk about it, but largely I start asking questions about, "What hurts you? Which movements? What weights? Can you tolerate this movement if you drop the loads down a little bit? Can you not?"
Dr. Dan Pope: And then after we get through that whole subjective process, I go in the gym and actually live with them a little bit. So if I don't know or if the patient doesn't know because they've stopped all their training. I work with a lot of psychopaths that will just blow through all their pain, so they have a good idea of what hurts and what doesn't. You know what I mean?
Dr. Dan Pope: Oftentimes you're trying to get folks to admit that something's actually hurt, because they don't wanna say that. [chuckle] Like I'm gonna take it away from them if they say that it hurts. But you do see some folks that they basically stop, they haven't lifted in a while, they're just very fearful of moving.
Dr. Dan Pope: And I think the answer there is you go in the gym, you try loading up some stuff and it's an experimental process. And you just educate the patient like, "Hey, this is experimental, we're not sure what's gonna feel good, what doesn't. But at the end of the day, we wanna get you back to, A, strength training, and if we pick the right exercises from the strength training perspective, it's gonna help you with your pain too."
Dr. Yoni Rosenblatt: And then how much... You mentioned starting to load up that tendon, which is obviously gonna be somewhat provocative. How do you educate the patient on that process, like, "Hey, this is gonna hurt."? And B, to what level are you willing to create their symptoms?
Dr. Dan Pope: Yeah, for sure. I think it really depends on the individual. So largely, I use the pain monitoring model, which essentially it's been studied in the calf and achilles, it's been studied in the patellar tendon, so I think it's super relevant for those folks.
Dr. Dan Pope: So essentially you do, let's say a step-down task and then you rate your pain on a scale of zero to 10, and let's say it's like a five out of 10. Then you do a bunch of exercises, and as long as those exercises are below a five out of 10 pain-wise, and the next day when you do your step-down task, it's five out of 10 back to baseline, then those movements in the gym you did the day prior are okay, they're acceptable, right?
Dr. Dan Pope: There's a bit of research, and this is in the achilles, is this in the rotator cuff, in the low back, that if you push into some pain, you might actually have a better short-term outcome and at least the same long-term outcome as folks that don't push through pain with the rehab exercises.
Dr. Dan Pope: I try to flip it. I think psychologically that's super helpful for patients, because oftentimes they're avoiding pain but they don't understand pain, and you just let 'em know, "If you follow these guidelines, it might actually make you better a little faster." And that can flip the switch for some folks, to let them know.
Dr. Dan Pope: But like I said, some people are the opposite, some people are blowing through way too much pain and you're trying to pull back a little bit, so. It's tough for PTs, you really have to try to make a split-second decision based on a little bit information from the person you met one time, to try to figure out whether you're able to push or you need to pull back a little bit.
Dr. Yoni Rosenblatt: Yeah, yeah. And that's why you wanna ensure, and you alluded to this previously, you want that second visit. How do I give the patient enough, and enough confidence to say, "Hey, I'm gonna come back." 'Cause then you can start giving better educated guesses as to how they're gonna respond to treatments, but also style. So that goes back to a little bit of that rapport.
Dr. Yoni Rosenblatt: So coming back to that quad tendinitis or tendinopathy, you mentioned you would go to some type of heel tap, that's like the first thing on your list. Does that become their homework? Is that one of your go-tos with homework?
Dr. Dan Pope: Yeah, I guess it really depends. The heel tap is pretty good, but it honestly can be pretty provocative if someone's like, has a really flared up tendon. So I may start with a partial range of motion split squat or a very short step-up or something along those lines. Maybe if they can't handle something that's unilateral, we'll start with a squat.
Dr. Dan Pope: So it really depends on how irritable that patient is. If a patient wants me to write their entire program, which I do oftentimes, and I can just change all the parameters of the training as much as I can, what I like to do is train them three days per week with their lower body, and I wanna make that look like a regular lower body strength training program.
Dr. Dan Pope: I wanna kinda make it look like a training program, so if they're a Olympic weightlifter here and they're supposed to be squatting three days a week, there may actually be three days per week of squatting, if they're able to handle that. But largely I'm probably gonna have a squat at least once on one of those days, some sort of deadlift variation on another day.
Dr. Dan Pope: And then I'm probably gonna have, let's say, two to four exercises to strengthen the lower extremity with probably two of those exercises being quaddy in nature. Right? And then I may actually have them do some additional quad work on off days.
Dr. Dan Pope: I don't know that you need to do that much, but if you look largely through some of the tendinopathy literature, folks are doing something along the lines of exercises every other day, to exercise as much as twice a day. So at least in my mind, three days per week is probably a minimum effective dose.
Dr. Dan Pope: And if you want your rehab program to look more evidence-based then adding a few extra days is probably going to help them out, although you know this as well, we don't really know what the best dosage of exercise is for these problems, and it looks like there is... I hate this saying... I love this saying, I say it all at the time because I like love cats, but there's more than one way to skin a cat. Right?
