September 5 2024
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Welcome to the True Sports Physical Therapy Podcast with your host, Dr. Yoni Rosenblatt. Today, we focus on the specialized care required for elite gymnasts with Dr. Hanna Sadowski. In this episode, we explore the unique challenges and treatment strategies involved in managing low back pain in this high performance group.Join us as Dr. Sadowski shares their expertise on the biomechanics of gymnastics, the common causes of low back pain in gymnastics,Hey guys, welcome back, and thank you so much for downloading this episode. I really appreciate you. You can listen to a million and one songs. PT podcast. So I really wanted to thank you for downloading this episode. Today's guest was Hannah Sadowski. Hannah got her doctorate from Florida International University in 2019.She works at Old Bull Athletics down in Miami, and she is an expert at treating gymnasts and cheer athletes, and she does a great job of breaking down the dreaded spondylolisthesis, how to diagnose it, how to rehab it. She has some really. Great tidbits on frequency of visits and then how to progress some of the higher level gymnastics moves.And honestly, I had no idea how to do before this conversation, so I think you'll get a lot out of it. As always, let me know what you want to hear, what we did a great job with, and what you'd like to hear more of. You can reach us at true sports PT on Instagram. That is the best way to shoot me a DM. Um, and then just let me know what other guests you want us to have on.That's how we got Hannah on here because I heard she is an expert and she definitely lived up to the billing. So enjoy this conversation with Dr. Hannah Sadowski and let me know what you guys want to hear. Thanks so much for listening. Welcome back to the true sports physical therapy podcast. We got. Dr.Hannah Sadowski with us today, working currently at Old Bull Athletics and you are a gymnastics guru. So, that's what I wanna dive into. Thanks so much for being here. Absolutely. Happy to be here. Thanks for having me. Yeah, no problem. Um you come highly recommended by Katie. So, um I can't wait to learn from you.Now, Low back pain specifically in the gymnastic population is something that I have struggled with mightily when trying to rehab. Just give me an overarching framework as to how you look at these athletes that are coming into you high level gymnastics with low back pain. Sure. So pretty common to see that as someone who comes in generalized low back pain.I really want to make sure I can pinpoint what it is that's causing it. Typically in the gymnastics world, you automatically think spondy or spondylolisthesis, but that's not always the case. So I'll really break down in my evaluation, being able to pinpoint what specifically is going on. And how do I do that?Yes, that is my next question. The tricky part. No, it's really pretty simple. I'll look at active motion first. Unless again, they're really intolerant to even some of those active basic positions, but I want to find out where the provocation of pain is coming from. So general motion of the spine, I'll look at forward flexion, extension, side bending, and then to dive a little deeper forward flexion with rotation.And then extension with rotation. And then again, looking for a patterning and trying to pull out the pieces that stand out and that cause pain, but also the things that don't cause pain. We want to know both. Okay. What doesn't cause pain? So, so that's an interesting tidbit because I assume if, if motions don't cause pain, that's where you're going to live rehab wise.That's where you typically want to start. You want to have them moving into those pain ranges that don't provoke more pain. It's usually like a tissue sensitivity type thing. So yes. Okay. Now, do you care? Whether it is an actual spondy, whether that's been verified on x ray or CT, does that matter to you?Yes, it does. Tell me why. So typically your spondies and they're coming in because of pain is that they're really in pain. These athletes tend to have a history of. tucking things under the rug and not telling coaches or medical providers about pain. So usually when I do get them, it's because they actually are hurting.Um, the reason it matters is because you actually do need a period of rest with these spondees. You can have an acute spondee or you can have a chronic spondee. So regardless it's flared and in that moment it's hurting and we need to take care of it. So with these true spondees, we need to know. Because we need to have that period of rest, that like appropriate period of rest.Otherwise the pain typically sticks around far, far, far too long. And then from there, other, other things can become issue. So a typical spondy, again, I don't really care if it's acute or chronic, but knowing in the back of my head that it might not heal. It's a one key component. Um, chronic, you typically can have a shorter rest period and just manage symptoms, whereas acute, you do have a typically longer rest period in the beginning.Before you really ramp back up into things, but so break that down for me. How long? Um, How long do you rest when you have an acute spondy? Typically, the whole cycle for our spondy healing is going to be like four months. Um, about eight true weeks of rest on an acute slared up spondy is recommended. And how are you defining acute?Once they get their imaging. Okay. So they can, they can, okay. They can tell how long it's been. And so if they have an acute, um, if they have an acute spondy, you don't care about the amount of slippage, just that if they tell you it's an acute spondy. Then you're going to shut them down for eight weeks.What does shutting down look like? Do you send them home? Hey, I'm not going to see you for eight weeks. Or is there, is it, um, more like recovery rest or active rest is pretty much be just be a kid. And I say like you, it's that long because the spine is really hard to just not be on, um, sitting, walking, you know, even sleeping all these different normal ADLs are going to put work or force through the spine.So it's really hard to just say, yeah, don't use it. That's kind of why that longer rest periods in there, I usually say four weeks completely. You don't even need to see me truly just rest, but then on that four week mark, they can begin initiating a parent who really wants them to get going. Sure. There's plenty of things as a PT, I can give them that are not going to provoke or cause any type of irritation to the spine.That will be beneficial. Yeah. Yeah, like a period of four weeks rest. I'm