November 14 2024
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It's the True Sports Physical Therapy Podcast. Tune in. You might just learn something. Catch all of the full episodes on all streaming platforms. And as always, the link is in the bio.Hey, True Sports family. Thank you so much for downloading this episode and giving us a listen. As always, let us know what you love. Let us know what you hated. True Sports PT on Instagram. I will reply to any message that you put there. This conversation with Dr. Stacey Barber is wide ranging. We talk about Achilles tendinopathy.She's really, first of all, an interesting person, but also her injury past made, gave great color to this conversation. Um, Stacy ruptured her Achilles tendon. We'll get into her rehab journey and then re ruptured that tendon and we'll get into how she handled it the second time. We also talk about.Achilles tendinopathies, how she loads them, when she loads them, how she treats patients. And then she's got a booming business in Arizona. So we talk about the way she built that clinic, the way she's growing that clinic. She's got some amazing virtual options. So there's a tremendous amount to learn here as always.Share this, please leave us a five star review, um, and let us know who you want us to have next. Without further ado, here is Dr. Stacey Barber. Welcome to the True Sports Physical Therapy Podcast. We got Dr. Stacey Barber, otherwise known as The PhysioFix, with a massive following on Instagram. Obviously made your name for yourself already in the Phoenix, Arizona.Um, location. And I just love what you got going on clinically. I love your social media platform. You're doing so many things well, so I'm really happy to have you here. Yeah. Thanks so much for having me on. I'm excited for the conversation. Okay. Hell yeah. So let's dive right in. Um, when we were batting around some ideas on, on what to cover, um, Achilles tendinopathy seems to be.Top of mind. I wouldn't even say that it's one of your expertise, right? And then you just shared and it's clear on your, your Instagram. You've been through it having suffered two Achilles ruptures yourself. So walk me through your Achilles rehab and what you learned during that process. Yeah. Yeah. So, Unfortunately, I sustained an Achilles rupture.It was actually at our office holiday party. So the, you know, when I first opened my brick and mortar, you know, it was so small and I didn't have a big enough team to actually have an office holiday party. So the first year we had a big enough team to have an office holiday party, we decided to go to this place called, um, Sky zone.It's like a ninja gym, one of those like obstacle course places. And so I ran up the worked wall, like one of the first things I did. And, um, the short walls where I started, that wasn't hard enough for me. I was like, I got this. So I tried the harder wall, which is like 10 feet tall. And I'm pretty sure I was a college gymnast.So I'm pretty sure. And I was determined to get up that wall. Anyways, I pushed off harder than I've ever pushed off in my life. And clearly I ruptured my Achilles. So that's kind of how I did it back in like December of 2021. Uh, I immediately reached out to one of my favorite orthopedic surgeons, you know, got surgery right away.I knew that outcomes were better if I were to go the surgical route, cause I'm just so. Um, and he's such an athletic person and very competitive. And so I knew that I would probably hurt myself again, had I not gone that route. And, um, Actually my recovery was pretty, pretty good. I was doing kind of an advanced accelerated sort of like timeline.He let me like do early weight bearing about five weeks. Usually they'd want you to be non weight bearing for eight weeks. Um, So, but everything was really going really well. I got my first single leg calf raise back at about 11 weeks post op, which is kind of unheard of. Um, and it wasn't like, you know, a baby calf raise.It was like an actual calf raise. So I had developed my strength back. You know, we did a ton of like BFR. I know we'll kind of dive maybe into some more of that stuff in a little bit. Um, but my second Achilles rupture happened on the same side when I was about 14 weeks post op. I was just doing these little mini hops, which I had done for several weeks.And I don't know what happened on that, that day, but it popped again. And I had that second time, a 90 percent re rupture. And I decided to do the non surgical route that time because it was 90%. So there was something still attached at that point. So I was like, Let me try the non op route. And then also, you know, now looking back, it wasn't for this reason, but I was, I'm thinking now like what kind of cool experience I have.I've gone surgical route and I've gone the non surgical route. So I can kind of relate to my patients and those that have gone both, um, both routes. Um, To be able to help them better to understand this whole experience and like, what's the best outcome for them. Um, but yeah, I'm fully back now. I was actually fully back a year post op I'm an Olympic weightlifter.So I got back to the platform and I qualified for nationals. So I hit the same exact numbers that I hit previously to this injury. So I'm fully back and I'm still, I've still been lifting this whole time, no problems at all. Going forward, but, um, I don't know if you want to dive into specific details. I like what I do for my recovery.Oh my God. I want to dive into all those things. So, um, first of all, was it, um, was it a standard repair or did you go internal