Dr. Dan Pope: And at this point, we don't really know if doing exercises twice a day is better than every other day, and oftentimes I'm just like, "Alright, let's go minimum effective dose, let's make this training program look like the training program that you want to. And if you're getting better in the course of time, you're reaching your goals, then good, we're on the right track."
Dr. Yoni Rosenblatt: Yeah, I think it's tough to know by and large, what is that minimal effective dose, right? That's definitely a challenge. Are there exercises that you say, "Hey, you gotta do this twice a day," if you're looking for certain outcome?
Dr. Dan Pope: Not too much. I will mess around with that for let's say hamstring strain injuries. The only reason is that these folks usually get hurt in the middle of a season, it happens all the time. And I've read some research about mTOR and how long that gets turned on after you exercise, some research saying it gets turned on for four hours at a time and then it shuts down for a bit.
Dr. Dan Pope: If we want to stimulate that hamstring to heal as fast as humanly possible, I may end up giving athletes tougher exercises once a day, and then maybe a couple of other times throughout the course of the day, some easier exercises, just to move this along as fast as humanly possible, just because they're in the middle of their season and they have something important they need to get back to.
Dr. Dan Pope: But otherwise for most tendon problems, I'm not loading that frequently. I'm probably doing something like once a day, once every other day.
Dr. Yoni Rosenblatt: Okay, and then what... If you're putting them through that, I think you described it very technically as "quaddy" movements.
[chuckle]
Dr. Yoni Rosenblatt: If you're doing that twice a week, maybe you get more of a hinge once a week, and if you wanna hit him again in those days that fall in between, what do those exercises look like?
Dr. Dan Pope: Yeah, something that's a little bit lower level. And I think I skipped over that. So three days a week you're doing something heavier, the other days of the week you're doing something little easier. So it might be a knee extension machine or sissy squat for higher repetition, something along those lines.
Dr. Dan Pope: So something that's not super stressful to the tendon, something that's maybe slower, higher reps, maybe some BFR on those off days, but stimulates the tendon a bit in a different way.
Dr. Yoni Rosenblatt: Okay. Yeah, thanks for answering that. Any other things pop out to you when you look at that quad tendinopathy, very early stage, when they come in to you? Anything else you wanna make sure you hit or check or test?
Dr. Dan Pope: Yeah. There's a bit of research looking at, let's say, Thomas Test and basically straight leg raises and showing if you improve those, it maybe help your outcomes. But largely, I kinda jump straight to loading if I can. You know? I think you have to look at the person. What's that?
Dr. Yoni Rosenblatt: You sound like a power build guy.
Dr. Dan Pope: Yeah, I know. That's my favorite. But there's also an argument be made that you may alter someone's technique. Let's say that someone is very, very upright with their squatting, their knees are shooting forward a ton, then they're just really loading the quad tendon a lot with their exercises.
Dr. Dan Pope: I think this becomes a problem for someone that has chronic issues, that's having a hard time getting out of pain and staying out of pain. Sometimes I'll make a change in their exercise technique to make it a little more hip dominant. Right?
Dr. Dan Pope: This becomes a problem because if you're working with an Olympic weightlifter and they need to be very upright, we kind of have to get to the point where they can tolerate that position. So my preference is probably going to be to get them back to the position that's best for their performance, but if we need to make a change at least temporarily, we will. And that mean mobilizing certain structures or adopting a different squat style or something along those lines, so.
Dr. Dan Pope: I think the lowest hanging fruit is to look at load, but obviously you need to treat the individual, you need to look at all those parameters, mobility, how they move, look at their training program, volumes, intensities, all of that.
Dr. Yoni Rosenblatt: Yeah, I love that. Okay, so it took a little bit to get towards that Thomas Test range of motion that I was waiting to hear about. So how do you program that into someone's home exercises?
Dr. Dan Pope: Yeah, for sure. I think mobility in general, it's kind of a personal passion of mine just because I think Kelly Starrett, I dont know how to say his name appropriately. But he was...
Dr. Yoni Rosenblatt: It's alright. You know how to say my name, so.
[laughter]
Dr. Dan Pope: Yeah. Good stuff. He was one of the first guys that got us thinking about this stuff, right? MobilityWOD and how important it is. And I started to look into some of the literature just because I tend to do that, I'd like to have some... I just feel pretty strongly that I think we don't do a great job as a profession. I think we're getting better.
Dr. Dan Pope: But the analogy I make is, if you go to the doctor and you have some sort of illness and you need a medication, the doctor is gonna say, "Take two pills a day, twice a day for two weeks." And if you come back and it's not working, they bump it up to three. And if that's not working, they change the medication.