usually totally cool with, and then pick starting up at that four week mark and diving into the actual treatment. Okay. So let, let me push you on that a little bit, because I always give my patients kind of two speeches. Here's my one speech of what is absolutely best for you.Here is my real world, whether it be insurance or whether it be finance that I'm, I'm going to say, here's the best use of your benefits. Um, What's better for this acute spondy? Is it better that they come in during those four weeks or is it better that they sit home? In the beginning, it's better that they hang home and just be a kid.So don't do anything. Now, why, why is it not better to come in and do clams and stretch your hip flexor appropriately and do all the stuff that you would do if you had a parent pushing you? Why is that not better for them long term? They are. Typically these athletes, again, they're very, very strong. These types of movements they can already do.And yes, they're great. And could I show them at one time and they do it on their own? Yes, but they usually get very frustrated, very fast board. They don't want to do it. And then they feel okay. If I can do this, why can't I do everything else? So again, just from past experience, knowing the research and seeing the new literature, give them, give them four weeks off.Hey, go be a kid. You can walk, you can do this. Just don't participate in your sport. And then we're going to come in and we're going to go, we're going to take off. And we're going to run with it. Okay. And so, so that's really insightful. That's kind of, you're, you're not going to necessarily see that in the literature, like you're making a decision based upon the way you've seen these things play out your experience.You don't want the kid to get a false sense of security that, Hey, I'm fine. And you also don't want the kid to burn out early on. That's probably a lesson for the parent that's pushing you. So stop listening to those parents that are pushing you. Um, and, and just do what you think is best. Now, after they do those four weeks of.chilling, then where do you start? Yeah, so I'll reassess symptoms again Okay, and see where we're at in terms of I sort of break things down Active spine movement and then table spine movement and palpation. So looking at the local spine versus the global movement. And so I'll reassess symptoms there, but a lot of it is going to be working again into that position that is not provoking.And because we're talking spondy specific, it's not just true that extension will be the only thing that hurts. I've had plenty of cases that forward flexion hurts. You know, you said your glute bridges. Okay, post your pelvic tilt and you'll be fine. No. So you really just have to assess the symptoms and go from there.You start off with your typical proximal strengthening. So I'm looking at the hips, the core and the shoulders. Okay. And so you make a good point because I've seen this a ton of times where you just, and I see it also in disc pathology, right? Where it's like, What do you mean? The textbook says you're going to have more pain with flexion, less pain with extension, but you're the opposite, but you have a disc.Uh, I think we got to get away from that. Like a spondy can be painful in any direction. It's not just extension, like you said. So I think that point is well made. How do you come up with objective measures? To then come back to and say, see, you are getting better. You, you weren't able to get through this range of motion.Now you can get through this range of motion. What kind of tests are you doing there? So I'm looking at first is generalized range of motion in these spine movements. So maybe they could, couldn't extend before at all, any bit of extension back, or maybe they were extending back, but there was no anterior hip shift.You know, so looking for certain degrees of motion or patterns of motion, side bending, same thing. I'm measuring tip of finger down the leg, looking at range of motion and then looking for comfort when they go through these ranges, like are, are they completely grimacing the whole time? So objectively the range of motion, the actual, how do you measure that?Um, Pretty much side bending is the easiest measure. Tip a finger down extension. I'm looking at areas of the curve of the spine. So slightly subjective, but I'll photograph and actually measure how my angle looks. So using photos to track that, um, and then your table assessment, so prone press up prone, press up with rotation.So using that more of like a functional movement to, you can't measure, are you measuring that or no? No, I'm looking, I'm looking for more of their subjective opinion. You can measure rotation and I'm looking at like point of where their shoulder is rotating back. So land body landmarks. Yep. And then you'll bring it up side by side on an iPad or something and show, Hey, you are getting better.Yes. Okay. Um, and any other measurements? Are you, are you using a goniometer ever? Barely. So why did they teach us that crap in grad school? Okay. Are you using an inclinometer? Okay. There's no inclinometers to be found at Old Bull, unfortunately. Okay, yeah, and you won't find them in True Sports either. Um, do you, If you had your ideal setup, you could have any tool that's out there.What would you, what would you use for specific back or kind of no, give me, give me low back. I want to stay. I have enough trouble staying focused. I want to stay focused on this low back then. Yeah. So, I mean, a great stick. A good dowel because I have to look at overhead mobility. So honestly, a good, nice dowel.It's about an inch and a half in diameter does the trick. And like my weights, because that's the progress there is how strong they're getting typically posterior chain and. Um, yes, we can use again, like resisted cables. We just got this cool new toy that gives us lots of fun, like output measures, but it's really in.The function and the progress being made in the progressive overload, because that's, what's going to translate to the force that's going through their spine. We don't have force plates. Unfortunately, at Old Bowl, that would be a wonderful tool because again, the end goal in all of this is to replicate the forces that goes through a gymnast spine every time that they punch the floor.So being able to say, okay, this is how hard you're going to land during this tumbling pass. Let's see how high you can jump and how much you can absorb force. Something similar. Yeah. Of course, plates, a good dowel and weights. Okay. So, so not, not a huge amount. Um, so you mentioned that