brace with the first, with when you had the repair? I had a parser pair. So that's like the parser pair is when they use this like jigsaw sort of system and they didn't open a pair with a parser jigsaw.So I have two different procedures kind of combined into my procedure because my surgeon said that my So when they look at Achilles ruptures, they look at like when you're fully plantar flex, what's the closest that tendon can get. And mine couldn't didn't overlap at all. Once it was fully plantar flex, because that's how much I had like destroyed my tendon originally.So they're like the only way you can actually, you know, um, Get back to where you want to be is surgery. So that's why I went surgery first. And then also because, um, there was no overlap. They had to do the open procedure because they couldn't get enough. So they had to go in there. Like, you know, I have a gnarly scar.It's really, really disgusting, but, um, it's, it's. You know, it's one of those things I just have to deal with nowadays. But, um, so they went in, they cut it open and then they, they use the jigsaw. So they did like a formal repair and then they did this like pars, which is like the percutaneous sort of like jigsaw thing where they like go through and they go down and then they drill to heal two holes in my heel to, um, have this like distal stability attachment point because my surgeon, once again, he knows he knew what I wanted to get back to and how much I was gonna be tugging on those anchors and he wanted to just.provide more additional stability for the Achilles to help it heal. So I had very similar to, um, what Aaron Rogers had, but I had it with an open repair. So the second part of what he had is what I had as well. Okay. So the jigsaw is your call as you call it. Um, I would call that the internal brace, but you guys, that's, that's usually a quicker recovery.So I love hearing that, um, you were able to get out of the boot earlier. Cause that's kind of standard with that type of repair of repair. Um, you're getting more aggressive, um, earlier on. Which bodes well, what do you think went wrong? Like, why did that thing break? By the way, I've never seen an Achilles re rupture.God knows I've seen ACL retires. Unfortunately, I haven't, but that's not by virtue of the fact that I'm a great therapist. It's by virtue of, I just see more ACLs. So, um, okay. So why do you, why do you think that sucker re rupture? Okay. Well, business stuff was very hectic at that point. And now like looking back to where I'm at in my current life, I'm like, not that nothing is as hectic as my life is now.But back then there was like, it's still like a lot going on. So honestly, I think that, you know, every tissue needs to be hydrated. And I was super dehydrated this specific like day. I remember that I was up late working the night before, maybe like till like 2 AM doing some stuff for the business, um, which was not ideal for like healing and recovery.And then like, you know, I had Full day of treating patients. Um, I did my own workout in the middle of the day. And then, you know, the very end of the day, I had my own therapy, you know, I was working with one of my colleagues and they were like guiding my care. So I was not guiding my own care at this point.Um, and you know, obviously I didn't disclose to them that, Hey, I haven't really drank enough water today. I didn't really sleep very well. Like all the things that we ask our patients about, like, you know, how are you feeling today? You know, I was like, I'm fine. I like, I'll get through it. And I think it was just kind of one of those, like the, the The perfect storm sort of thing, like worst case scenario, it just happened.Yeah, but, but you make a great point with, uh, the import of hydration with the import of recovery and sleep. And now we're able to track all those things really well, but also. We ask our patients, how are you feeling? And too often, I think that that's just a throwaway question. So maybe digging into, into details of how well did you sleep?What were your recovery scores? How much have you drank? Do we know that hydration is correlative to Achilles tendinopathies or Achilles injuries, uh, Achilles ruptures, or this is anecdotal? This is anecdotal. So there's nothing specific in the research. There are some like case studies, you know, and there's like, you know, small sample sizes, um, for stuff like this, but nothing, that's like a big meta analysis at all.But there is a ton of meta analysis on just the fact that like, you need to have hydrated tissues in order to have like optimization of those tissues for them to be working like they're supposed to. So if you want to just like, you know, draw Your conclusions from that, obviously a dehydrated tissue is going to be functioning as well as a hydrated tissue.And that definitely could be one part of the reason why we ruptured it. I just, I don't give that enough thought. So thanks for bringing that to light. Um, it's really interesting to think about including that. Okay. So you said, what'd you say? 11 weeks in you had the world's best heel raise. And you felt your calf burning like crazy, right?I did not say that. I think that's what you said. No, I said I had a great heel raise. It wasn't like a baby one. Like sometimes people would just do like a bouncing one. And I'm like, that's cool, but it's not like a true heel raise. That's like a rebounding heel raise. Like, no, I actually had like, I could stand there.I could be sitting there. Still, and I can do a calf raise my heel height. Wasn't nearly the same as my other