Dr. Dan Pope: So doctors don't normally say, "Oh, this is your problem. Here's a bunch of pills. Go ahead and take 'em. You need to need to take more pills." It would be a very specific dosage. And I think you'll find that there is a specific dosage of stretching that works well for folks, at least for stretching five or more days per week, around 60 seconds is appropriate.
Dr. Dan Pope: So you may do some sort of stretch like, I don't know, half-kneeling hip flexor stretch, something on those lines. 60 seconds, five or more days per week. I'm also a huge fan of... It's funny because we used to call it "eccentrics" if you look through some of the literature, now it's called "more weighted stretching". Right?
Dr. Yoni Rosenblatt: Yeah.
Dr. Dan Pope: But essentially, if you load someone into a stretch. So think about if you're doing, I don't know, a loaded Thomas Test where you have a weight on someone's foot and you're dropping their leg under control into a full stretch position, that would be an eccentric or weighted stretch.
Dr. Dan Pope: Quite a bit of research to show that's as effective as static stretching. And the other thing that's interesting is the frequency doesn't have to be as high, so you can get away with doing that two or three days per week. I think at the end of the day...
Dr. Yoni Rosenblatt: There's the gold that I'm pulling out of you. That's awesome and that's a great little tidbit. Now, why do you call that eccentric and not an isometric stretch?
Dr. Dan Pope: Yeah, I think it's just semantics. Even when... So there's a couple of like med analysis, systematic reviews are looking at eccentrics for improving mobility. When you go back and look at the studies and the methods and the exercises they choose, they're really just doing a weighted stretch and usually focusing on the eccentric portion.
Dr. Dan Pope: But they will oftentimes have a concentric portion to it as well, aand I think some of the newer literature just kind of like was like, "This is not just eccentric, this is weighted stretching." [chuckle] So they just call it something different.
Dr. Dan Pope: So largely, when I prescribe these exercises I just have them utilize a slow eccentric and a pause and range into the stretch. I think that's an important part. So a lot of folks will say like, "Oh, strength training improves the range of motion, so just strength train, do like Nordic hamstring curls to try to improve your hamstring mobility."
Dr. Dan Pope: That's probably not gonna work just because you're not taking that into an end range stretch under load, I think that's probably key. I think you will find the folks that train in a partial range of motion will potentially get stiffer. You see that in powerlifters, powerlifters are very stiff in their upper body. The stiffer they are, usually the better they are too. And it's mostly because probably they're training with heavy loads on a partial range, right?
Dr. Yoni Rosenblatt: Yeah, yeah. I love hearing this because I had a couple of athletes that worked with a strength coach who only works in these partial ranges with high loads and just absolutely craps on any program that isn't solely that. I'm like, "I don't think that makes sense. And so I don't think Dan Pope thinks that makes sense."
Dr. Dan Pope: That guy is terrible. He's such a horrible person.
Dr. Yoni Rosenblatt: I know. But why... Guys train with him, it's nuts. "He's a horrible person", I like that. That's aggressive. [chuckle]
Dr. Dan Pope: Yeah, I try not to crap on... I hate... One of my pet peeves, and sorry, I'm derailing a little bit, but I hate how much we love to throw each other under the bus in this profession. It's bad. I feel like there's way more people out there producing content talking about how everyone else is wrong, as opposed to trying to help the profession. [chuckle]
Dr. Yoni Rosenblatt: By the way, you think it's just our profession, or you think this is society?
Dr. Dan Pope: It's probably society, to your point, right? But I do think there are some industries that are a bit better than we are. I don't know. There are, specifically on YouTube, there's a lot of people that are super helpful and trying to help people in general, and it's funny, a lot of folks have gotten very popular in the physical therapy world, doesn't even know about them, just because they bypass all that riff-raff, you know? But yeah, you're right.
Dr. Yoni Rosenblatt: For sure. Now notice, we're such great dudes, we didn't even mention the guy's name. So good job, Dan. Just taking the high road, I appreciate that.
[chuckle]
Dr. Yoni Rosenblatt: Okay, so where were we? We were talking about loaded stretching, essentially. Which by the way, sounds very FRC to me, functional range conditioning. So it's like your ability to get to these end ranges, own those end ranges, potentially load those end ranges.
Dr. Yoni Rosenblatt: Are you telling me you've seen outstanding benefit in the quad tendinopathy group with those interventions?
Dr. Dan Pope: I'm not sure if it's the stretching specifically that's making things better. It's hard to know, right? You get this confirmation bias. You're like, "You know, when I loaded the quad and I did the stretching and then my patient got better. You need to stretch." I don't know what's necessarily making it better.
Dr. Dan Pope: I think there is a compressive element, at least for the quad tendon in the bottom of the squat. So what's interesting about the quad tendon, and maybe the reason why I see more quad tendinopathy as opposed to patellar tendinopathy in weightlifters anyway, is because when you get to the very bottom position of a squat, the quad tendon actually goes into the patellofemoral joint and just shares a little bit of loading and surface area with patella.