you're looking at spinal mobility.Um, tell me what other ranges of motion active or passive your measure. Um, overhead shoulder mobility is huge. Okay. Okay. And you're, and you're testing that. Are you just testing that in sitting? Are you testing on standing? I think that matters, right? Because of what's transpiring at the lumbar spot. Yes, absolutely.I'm going to first look at it in supine and see if I note any restriction, and then I'm going to take them into seated, either like crisscross or pike sit, and then look at it there both in a pronated and supinated grip. I'll, I'll target both. And then I'll take it up to standing. I look at all three.Because of the degrees of motion that we're adding in each position. And then the different grips are because of the lap, like the attachment point, when you're supinated, it gets a little more locked in on stretch versus if you're pronated and these athletes have to have their hands in both positions.Yeah. Okay. So, so that's a great point. Um, in terms of like I'm thinking how we rehab lacrosse players versus gymnasts that that's an important point. Um, understanding where their hands are. So, thanks for pointing that out. Okay. That's the shoulder. Tell me what you're doing at the hip. I'm looking at again, mobility.Good word pattern. Yep. What are you measuring? I want to show them progress. Yep. Yep. So at the hips, we're going to look at, I'm going to video and record how they squat, how they lunge, how they hinge huge, huge, huge. And then I'm going to ask them, okay, let me see your splits, different things that are a little more geared towards the sport.Um, let me see your bridge and then let me seeyour drop landings, something like this. So whether it be drop off the bar, whether it be a depth drop, because I want to see again, how they're absorbing and how they're producing force because this is what the sport's all about. Yep. Yep. Okay. And is any of that objective? Yes. What, what number are you putting on them?In terms, well, I'm gonna base a lot of my objective measures off. The return to sport testing. So we're looking at like single leg heel tap test. So we have a lot of data on that and we know some normative values, so I'll see where they're at. And then we progress in and reach towards what we can track in the literature to be a normative value for a high level athlete.Okay. And And can you walk me through that test? Yeah. So easiest one heel tap test. I go both versions, lateral and anterior. It's going to be eight inches is your standard test height baseline. We'll mark them where they're at. If they can't quite get eight, we'll start at four, six, something along that line.And we're going hands on hips, reduce any of that movement, motion and have them heel tap. So on one leg, bend the knee. Lightly tap the opposite heel to the floor. Stand back up. Couple of things we can measure based just on that test. Strength, quality of the movement, any type of ankle, knee, hip restriction, or weakness, discrepancy, motor coordination.I'll tie in just from looking at that one test. Okay. And what, what is, what is the normative value there? Typically, if we're going for speed around 30 taps we're looking for in the 15 seconds. So like speed, speed, we're trying to get tempo. We're trying to have no wobbles. We're trying to stay consistent.The other nice thing is to just compare them from left to right. So first put them to their own test and then compare them to these normative values. Um, Yeah. And then the same thing for anterior. So one bias is that knee a little bit more of that knee strategy. Hey guys, quick pause and a quick shout out to this new masterclass that we just launched here at True Sports Physiotherapy.Myself and Dr. Tim Stone put together a masterclass of ACL rehab, and we call it from table. to turf and the reason we call it that is because it's going to teach you exactly how to get your athlete all the way from post op day one with the nitty gritty of regaining all of that range of motion with the tips and the tricks that we use here at true sports physiotherapy that gets our athletes better faster and stronger and that's early and then how do you progress that athlete all the way onto the field with a ball in their foot or stick in their hand or whatever their sport is and teach them How to accelerate, how to decel, how to change direction, all the mechanics that go in there.What drills do we use to get our athletes exactly where they need to be back on the field and even better than before injury. And I want you to sign up for that class. Now you can find it on our website. You can shoot us a direct. Message and just say, Hey, send me the course it's right now on sale. So make sure you sign up.Now it is fully accredited to get you all of your continuing education hours, sign up for the true sports masterclass ACL from table to turf. Thanks guys. Yep. Yep. Okay. So, so that makes sense. I, I'm just surprised to hear you go to heel tap because that's pretty far away from their low back. Right. So is there, are there any normative tests?Are there any objective measures to look at core strength? Do we. Do we care about measuring that? This is some of the gray area that I run into. Like all these, all these athletes are rock stars in terms of their abdominal strength. How do we give them something objective or baseline tests to say, actually, you don't do a great job controlling, or maybe you are a week there.Are there any tests that move more proximal? So you can look at like your double leg lower test. Typically the athletes are going to be really great at these, but we want to know for how long. So is it an endurance thing? Yeah. So while the objective measures are not so clear cut, I will create my own objective measures.Hell yeah. Okay. Give me the, give me those measures. The, the Sadowski test as I love to call it. So the double leg lower is the standard you're going to force around 10 reps as a gymnast. We know that 10 reps of anything as basic for them as a double leg lower is not going to be enough. So pushing for 25.Okay. Around that 20 to 25 mark. Do we then get any of that change in core bracing or arching of the low back? Okay. And how do you, how do you measure to make sure that their low back is staying flush? Um, my hand. Okay. My hand. And then. their ribcage positioning and their ability to maintain the same depth of lowering throughout the rep count?Or do they shorten the rep range to maintain that low back flat? Again, different indications of either muscle fatigue or muscle weakness after a period of time. I'm also then looking at