side, because that's one of the things that's always going to be a little bit different that we're always trying to like close that gap. But I had a pretty decent heel raise. I was impressed with myself.How you should have been, apparently, how did you get to that? And give me an example. Um, cause I could give you a million examples of this when athletes cannot do that. They can't get that heel raise. What do you think was different with your rehab? And, and what have you struggled with, with patients in the past was specifically that heel raise.Well, I think number one, the biggest reason how I was able to get back to that point so quickly is my, like pre-injury baseline, right? I was, you know, an athlete for a long time, like I was a collegiate athlete, division one scholarship athlete. Like I, I basically have always trained really high intensities and I've always made sure that I checked all the boxes, right?I, I do all the mobility work, I do all the strengthening and stuff like that. So I knew that like my baseline was good and then right away. I didn't have any like phase that I was like, I'm not going to go into the gym because I just had an injury. It was more of what can I do to work around this injury to keep everything else strong while I go through this recovery with my Achilles.So I was doing BFR literally before I even went into surgery, like BFR on the quads, BFR on the hamstrings, even like isometrically in my boot, I was like pushing against, you know, like just that resistance and like doing BFR that way. Um, so I was maintaining as much strength as I could. Immediately post op, I was still shrink training and doing it as much as I could, like four days a week of shrink train, just very regimented in like what I do.And then I was doing BFR right away. And then another big thing that I discovered during this was how important it is to do like some heavy resistance. For the, um, Achilles, specifically the soleus as quickly as you can. So a lot of people do like, you know, body weight, soleus calf raises, or like seated, like maybe with 10 pounds, and that's not enough.And I, luckily I did a deep dive into the research and I was like, this is what I need to do. So even when I wasn't doing physical therapy, I was making sure three times a week I was doing, trying to get up to one and a half times my body weight added to my soleus calf raises. And I was using the knee extension machine that I have in my gym, to be able to do that.So I would like. Sit on a box and then put the foam roller thing over my legs and then do some really heavy 300 pound resisted, you know, calf raises as quickly as I could to build up that strength. Um, so I think that was, how quickly were you hitting that? Um, one and a half times body weight. I think I was hitting that close to like.Eight weeks post op. Okay. So, so pretty close to when, um, your, your weight bearing like three weeks after you're already doing that. So, so I love that. What were you doing? You mentioned the isometrics, um, while you were non weight bearing and you were in the boot, anything else that you were doing to try to encourage full, let's call it a gastroc soleus recruitment.Yeah. I was doing a lot of toe exercises. I'm a big fan of like, you know, making sure that like, you know, work, you work on those deep intrinsics. Okay. So like picking up things, man, I was doing like toe yoga, you know, lifting your big toe, lifting your little toes, just trying to like reestablish that connection, that mind, body connection with my body.Um, I don't think I really had that much of a disconnect. I think the, the hardest thing for me was mainly the, the. The height of my calf raise, that's still a little bit less on that side. And then, um, mobility, I, I actually think that I did maybe a bit too much mobility earlier on. And then I had to, at a certain point I realized it was coming back too fast and I wanted to like back off, pump the brakes.And then I still have a little bit of a deficit. So I have a little bit lack of dorsiflexion on that surgical and non, you know, just the injured side compared to my other side, which is fine because I'd rather it be short and tight and actually like, you know, We're actually have elasticity and that like recoil versus it to be too long and lengthened and then never be able to actually do anything.What kind of things, um, were you doing for mobility that early on? Did, did your surgeon put restrictions on you with dorsiflexion? No. And that was the crazy thing. So he didn't, you know, he treated me like that. I knew everything. And to be fair, like we know a lot of, a lot of different things, but we don't know everything about this one specific thing.I didn't at that point. Right. So it's like, he was like, Oh, you know what to do? And I was like, yes, I know what you're everyone's protocol say, which are, you know, there's so many different protocols out there. So I know what those say, but there's never any like, hard, like hard limits of saying like, don't do this amount of dorsiflexion at this point.And so now, like when I like work with my patients that are a lot of Achilles injuries, I don't have them do anything past neutral for 12 weeks and spend, and then we don't do loaded dorsiflexion until after 16 weeks, because that's that like tricky point of like, where you're feeling strong, but you might injure yourself if you like, Push too hard, too fast.So I was doing just like normal body weight exercises. I wasn't even doing anything crazy, but like, um, some ankle rocks. Um, I think it was just like, I was doing