Dr. Dan Pope: So you get a compressive element of the quad tendon pushing into the joint. And we're not exactly sure, I mean there's a ton of hubbub right now, especially with subacromial impingement syndrome.
Dr. Dan Pope: It's funny because let's say with gluteus medius tendinopathy, there's this big push of like, "Okay, there's a compressive element of the gluteal tendon wrapping around the greater trochanter that's causing these issues." But then in subacromial impingement we're like, "There's no compression of the... [chuckle] On the tendon. That's not causing tendinopathy." Right?
Dr. Dan Pope: I don't know, but there may be an element of compression on the quad tendon that's causing more pathology. It'd be my guess that that's probably occurring a little bit, and the reason why you may see it more in weightlifters. So if we wanna maybe reduce some of that compressive element, if we stretch, maybe that unloads it somewhat. You can make that theory.
Dr. Dan Pope: I will try to add that into my patient's programming. It's just that I don't know that we need it to get folks better, based on the literature we already have. And I haven't seen any studies that say stretching into Thomas versus not.
Dr. Dan Pope: I may be wrong on that, 'cause I think there's that one study I mentioned prior was looking at straight leg raise as well as Thomas Test versus exercises. So I will add into the program, but I'm just not sold on it being something that's gonna make your outcomes way better.
Dr. Yoni Rosenblatt: Yeah, yeah. I totally hear that. It's interesting you're mentioning these waves we go in, in terms of how we treat. So now, we love loading the quads and Pope says load your freaking quad, you're gonna get better. Right?
[chuckle]
Dr. Yoni Rosenblatt: When I came out of school, you know what it was? "Do some clamshells." And I didn't even hear you've mentioned clamshells. So tell me where hip strength falls into this quad tendinopathy group?
Dr. Dan Pope: Yeah, that's an interesting one, and I think it is relevant. I think largely if you look at the research on quad tendinopathy, patellar tendinopathy, loading the quad seems to be the best thing, based on the evidence we have right now.
Dr. Dan Pope: For patellofemoral pain, I think you can make the argument to load the hip. We do have research to show if you just load the hip or just load the knee, you tend to have a similar outcome. Also has some research if you attitude together, you tend to have a better outcome.
Dr. Dan Pope: So I do think that patellofemoral pain is probably a little bit of a different beast in comparison to patellar tendinopathy, but going back to let's say that athlete that's very, very quad dominant, that loads up the quads a lot, loads up the patellar tendon a lot. They may end up getting more patellar tendinopathy just because that's their kind of movement strategy.
Dr. Dan Pope: It's interesting, because you'll see some research that folks that have better jump performance tend to have more tendinopathy, and it's like, are they just better at loading up those tendons and they do it more often with more speed, and that maybe lends itself to more tendinopathy over the course of time?
Dr. Dan Pope: So I think that if an athlete's primary movement strategy is to move through their quad and that makes them a good athlete, then I wanna try to restore the ability to do that. You can maybe make the argument, and there are some case studies to do this, which I think is smart, if you change someone's movement strategy or landing strategy to be more hip dominant, get their hip stronger, teach them to land in a more hip dominant fashion, teaching them how to squat in a more hit dominant fashion, you're gonna offload the patellar tendon and quad tendon.
Dr. Dan Pope: So I think you can make an argument that you can train the hip and then teach someone a different strategy and help to solve their issue. I say "solve" because I think at the end of day, you're trying to re-establish the ability for the quad and patellar tendon handle these loads, so I wouldn't stop loading the quad.
Dr. Dan Pope: But for long-term health for that athlete, it may require them to adopt the more hip dominant strategy for landing or squatting, and I think that's where you make the argument for adding in some more hip strength.
Dr. Yoni Rosenblatt: Yeah. I think that makes a lot of sense. Although, keep 'em in... You gotta get them back to their quads or their gonna lose that explosiveness, right?
[chuckle]
Dr. Dan Pope: It's pretty funny, it sounds like you're coming from a strength background a little bit too. But back in the day when you were in the gym, the hip was king, and you always have your heel down always. And now it's like, "Alright, you gotta isolate the quad and the calf." And it's like, "What?" [chuckle]
Dr. Yoni Rosenblatt: Yeah, it is crazy. By the way, remember, not you but definitely me, when I came out of school, it was "knees behind toes". If I would have been the first to Instagram with the handle "knees behind toes", I'd be a billionaire.
Dr. Dan Pope: You'd be crushing it.
Dr. Yoni Rosenblatt: I'd be crushing it. 'Cause that was king. Now we go the other way. I think you just gotta... You gotta stay up on it. And what I appreciate about your outlook is you're in the lab, you're treating like what's working. And I think that's a struggle I have with some of the education is, are the professors, are the researchers, are they treated? That's totally different.