positional core strength. So do they have the ability to hold their hollow body position? And you have them straight leg, straight legs, arms overhead.And that sounds horrible. And what's more, what's normal. So we're shooting for a minute on all of these. Okay. This is like a solid minute is excellent. If they can't reach that, you know, then we have room to work, but hollow body position, arms overhead space between the chin and chest, shoulder blades off the floor, heels about four to six inches from the ground.Okay. So it's a beautiful C shape or what I call like a spoon, call it their spoon shape, rounded on all edges. Then you flip them over, their arch shape, the exact same flipped over. So being able to get those arms just behind the ears, show a nice curvature, C shape in their body, maintain that position.hollows, which again, C shape, shoulder off the ground, heels about six inches. So can they. Maintain these positional strength. Okay. Also looking for a minute there. Okay. Um, so, so that's awesome. I could see room for like, I'm, I'm always teaching my, my dead bugs or my hollow holes. I'm putting a towel under them and having them pull it so that they have some type of cue to know, Hey, my back is coming up.Um, but I would imagine early on, this is pretty painful, right? Yes, it can be. Yeah. So, um, can you give me a scaled version of that? Yeah. So we, I will typically start with like diaphragmatic breathing, breath work, being able to just control the diaphragm moving and tolerating some abdominal pressure. And from there, you can work just squeeze it like squeezing bear crawls for me or bear crawl position.Is another good way to get abdominal bracing for a brief bit without having to apply too much pressure, you know, just a simple liftoff, you get that activation and then come down and then it's really easy to build on hold for longer lift an arm, lift a leg, things like that to create more tolerance. To the brace position.You can also work on keeping the legs down. So same dead bug position, but with the feet down and then manipulating where the limbs go. So you can, from the bottom up, you can move an arm, you can hold onto a band and not move anything. and things like that. Okay, that makes a lot of sense. Now, um, talk to me about hip ranges of motion.Um, I would normally throw in a Thomas test as a piece of my evaluation because I think the hip flexors create a large amount of lumbar extension, thus exacerbating the spondy. Tell me if that fits into your world and what you usually see with a high level gymnast. Yeah, so absolutely. Thomas test is actually like my favorite test of all time.And I, same thing, I sort of have like my own twist on the normative value. Um, I always make sure that there's nothing blocking me. Like I want to make sure that the leg can bend as far as it might need to. And then I down into extension. Okay. And then I make sure that they can hug that knee, like to their chest touching.This creates a full cross body pattern, which replicates majority of their skills that involve a split. So, because we know. Typically spotties exacerbated with extension and they do so many split patterns. That rear leg is in extension. And so we need to replicate that Thomas test stretch similar to what those skills are like to really get an idea of what may be tight or limiting them on that hip flexor component.Yeah. Yeah, go ahead. I have them tuck the hips under as a cue to lock the lumbar and really get the extension of the hip flexors and see like, again, where are we getting just a stretch? Are we getting pain? Like what's going on when we test this and what kind of degrees of motion are you usually seeing their usually they're gonna they it's because I consider it to be a positive test because the leg again is elevated off but the range of motion is typically large.So to someone who might not understand the sport and these great ranges, it seems like amazing. But if you have a little more understanding of it, it's not quite where it needs to be. Yep. In this sense, you need full hip flexion. So if they can go there, they need to go there to hug that knee. And then we're looking at where's their full hip flexion.extension. And are we yet in a crossbody pattern replicating a split of 180 degrees? Yeah. And this might be the only time that I, that I use a goniometer. Um, to measure both hip angle and the angle because I think that that's an important differentiator. So if you're seeing these spondees come in and hey, it looks like they have massive amounts of hip extension and I think you do a good job of spelling out that that other leg needs to be in massive flexion, massive amounts of flexion, right?And then what is transpiring? of your two joint hip flexor versus your one joint hip flexor because it could be either of them um that that are taught so giving a good um objective measure that's something you can come back to you can give them the stretches you want to or you can give them the loading um in in a in a elongated hip flexor um and then come back and say okay is this better is this not better i just like that it gives you kind of somewhere to go anything else you're looking on at evaluation when this patient walks in not that that's not enough Yeah, I really want to know what, like all the key components that are provoking their pain, shaking my table.I was told not to do that. Um, I w I really want to know all those key components so that I can test them based on what they're telling me. So every evaluation is going to be a little bit different. I want to look at hanging is hanging, provoking their pain because of a spondy, some, yes, some no. And so we want to look at things like that.I want to look at compression. So a heel drop test again, is it provoking? Is it not provoking? Um, and then I'm going to look at their glutes. A lot of times the tightness surrounding their glutes is they're limiting another piece of the puzzle. Um, and then from there, the different rotational patterns.Okay. So it's really like running through all of these screening tools and piecing it together. But overall, shoulder mobility, huge, hip mobility, huge, and hip mobility adding in like glutes included, hip flexors included, adductors included. Yep. Yep. I think that makes a lot of sense. Um, can you tease out the hanging piece?Like what is that? What information is that giving you? So because of bars, which is the, you know, they're hanging at, that's really the only event of the four and women's that they're hanging is, is the traction from hanging provoking pain. And what's that going to do treatment wise? We