things that I wasn't realizing that was like really loading it. So I was doing squats to box, but I was stopping at 90 degrees, but it's still loading that ankle into dorsiflexion from like, you know, up.Top all the way down to that box. So I was doing things without realizing it. And then I started feeling that like length come back and I was like, I got super scared. Yeah. Yeah. So, okay. So you say you're not doing, you're not going past neutral now for 16 weeks. Does that, does that include, um, like squat work?I mean, you're going to drop past that, right. With a positive shin angle. If you're doing squat work, do you worry about that? Or you're saying you just don't do plantar flexion? Um, Past neutral, I guess, or starting from, um, a dorsiflexed ankle. I pretty much put everyone on a heels elevated squat position when they're squatting to be able to get them into that.Like, so I don't want to go past zero degrees. Right. So any amount of dorsiflexion, I don't want to load it until we're getting into that 12 to 16 week range, depending on how strong someone is. So those are kind of like, I mean, nothing is like a hard and fast, like timeline. It's. It's, it's based on the person in front of you, but that's kind of how I do it.And so I always will, you know, use, we have like wedges in my office, so you can do like the 10 degree wedge or the 15 degree wedge or add them on top of each other. We do a tons of heels, elevated squats anyways, to work on more like quad specific strengthening versus, you know, just doing, um, a lot of things to work on.full range of motion squats. Those will come, you know, we just got to focus on the hitting the basics first because no one wants to redo this because trust me, like it's not worth it. No, no, it sounds terrible. Um, so talk, talk to me about electric stim. Does that show up in your rehab at all? So I did some electrical stimulation more so, um, from the side of kind of like pain mitigation.So I was having, you know, some like twinges of pain here and there. Um, I was doing some, some of that sort of stuff. I wasn't doing Russian stim Back then nowadays, when I do work with somebody that's post op Achilles, I do do Russian STEM with them for the Achilles, because I do think that that's beneficial just like for ACLs, right?Like, you know, you get those pads on, you start getting those really strong contractions. And I think that is really beneficial, but it's one of those things that over time I've had to like learn my own system of how I want to approach this injury and things, obviously they should change over time as we like learn more and we have more patients and more experience.experience. So back then I was not, I was just more using it for like the NMES sort of thing. Um, and just kind of, you know, what felt good and it did help. It helped. I had a lot of nerve pain at first, kind of like when things were waking up and it helped to kind of get over that quickly, but I didn't use it for like actual muscle contractions at that point.Okay, but now you do. So walk me through how you use that nowadays. Yeah. So I, we, uh, we have a Chattanooga stem. Do you have one of those? Um, so we kind of use that. Tell me about Chattanooga. Yeah. Chattanooga is just another one of those systems. Um, that has like the, the really nice different. Program. So you can do Russian STEM.You can do like all of the nice, easy, like muscle recovery settings too, that they're already like pre programmed. So I, the one that I like to do is like five seconds on five seconds off, because once again, I did a deep dive into the research every single, like few months, I kind of dive into like, what's the newest thing with Achilles rehabs to make sure that I'm staying up to date with what they're saying.seeing, um, in the clinical studies too. And there's a lot of research nowadays that show that they like to do four or five seconds on for isometrics. And so that's exactly what I kind of use that setting for. So five seconds on five seconds off to try to facilitate, um, that quicker recovery. And I'll do that for five, 10, 15 minutes, whatever the person can tolerate, kind of building like gradually, um, up for each of their sessions.Yeah. Okay. Love that. And the, uh, I love the Xynex unit because they give you a, uh, like handheld on off switch. So I can do a whole bunch of exercises with it. Once they're weight bearing, um, I love the idea of using it very early, like post op day one, um, when they're non weight bearing, I, the biggest struggle that I see with my patients, I've never been through this injury myself, but the biggest struggle I see with my patients is.Is just that lack of activation, like they'll feel part of their calf or they'll feel just their soleus and they can't get the full gastroc head. And I try to mitigate that with electric stim. Any other uses for that? I mean, I mean, it sounds like you're doing all the right things, but, you know, I think that Using your stem to and you can use it with BFR.So you can kind of do it like, you know, in adjunct sort of therapy with like, you know, both of those two different systems. I like to do that. I also like to do it, um, with like feedback. So like biofeedback is a big tool for Achilles. So I'll use like the stem to help like almost like. Activate or initially activate the muscle and then have the push, the person push through, and then let's see how much force output they can do.We have a dynamo, we have four stacks, so we can kind of measure how much they're actually like outputting. And that's kind of cool too, for them to