Dr. Yoni Rosenblatt: And that's why I like bringing guys like you on the pod, because this is true sports physical therapy, like you're doing it as we currently... As we talk basically. And so there's so much value in that. We don't just live in journals, we live in the gym.
Dr. Dan Pope: Yeah, that's tough. I think part of it is that as physical therapists we've shot ourselves in the foot, just because...
Dr. Yoni Rosenblatt: In so many ways.
Dr. Dan Pope: Yeah. We practice, and in our defense it's, in terms of the literature in physical therapy it's new, it's blossoming, we're pushing more over the course of time. But physical therapists in general practice so differently from clinic to clinic, and that's a bit of a problem.
Dr. Dan Pope: So I think that we're all kind of coming together and there's a sense of elitism of like, "Evidence-based is king." And I would agree. I think that's the way to go. But oftentimes our heroes are the researchers, and I think they should be, but that's also sometimes not fair to some of the expert clinicians and what they found to be effective.
Dr. Dan Pope: There's always this argument of what evidence-based care is, and experience as part of that but it's often times maybe minimized over what a research study will say. And research is so nuanced, right? Research will show a trend in a specific population. There's always gonna be outliers, 'cause folks do really well with one thing versus another.
Dr. Dan Pope: So it's very nuanced, and I appreciate you saying that. I think that is really important.
Dr. Yoni Rosenblatt: Yeah. And that's why I love sharing as many tools as possible. That when things don't go the way the journal says they should go, what do you pull out? What do you do? So let me ask you this. Anything passive. Do you do any passive interventions in this quad tendinopathy group?
Dr. Dan Pope: Yeah, I may. I may a little bit. Oftentimes it depends on patient preference. Usually out the gate I'm trying as best I can to get them on an exercise program and get them to train, but I will utilize some quad soft tissue work. We can try some laser to the tendon, see if that helps them out over the course of time.
Dr. Dan Pope: I think there is benefit to some of these. Oftentimes patients will get some pretty good pain relief from that. And if they do that and they're okay with the notion that manual therapies are more of a temporary thing, I'll keep going with it. I have no problem doing passive treatments, I know that they're... If you say you do passive treatments, you may get nailed from one side of the physical therapy spectrum.
Dr. Dan Pope: But if you have a tendon issue, you have to load it. That's super important. But I'll also do some soft tissue work to the quads, maybe some laser, a little bit of stretching. If people feel good doing it, I'll definitely do that. I have no problem with that.
Dr. Yoni Rosenblatt: Okay, dry needling. Does that show up in your world?
Dr. Dan Pope: I do dry needle a decent amount. This is a pathology I tend not to dry needle as much. I will actually have some physiatrist ask me to do more soft tissue work and dry needling in tendinopathy patients as part of a well-rounded program to help folks get better.
Dr. Dan Pope: So if the traditional loading is not working really well, they'll try something like extracorporeal shockwave therapy with manual therapy to the quad, with some laser to the area. If that's not working, they may do some injections, additional injections, PRP, and they may do some scar tissue surgical techniques.
Dr. Dan Pope: I would say that as part of a well-rounded program for recalcitrant conditions, I don't think that's a bad idea. So if it's not working well with what you're doing currently, adding some additional things might be helpful.
Dr. Yoni Rosenblatt: Yeah, yeah. Again, this comes from a little bit more of the art side, but we have seen good evidence of increased contractility of a muscle immediately following dry needling. And so is there room for that? I'd much rather do that, spend my time needle, maybe with electric stim to get a good quad contraction. And then start loading 'em up.
Dr. Yoni Rosenblatt: Obviously the loading up, I think does, but that's one thing that I will tend to do if I'm gonna needle. The other thing is, and it sucks, is when it is super chronic, is wake that tendon up with aggressive pistoning. My goal with that is simply to encourage blood flow, create some micro trauma to the area.
Dr. Yoni Rosenblatt: I've seen it help. But it's gotta be really, as Dan Pope would say, recalcitrant.
[chuckle]
Dr. Dan Pope: That's funny.
Dr. Yoni Rosenblatt: For me to dust that off.
Dr. Dan Pope: Yeah. I think the other part too, a lot of folks that I'm dealing, with as a physical therapist, I work in this model that has a bunch of strength coaches too, and we let the strength coach be experts at what they are, strength coaching. So in terms of getting someone better and using our current model at Champion, often times most of the loading is actually occurring with the strength coaches.
Dr. Dan Pope: So if they're still doing physical therapy, I'm actually looking for additional modalities to help that person. Right? So maybe it is soft tissue work, maybe it is dry needling, maybe it's another type of modality to get that person feeling like they're making some progress, to improve their outcome, get them stick around some more. Whatever it is.
Dr. Dan Pope: And then I'm doing less loading, right? So oftentimes when... It's funny because if you look at fitnesspainfree.com, and you look at all the stuff that I espouse, it's super exercise-based, which I think it should be.