want to know tolerance because we are, they arch and they hollow on the bar and they do so at a large.Meaning high, higher force. And so we want to know again, like on initial eval, are you provoked and just hanging, because that's going to be something that I don't necessarily want to avoid or limit if this is something that initially isn't. painful. I don't want to wait until month four to introduce this when in month two you're feeling fine and we can start doing hanging positional hangs, you know, hollow arch hangs and things like that.Yeah. Okay. So, so you make a good point. It's similar to what you said previously, which is we want to tease out what, not just what they can't do, but what they can do so they can keep doing that, right? Like, let's keep this athlete more engaged, more active with what they can do. Um, so I think that's, that's a point well made.Okay. So you go through all this testing. What is your standard first round of home exercises look like for this population? Yeah. So the, this is pretty basic, your general kind of PT beginners work, but a lot of lateral hip strength. So again, we're trying to build this hip stability, create strength around the injured area.Side planking, that knee side plank, hip abduction, clamshells, things like that, where we're holding, looking for this. 60 second minute type of holds. Um, and then core bracing. So we're looking at bear crawl positions pretty much. If you can take your body and put it in each position, side plank to bear crawl, flip to the other side, flip to your back, dead bug.That's, that's our standard. Okay. And do you include any extensor strengthening in this? For the back? Yes. So yeah, again, dependent on. symptoms, but we can go like Chinese plank. What is that? That's, um, pretty much take two benches. laying your back space in between. Yeah. So think plank, but upset, but on your back.Yeah. We call that an Australian plank because it's the reverse. I love it. Why would it be called Chinese? I'm sure. Why are the Hungarians with squats? I don't know. I don't know either. Um, Okay, so okay, so you are including that and then give me a progression of that because I think that's where a lot of sports PT swing and miss.We know how to progress a dead bug. How do you progress the Chinese plank? Um, so again, you can start this flat, you can raise it onto benches, you can take off a leg and taking off the leg is a huge component because of the isolated max effort hip flexion, which is huge. Okay. Um, that, that end range hip flex, or excuse me, hip extension is huge.That's where a lot of times gymnasts lack a bit is that end range positional strength because of their flexibility. So yeah, taking off a leg, adding a kick component to something more dynamic to your static and looking at form. Rep count, speed and tempo and duration. Okay. Um, okay. Now you said the, the like stage one of the Chinese plank would be on the floor.What would that look like? It's driving the heels and the shoulders in and getting the hips slightly off the ground as you can. Little bit of glute squeeze. Okay. A little bit of a glute squeeze. Okay. And that's easier than putting them up on benches. Yeah, two benches. Okay. Um, okay. That makes a lot of sense.Then if you give them that for home, what are they doing when they come in the clinic? So we're trying to progress each position of difficulty. We want to make sure that their home program, they're understanding what core bracing means. They're building up their like base of the pyramid. As I like to term it.And then we are starting on that next level of the pyramid. So if they're getting good at their static holds. We're going to start adding some dynamic component and checking in. Can they still maintain this type of core stability that we're looking for while doing X, Y, Z. So easy example, let's take client cold on the forearms.Cool. They can hold it up a minute, minute and a half. All right, let's add an overhead. push and pull of a kettlebell. Are they able to maintain that same trunk stability while we're doing something else? Cause that's really all gymnastics is. Can you stay tight while you're doing flips? Any type of anything else?Can you stay tight? So, okay. Okay. That makes sense. Now, how do you, how do you handle as a patient's going through this? You know, it sounds super easy when we just talk about progressions and regressions and Here's what you do. Here's how you climb the ladder. What do you do when the patient says, I feel that a little bit?We will work through it. Some discomfort again is inevitable. We have to have kind of a boundary of what's too much, what's dangerous versus what's just like mild discomfort or a little bit of a warning sign. And I'll explain that through to my patients. Is this something that feels dangerous? Like you are going to get hurt?Or is it just a little uncomfortable? Yeah. And, and these athletes, especially the gymnasts, they are, they're just used to chronic pain, right? They're, they're always in pain. Yes, really sadly. So, um, do you give them a scale? Is it different depending upon the level of athlete? Yeah, depending on the level.Well, it's usually the higher level they are. They tend to understand their body better, but I usually will use like a one to three type of pain scale. If we're in that range, we'll, we'll keep working on the exercise at hand. If it's something that they're like, no, this is like a seven, eight. We're doing too much.And then we're also looking for like day after what are the symptoms? So we have a lot of just soreness or are you like achy and uncomfortable again? And then that gives us good clues into whether we did too much. We did too little. We did a solid amount. Okay. Okay. It sounds, I mean, it sounds like the way we would handle, um, a tendinopathy, um, by the next day.Um, okay. So then how many times a week do you want to see this patient? Ideal world. In the beginning, typically just one time a week is their understanding of what they need to do. That's, and I'll always explain to the parents and the athlete, if they are going to do what I'm teaching them. One time a week will work fantastic.Okay. And you see them at that, um, cadence for how long? For four weeks and then, yeah, and then into the next four weeks. So they rested for about four. We're working for weeks at once a week, building their core stability. And then we're starting that general strength program by the end of that. Second month, and then that third into fourth month is going to bump up.I usually recommend at least two times a week at that point to reintroduce all your