Dr. Dan Pope: Then if you watch me treat, oftentimes you're not seeing me do as much exercise, and a large reason for that is because A, they're loading with another coach, 'cause that's part of our model, or they're loading on their own. Just because if I have someone that I know is really good at training, then I feel like I'm wasting their time if they're just coming in, I'm watching them. Right?
Dr. Dan Pope: And I work with an odd population. I know that, right? I think the numbers, I was just looking at some of the numbers, like home exercise, home exercise program compliance is terrible, it's like 50% or less depending on the study that you look at. So supervising someone while they do exercises is one of the best things for them.
Dr. Dan Pope: But I have a group of nutcases that you're just trying your best to get them to stop exercising so much. So I know they're gonna do more exercise on their own, and I'm okay with them doing it on their own, as long as they're not doing something unsafe or they need something that needs to be watched a little more closely, I'll certainly do that.
Dr. Dan Pope: But to get back to my earlier point, I think that sometimes people are watching my treatment like, "Whoa, you do a little less exercise than I thought you did."
Dr. Yoni Rosenblatt: Yeah, yeah. I would think I'm the same way. I know I'm the same way, actually. Like a great PT, we said is a great strength coach, but also awesome teachers, right? So if you can teach an athlete what to do it, and I say this every single evaluation, "This your homework, do it at home. Don't waste my time and come in here and make me watch you do it 'cause you didn't do it at home. And I'm not gonna waste your time, I'm not gonna show you something you've already done."
Dr. Yoni Rosenblatt: And so what I like to do, and I think it's so important, is you better be ramping and educating that home exercise program or training protocol, every time they come in or however often they're coming in. But in office, and this is what you said, you're doing things that they're not doing on their own, or they can't do on their own. And that's the way I like to approach it.
Dr. Yoni Rosenblatt: So yeah, they'd better be able to load. I'm working with a line backer right now who, dude, he could teach me everything about strength and conditioning. I mean, this guy could teach Andrew Huberman about sport science.
[chuckle]
Dr. Yoni Rosenblatt: He's the smartest guy in the room always. And so what am I gonna do? I'm looking to fill in those little gaps. He knows how to load, he knows how to progress single leg strength. "It ain't rocket science," like Mike Reinold would say.
Dr. Yoni Rosenblatt: So just know where you are. Know who's in the room with, and know value you're gonna be able to add. That's why you're teaching there.0:49:00.9 Dr. Dan Pope: Yeah, I agree. One of the things I have an opportunity to do is work with elite level coaches too, which is awesome. Worked with a lot of coaches that are prior Olympians, teach at national level, international level. And when I have a patient that comes through the door, if they're working with one of those coaches, I'm not gonna say that I know how to program for you for success. That's stupid.
Dr. Dan Pope: I'm gonna help you from a rehab perspective, and I'm gonna communicate with the coach. The coach knows more than I do. So I have to be careful about what I say to do or not do 'cause I could make that person worse.
Dr. Yoni Rosenblatt: Yeah. That takes a... Well you live somewhat in the baseball world, right? As baseball players would say, "It takes a high level of feel." You gotta have feel. You gotta know who's around you and who people are working with. So, super valuable.
Dr. Yoni Rosenblatt: Let me ask you about plyometrics. When do you get... Let's say this is a field athlete, quad tendinopathy. When do you start moving towards your plyometric activity, and what does that progression look like to you?
Dr. Dan Pope: Yeah, for sure. I think short answer, as soon as possible. It depends on how irritable this person is. It also depends on in season versus off-season. So there's a lot of variables I start thinking about from the get-go. So if someone's in season, the last thing I wanna do is throw plyometrics at them. They've got a ton of plyometrics. I'm basically trying my best to pull back on plyometrics, get that tendon to kinda calm down.
Dr. Dan Pope: That's a population that would do really with something like a blood flow restriction training, just because you're doing slow reps, low lows, minimal stress to the tendon, and we know that can be helpful for getting folks out of pain, right?
Dr. Dan Pope: Now as soon as that person finishes their off-season, I'm probably gonna have a period of time of unloading that tendon. Also in the off-season, you don't need to focus on plyometrics in the very beginning of your off-season, so you can make the argument that naturally that person is gonna do less plyometrics. As they start to build some strength and tolerance, I'll naturally add it back in it.
Dr. Dan Pope: If I have an individual that has... I'll just say I had a runner the other day with some achilles tendinopathy and they've stopped running temporarily because of the pain. So essentially they're at a point where they can't run without a limp 'cause it's so painful.
Dr. Dan Pope: And generally speaking, if people can run with a five out of 10 or less... Or less than a five out of 10, excuse me. Based on research, I'm gonna let him keep running. As long as next day they're feeling back to their baseline. But if they get to the point where they can no longer run, but they can tolerate let's say, double leg pogo jumps, I may throw that into the program right away.
Dr. Dan Pope: 'Cause I wanna start getting the tendon exposed to what the tendon has to be able to handle at a lower level to drive some adaptations there. So for that individual, I'm gonna start them up with a loading program of different types of calf raises, maybe some kind of run, specific strengthening for the hip, quad and everything else, and put some low-level plyometrics in there.
Dr. Dan Pope: With the hope that over the course of time, they'll be able to handle more and more plyometrics and then eventually some sort of slow run progression. So I guess it really depends on the level of irritability.
Dr. Dan Pope: The place where you have to be a little cautious I think, where you won't wanna throw plyometrics to someone right away, is post-op. So largely, if I have someone that has pain, that didn't just have a surgery, I'm gonna meet them where they are in terms of the stresses they can handle and try to ramp them back to whatever activities they wanna get back to.
Dr. Dan Pope: So an Olympic weightlifter, they're not doing much plyometric, or their plyometric is basically cleans and snatches. Right? If I have a basketball player, they need to be able to jump, runner has to be able to run. So I wanna try to start progressing to that as fast as possible.
Dr. Dan Pope: If I have like a post-op rotator cuff, I'm not gonna do plyometrics at week four, even if they would tolerate it. That would be malpractice. That's not good. So I would say you have to protect that area after a surgery, but for the majority of non-op patients, I'm trying to throw as much as they can handle based on the irritability of that tendon.
Dr. Yoni Rosenblatt: I like that takeaway because your answer really is summed up with, "As soon as humanly possible, that's what I'm putting them in." As long as it's not post-op, right?
Dr. Dan Pope: Yeah. That's my whole deal though, I'm a huge exercise first guy. I think one of the things that we don't think about as physical therapists, and I understand, we're not in fitness. I am in fitness, that's my main thing. But if you tell people to stop exercising or you have an injury that derails their ability to exercise, they become less healthy, they become more expensive to the rest of the population, a ton of bad things occur from that perspective.
Dr. Dan Pope: So the more we can keep people active as much as possible, it improves your outcomes, patients will like you more, but you're also making them more fit, stronger, less expensive, so many positive things occur when we do that. So that's what I'm trying to do. Step one to step, whatever step you get to. I'm always thinking about that.
Dr. Yoni Rosenblatt: Yeah. Keep them active. Keeping moving. The value add there is unbelievable. You and I were talking before we hit "record" of the ability for the sports PT to now exist in these fitness facilities and how easy that is from a business standpoint. This needs to be your mantra when you go into those places, "We are going to keep your population healthy, active, continuing to move, continuing to do what they love."
Dr. Yoni Rosenblatt: It's gonna help the business you're walking into, it's gonna help your own business, it's gonna help the patient. And that's what it's about. And that's what it's about. So that's an awesome summation.
Dr. Yoni Rosenblatt: If they are a quad tendinopathy, what is that first round of plyos you're doing?
Dr. Dan Pope: I probably could try it with a box jump to like a sub-maximal box jump. I do like bilateral before unilateral, so I'd probably start with a double legged jump, and then progress to a single legged jump. I also like to start with a box jump, just because you don't have to handle the same deceleration, so you're jumping to a elevated surface.
Dr. Dan Pope: If you jump on the ground and land, you have to handle all the forces of landing from a height. The box jump you jump to a height, so there's no... Those deceleratory forces, I don't even know if that's a word, are decreased.
Dr. Yoni Rosenblatt: It is now.
Dr. Dan Pope: Yeah. So producing force first and then we practice landing and then we add some power to it. And then we progress to single-legged exercises, same thing, probably box jump first, maybe a pogo jump first, progress to more dynamic movements, add more power. That type of thing.
Dr. Yoni Rosenblatt: I love it. And does that happen before return to run, if running was giving him pain?
Dr. Dan Pope: I think it depends on the athlete. I usually don't see as many folks with patellar tendinopathy in the running world, although it certainly does happen. I think Chris Johnson, you ever heard of Chris Johnson before in the PT world?
Dr. Yoni Rosenblatt: Yeah.
Dr. Dan Pope: He had a really bad one for a while. I tend not to see it as frequently with runners as I would with like, I would say a court sport, basketball, volleyball, those are the big ones that end up having those problems.
Dr. Dan Pope: But yeah, I will try to incorporate plyos as soon as I can with those folks and it's gonna be specific to whatever activity they need to get back to. So runner is not gonna be dealing super high level double legged jumps with turns and lands and all that stuff, but a basketball player might.
Dr. Yoni Rosenblatt: Yeah, I think that makes a lot of sense. Okay, so you're still... You're taking on students, obviously. You're treating like crazy. You got this... You're relaunching a certification. Tell us about where we're finding this cert, how we can get it and who it's great for?