squat patterns, hinge pattern, lunge patterns, push pull patterns, things that are going to load the core axially, and then begin rotational when appropriate extension, things like that requires a little bit more in the clinic to get the demand that replicates gymnastics.Cause if you ask a gymnast, they typically have no more than like 25 pounds in the gym, which is also something I've been trying to work on that there shouldn't be more weight options in a gymnastics gym because they are really beneficial, but because there's not, they tend to need to be in the clinic a bit more.Okay. And so once they get to, um, month three and four, do you bump it higher than two times a week or no? Depending. I, again, we'll ask them like, realistically, what are you going to do at home versus if you're going to do absolutely nothing, then we need, you know, at least three times a week because it, training five days a week for four hours, there has to be some understanding that we need to get back to that level.Yeah, yeah, to build that capacity. Okay. Yeah. Um, and then when, when do these athletes, are they usually able to return to competition? So usually by after the fourth month. The goal, you know, typical, if you're perfect on timeline is returning to gymnastics fourth month, like that the fourth month, we're already able to toss back in some workload modifications in the gym.And then we ramp back up accordingly. It's hard to say perfectly, but you know, four to six months in an ideal world. Okay. And then that, that's, that's towards the end of the timeline earlier, Roland, are there any modalities or manual interventions that you think are important? If so, soft tissue massage, I utilize to decrease tissue sensitivity.I will say that I've had great, great, great results to then bring it's almost to decrease the CNS. Okay. Thanks. And allow them to come in from being like, ah, my back to, okay, I'm, I'm ready to, to do some things. So soft tissue massage typically works great if they enjoy and feel like ice or heat helps. How about it?No problem. They, they can, they can do that by all means, but otherwise I don't typically use soft tissue. And modality. And how long do you spend doing hands on stuff? Five, 10 minutes, five, 10 minutes. Okay. Through sports, physical therapy is growing like wildfire. We've had 14 locations soon to be more. We are throughout the state of Maryland.We're in Pennsylvania, in Lebanon, in New York, Pennsylvania, as well as in Delaware, in Newark and Wilmington, Delaware. Like I said, so many more practices to come and we always need outstanding sports, physical therapists. Our treatment style is unique. We are one on one with your athlete for 45 minutes, every single session, you do the entire treatment, you do the entire evaluation, and they are in state of the art facilities where you have room to run, throw, and jump, and really get your athlete all the way back to on the field and better and stronger than they were.We also have outstanding salaries. Comp structures, bonus abilities, 401ks, as well as a very strong continuing education offering, including in house continuing education. And we're looking for you. Now is the time, as we are growing like crazy, just shoot your resume over to Yoni, Y O N I at TrueSportsPT, or shoot us a DM and we will hit you back.We will get you in for our unique tried and true interview process and really make a determination. That this is the right place for you to grow your career and get your athletes better than ever. We can't wait to hear from you. Um, Okay, and then they come all the way through now as they're getting better higher level.It's super easy for you Um to run through gymnastic type motions Let's say you got a schmuck like me who's trying to rehab an elite level athlete I I can't do all that crap on the bars or whatever you were describing. What's your best advice to someone like me? to try to coach an elite level gymnast through this stuff?Great, great, great question. Thanks. Um, so really take a day, take a week and go into a gym, maybe just get the understanding of the skills that they're performing or ask them for videos. So you want to just really make sure you know what it is they're getting back to, because as a PT, you understand movement, you understand biomechanics, It's not going to be so hard if you can understand the movement they have to do.You definitely don't have to be able to perform it yourself. So don't worry, but understanding the like work demands of it, I think would be the most important thing. If you can understand that when you jump on your legs, for example, you absorb through the hip and then, you know, your basic biomechanics, that gymnast do that through their arms, right?Oh, interesting. How can we recreate something that looks like jumping on your arms before telling them to go do a double backflip so that I would just be very situational and someone else do it. Not necessarily. You have to train for three years at an Olympic level to then be able to rehab and athlete.So just, just understanding and breaking it down. Um, situational, what is the demand they have to do? Well, well, that's, that's a great point of, of the way you describe, um, creating, creating force, absorbing force through their arms, not just their legs. Can you give me some examples of how a PT should, Coach that and, and scale that.Yes. So typically it's easier to understand like a kit. Let's think Achilles tendon. Um, and we want stiffness. So we want to be able to decrease our ground contacts and be very fast off the floor. Gymnastics, we call that a rebound. Okay. So we want to be quick and fast. So we think, okay, we need to be able to create that same stiffness in the upper body.And I will usually start off plank position. Can they hold it? Can they do a plank step up? Can they do plank hops on their arms? You think on an easy surface, maybe on a trampoline. Can they do it, you know, from their knees first, then onto their feet, then can we fall and catch ourselves in a push up position?Then can we do a plyo push up? Then can we do repeated plyo push ups? Yeah. So all things just adding like we would for the lower body. Yeah, I think, I think that makes a lot of sense. Can you also walk me through, um, your handstand progression? Like how, where do we start that and how do, how do we scale it?Sure. Or how do we progress it? Just for the handstand. And if we continue on the spondy course, the kick up to the handstand because of the large cross body it takes to kick up, you get a lot of tension and pull on the low back. So I'll usually start progressing back in the handstand from a tuck up position, meaning they bend their knees and then push up or a pike position, but both the feet are together.Okay. And you can start that against a wall. You can start that feet on the box and moving your hands from a plank to a pike position. And then from there, you can begin adding in this cross body, cross body pattern. And see how they tolerate that. And then from that cross body L position is what I call it.You can start getting all the way to full handstand beginning first on the wall, then kicking up usually these athletes already know how to do handstands. So it's a very short period of time. They might need the wall, maybe just the same day because that they, they can do it, and then that's your entry into getting them back into skills that are gymnastics specific.But low load. Yeah. Oh, well, I think that's great advice. I see this a lot with rookie PTs um that don't have this idea fully mapped out before they start a session and they kind of get um frozen mid session because like crap like this athlete is so skilled at so many things. I don't know how to progress.I don't know how to scale but mapping out the entire movement before the session starts and then just trying to figure out where your athlete fits in that Spectrum. Um, I think would be really worthwhile. That's true across all sports. It's just gymnastics is far into so many. Um, I think it's worth like you said, finding even if it's YouTube, finding out what these athletes need to do and then deconstructing that motion because we should know how the human body moves, how to make it harder, how to make it easier.Um, I think that makes a lot of sense. Any other big skills that that I'm missing? The back handspring. The back handspring. Okay. Teach me how to do a back handspring and teach me how to teach someone else to do a back handspring. So the back handspring in particular, because again, Spondy talk. So it's like the key extension based skill that you begin at a young age.Usually. It's the one that causes the spondy. That's a repetitive over repeated scale. So they're already going to know how to do it. Most likely it's there. If they're coming in with a spawn with a spondy. You're jumping backwards, creating an arch position in the air. So we're here. Yes. For those of you listening, and it just did a great job showing that with our hands.So tune in. Yeah. Landing onto the hands and doing that rebound I talked about from your hand into the air. To your feet. So you started on your feet, jump backwards, touch your hands, and then push to your feet. Okay. So what's your first foray into this as they're coming out of spon? So you're looking at their arch pattern, and this is from as soon as they can tolerate some extension, think cat cows.Okay, awesome. You know, you're starting at something basic like a cat cow. Looking at that arch pattern. Are they getting a good C shape? you know, even extension from cervical through to lumbar. And then from there, you can start changing their positions of arching. So on their stomach, can they lift up an arch C shape?We talked about that one positional hold, then we can put them in tall kneeling. Arms up overhead, extend back, looking for the same exact pattern, but now we involve a lot more hip extension and glute lock when creating that pattern, which is going to slowly start to mimic the backhand spring. From tall kneeling, we can take it up to standing.From standing, we can take it depending what you have access to, to like a jump back some, you know, there's big mats out there where they can jump on to if you're in the gym, but we're looking at standing and then adding a dynamic component. So I go med ball throws overhead in the clinic, and that is going to bridge you into.Your jump, which at that point, the jump is the backhand spring. Okay. Yeah, that, that makes sense. Um, your first overhead reverse med ball calls, is that kneeling or is that standing? Kneeling. Kneeling. Okay. You go kneeling, you go split stance, you go standing. Typically, well, you can do split stance, but I would do standing first because the split stance adds that excess extension from that rear leg.Okay. So I would go, Tom, Neil, Stan, and then start like varying it, getting creative, split stance, things like that. Okay. Okay. That makes a lot of sense. Now, can you, cause obviously you're a freaking expert at doing this. Can you think of a time you made a mistake, perhaps early on rehabbing these athletes and what you learned from that?Um, early, early, early on that pain scale, we kind of talked about used to, uh, you know, Get in the way of progress for sure. Where they're like, nope, this hurts. Nope, this hurts. And it can cost you not a little bit of time, I would say. And so maybe there in the past, I definitely have underdosed, which thank goodness I've learned from, and I'm able to see when it is appropriate to maybe scale back versus continue on.But. Having like a way better understanding of what the body can do and what gentle exercises really are. An additional, like keeping someone on a cat cow or a side plank, and they have a little bit of pain by no means is indication to hold them back for like weeks on end. They, you know, a little bit more load, a little bit more work to brace and keep chugging along is definitely something I've learned to build and work through to get them to the outcomes that they want.Yeah. And what do you think yourself not included outside of not properly dosing? What are the biggest mistakes that general sports pts make when dealing with this spondy case in the gymnastics population? Not getting them the demands that they need. So yes, which kind of ties into underdosing. But leaving out demands that the sport requires.Yeah. Yeah. And it doesn't have to be dosing, but it, but it could be, um, you're not hitting the positions that they need to be in. Right. Right. So if you don't understand what they need to do, you're going to clear them to return, but they haven't, They haven't replicated those movements yet. So maybe it is a little bit of overdosing.But um, I think that's, that's definitely true in, in all sports. Um, can you dive into thoracic spine? We didn't talk a lot about that. Um, how important is it and how do you measure it? Yes. T spine. Very, very, very important because we need our C shape. Yeah. My favorite way to describe it. Um, again, I'm typically measuring based on photos so that they can see what we're looking for.A lot of times they might not be missing the motion, but they're not accessing the motion, trying to get them to just understand this is