Dr. Dan Pope: Yeah, for sure. I have a certification, it's a Fitness Pain Free certification. I feel like everyone has a certification nowadays, so. [chuckle]
Dr. Yoni Rosenblatt: I do not have one of those.
Dr. Dan Pope: You gotta get one. They're great.
Dr. Yoni Rosenblatt: Okay. [chuckle]
Dr. Dan Pope: But it's about four years old. I continue to update it. So I always tell folks it's basically like a university education of working with strength and fitness athletes in a physical therapy setting. So I try to fill in all the gaps that you miss in physical therapy school. It's the certification I wish I had coming out of PT school.
Dr. Dan Pope: Exercise technique, programming, exercise selection. Basically how you treat a quad tendinopathy, rotator cuff tendinopathy in the strength and fitness world. I feel like that's an underserved population, but a very, very important population. So tell you exactly how to do that.
Dr. Dan Pope: It's open for enrollment four times per year, so basically you can't sign up for it right now, but it is open for enrollment at the end of March. If you sign up for the wait list, which you also get access to the Fitness Pain Free Mini Course. Which is kind of like a smaller version of the certification, get a taste of it.
Dr. Dan Pope: But yeah, the certification launches at the end of this month. If you guys want more information, I'll send that over to you, Yoni, so you can share that with your listeners.
Dr. Yoni Rosenblatt: Yeah, I would love to do that. I think there's... You're right, it is such a gap in PTs knowledge, and that's why I like getting guys like you on who are living, breathing and teaching appropriately.
Dr. Yoni Rosenblatt: So one last piece of advice that you would share with the growing sports PT would be what, Dan Pope?
Dr. Dan Pope: Keep learning. Try to get better. I think that's important. I can't hate on physical therapists that do this. Right? I don't know, I'm a husband and I'm a father, I have other interests in life. I get it when people go in and they punch the clock and they leave at the end of day. I think you have to do that in some ways just to protect your sanity.
Dr. Dan Pope: But a lot of new grads that come out super hungry to learn and grow, and then oftentimes to get beat down by life and they lose that. I'd say try to stay hungry as best you can, keep learning, keep growing, find a population you love working with. Keep studying.
Dr. Yoni Rosenblatt: Find the population you love treating, find a place where you have leeway to treat them. You have the time to treat them, you're the facility to treat them. I think that's how you stay, you keep that fire on.
Dr. Dan Pope: I agree. It's tough, it takes work, and we don't learn that in physical therapy school. So we don't learn about marketing, we basically are taught how to do physical therapy well. Or at least we have the foundation of that. And then we start a job, and then most people just kinda stay in that job and things stay the same for the rest of their career.
Dr. Dan Pope: But you have all the power in the world change that. You can market, you can find the population you want. You can draw them, you can start your own business, you can do entrepreneurial things on the side. You can do a combination of training with physical therapy. You can do cash-based. There's so much cool stuff you can do.
Dr. Dan Pope: But it just takes a little extra effort and knowledge, and I think the barrier for physical therapists, if you compare us to dentists or chiropractors, there's an expectation going into those professions, you have to be entrepreneurial and business-minded. For physical therapists, there isn't.
Dr. Dan Pope: But you can still apply that to your own life as a physical therapist, and there is an enormous opportunity 'cause most folks don't wanna do it. So I'd say, follow folks like yourself and me, that are trying to do the same thing. Are trying to find a fulfilling life in this career.
Dr. Dan Pope: We're not so upset every single day that we're not treating the patients we like, that we're overburdened, that we're burnt out, we're not getting paid enough, and the like.
Dr. Yoni Rosenblatt: Yeah. We're gonna find those patients. Dan, freaking inspirational, dude. Good knowledge. Good fire. Thank you so much for joining us on the True Sports Physical Therapy Podcast. That was good.
Dr. Dan Pope: Thank you so much for having me. I always love being on these things, I really appreciate it. You're doing a bang-up job with your podcast. I was looking at all your guests and I'm like, "Man, you're killing it over here." Good job.
Dr. Yoni Rosenblatt: I appreciate that. But this is the highlight, actually.
Dr. Dan Pope: Wow, number one.
Dr. Yoni Rosenblatt: This is number one.
Dr. Dan Pope: I don't know if you can pin this to your podcast page, but you might think about it. That's probably gonna get you some extra views. You know?
Dr. Yoni Rosenblatt: Great idea, yes. Let's see what Kelly Starrett says about Dan Pope being number one.
Dr. Dan Pope: Yeah. Yeah, I'm definitely better than Kelly.
Dr. Yoni Rosenblatt: Way, way better.
[chuckle]
Dr. Yoni Rosenblatt: Dan, thank you so much. To all those listening at home, thank you so much for joining us. A lot of great stuff here. We'll share all the information, all the notes. Thanks again. We'll see you next time.
Dr. Dan Pope: Thank you very much. I appreciate you having me.
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