what you have to do. And it might not be a limitation. It's just motor coordination. Yep. And so give me some exercises. If that, if you think that is their number one restriction, how do you educate them on that?And then how do you give them what to work on? for that. Um, education wise is giving them that visualization saying, Hey, this is what you currently look like, like a number seven, you know, we're going like hard arch at the lumbar straight on the thoracic. And this is what we need to look like for force to be absorbed a little bit better throughout the spine, which is that C shape again, arch positional holds excellent for that tall kneeling arch back.So that's going to be tall kneeling. Grab a dowel told you already. That's my, one of my favorite tools and arching back and you can limit the range or you can increase the range really easily, having them tap back maybe to the wall versus a lower mat. And then educating on how to. lock out the hips and squeeze the glutes.I'm usually looking for a nice forward hip shift when they initiate. And then I'll usually say like, open up your armpits. That's, that's one of my go to cues is like, I want to, I tell them again, they're kids. I want to smell your armpits, open them up for me. And that'll help get some of that T spine. So I'm looking at those two things, hip shift forward.and then opening the armpits or getting more arch from the T spine to create that C shape. Do you ever find yourself, um, with a hypomobile T spine where you go foam roller or lacrosse balls? Yeah, and that will come in, um, ties really quite often with tight laps. Yeah. Yeah. Big time. Um, my favorite, what I've been doing is we have pretty big size med balls at old book and just going seated T spine extension, right, right over.Yeah. And, and including overhead reaches with that. Yeah. Sounds like it'd be really important. Um, with your favorite Dell, um, when do you get into reverse hypers, GHDs, uh, Jefferson curls, like some of the higher level loading of extension. Sure. Once I, their capacity for like pretty basic functional movement.So split squats, squats, things like that, where they're tolerating some load through the low back nicely, then I'll start dosing in these more isolated low load backs. And I say that because. A lot of times it's hard to differentiate between pain when doing those and fatigue. And if you've ever done them, you know, like you are going to seal your low back and it's tiring and it's hard work and it feels really tight and tense after.So I like to build a capacity of some form of like axial loading, spinal bracing first, and then start introducing. So they have an idea of, okay, this is work and it's just not pain. What do you say? I find myself saying to patients that pain, especially with this presentation is very often under like a quarter or nickel size versus this large, um, surface area of ache and discomfort that often comes with these reverse hypers.Is that, is that worthwhile? Is there anything to that? Yeah, that, that's excellent. Um, The only thing that I've recently seen in a lot of athletes is single sided, still that broader ache and pain, which I find usually comes from like that QL discomfort because they've guarded for so long. So sometimes my athletes tell me like, it, it hurts throughout the whole.area, but then pinpray local pain is like you said it, that quarter size, like right over where they pretty much have the fracture. They're like, yes, that's it. But again, getting them to understanding, usually it comes because it's weak because it's been guarding for so long. Um, that dull ache that's above and below and sort of left and right.Yeah. Yeah. Okay. That makes a lot of sense. Um, give me some resources that our listeners can access, um, how to become an expert at dealing with the high level gymnast population. Yeah. So Dave Tilley puts out a lot of excellent, excellent research. He has spent many, many years fine tuning and coming out with some of his own.Um, aside from that. I am constantly looking at really just the most up to date meta analyses on Google Scholar. So going to those different, like, resourceful libraries and reviewing the information. There hasn't been much produced compared to other sports or things like ACLs or, you know, baseball players, overhead positions.Recently, little by little, things are coming out, but I love all of Dave Tilley's stuff and he's put together like excellent CEU courses and has pulled together a bunch of information, including a recent one on Achilles ruptures, which ties nicely to post Olympics. So I use that for my, for my resources.And then I reach out to the other people in the field. I have a couple of people on like each end of the coast and we'll meet up, we'll talk and dive into things we've found and cases. That's really awesome. Um, okay. Yeah. I know, I know Dave Tilley well up at Champion, um, in Boston and we just hired one of his students who is, who's a former gymnast and an absolute stud as it pertains specifically to spondees.Um, so I think that's a great resource and you make a good point there. While it's not an expansive discipline, It of literature that's out there specifically on this, there is information out there and whether it's social, whether it's Google scholar, whether it's pub med, you just got to do a little digging.And I think too often our, our new grads come out and they're like, well, they didn't teach us this in school. It's really incumbent upon you, everyone listening to this, do your homework, get out there, find these, this information and you've been an awesome resource. I highly recommend anyone following you.Um, To use you for this information as to how to get these at times stubborn back pain patients much better How do we find you hannah? You can find me if you're in Miami, you can stop by at Old Bull. Um, we have two locations, Coral Gables, Pinecrest, come hang out for the day. Otherwise, Instagram is another great resource.You can find me at H Sadowski. And then my email, Hannah at OldBullAthletics. com. All questions, welcome, concerns, anything like that. Happy to help. You have been awesome. You told me a ton about a very challenging patient population, at least for me. So thanks for educating me. Thanks for educating our audience.The true sports family really appreciates you. Thank you so much for your time. Had it, of course, this has been wonderful. And I hope we get to meet again. Hell yeah. At Zach, the Baker, I'll see you there. Okay. Thank you so much, Anna. Have a great day. Bye bye. Bye bye.
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