see like, okay, now that kind of got me going, but let me continue that contraction and let's see how far I can get. And then I actually use those numbers, um, when we're doing exercises.Cause there's a lot of, um, Really important data that says that we need to be training the Achilles 80 to 90 percent of its, um, one rep max, or like it's maximal velocity, uh, contraction. Then, and so we'll use that highest number and then do back offsets. So we're actually training in a certain zone and sometimes using that STEM can help facilitate that.Love that. That's awesome. We use, um, a 10 deck a lot for that to just to measure, um, rate of force and how much force is being produced. So, um, I think that it's really easy to set up like that. Hey guys, quick pause and a quick shout out to this new masterclass that we just launched here at True Sports Physical Therapy, 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, physical therapy, 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 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. One of the, one of the struggles I've had very recently was rehabbing larger athletes coming out of Achilles. Uh, you mentioned, I would never mention this. You mentioned that you're a smaller athlete. You were a gymnast like that to me, that's the ideal athlete to rehab coming out of this.They don't have a lot of body mass and they have a whole bunch of muscle mass. What do I do with the guys that are just too heavy possibly to get that heel raise appropriately? Like I struggled with like, how many ways can you do plantar flexion? Okay. They still can't do a heel raise. So now what do I do?Walk me through what I should be doing with my heavier guys. Yeah. One of my favorite ways, and I've actually never seen anyone still to this day, do the specific exercise, but I was trying to figure out ways I could offload and be able to like measure like my progress. So for a single leg calf raising, although you do band assisted pullups.So I did the same thing with a band assisted calf raise. So I'd hook the band, like, you know, from a rack and I pull it down and I put it on the opposite knee. So it's just the one leg that's on the ground. And then I'm measuring which band resistance I'm using. So am I using a green today? Am I going down to a purple?Am I doing a purple and a black? Like, so you're actually like measuring, like, you know, stepwise. This graded exposure sort of like, um, mentality. And like, so that's what I do with the people that having a harder time getting that single leg calf raise back and then, um, using things like a leg, a leg press machine, you know, like you can do leg press, like it depends on if you have one that's an incline or one that's just horizontal, but you can measure that too.And then like, once you're getting close to your body weight or their body weight, then, then you're knowing you're able to tell them, okay, you're actually able to do this. And then. Once again, using your, your, um, any sort of your force output sort of measurements. So if you're able to actually get to whatever their body weight is, they're able to generate the force.Now, where are we, where are we weak? Are we weak at the beginning of the range of motion, the middle of the range? So like, so you can kind of figure out like, where do we need actually train to get you stronger to be able to do this? Or is it like a motor control programming sort of thing? Like neuromuscularly, you're not able to facilitate the whole like facilitation of the movement, you know, so to like break down those sorts of things.I think that's awesome. I saw that recently with, um, with an athlete who's trying to get back to football, um, and he could do everything functionally, he could not do an isolated. And it's like, you want to wait for that isolated heel raise to happen before you start training explosiveness, et cetera. Um, what I found was ways to encourage more full body movement so that he could get some of that neuromuscular patterning, let him do some football like activities, which is all he does all day, every day, and that started to actually help and was, there was a carryover effect to his isolated heel raise.Um, so sometimes you got to make sure that they're strong enough or that they're far enough away that. From surgery that their tissue has healed, but, but introducing some force or some fluidity into their movement patterns certainly helped this guy kind of get back all the way to the heel raise. So, so that goes, that goes a long way, just like things to think about.Then, um, walk me through when you introduce plyometrics, how, you know, they're ready for plyometrics. Um, Along the Achilles, uh, continuum. Okay. I mean, we do something similar to like some performance tests that, you know, to make sure that people are ready to start initiation of these different things, um, I don't think since it is hard for people to get that single leg calf raise, I don't hold them back to being able to start doing plyometrics until they have achieved that single leg calf raise, which I know some clinicians would think is absolutely like.crazy. But once you start doing some of those like faster twitch activation or movements, like you said, it does help facilitate. So sometimes you'll do it for like four weeks at like some, like just, you know, basic like single jumps. Right. So you're doing just like. Broad jumps and like, um, maybe you'll do like, um, lateral broad jumps and you'll do vertical jumps, your box jumps, your, your drop jumps, like all those landing drills.And then all of a sudden they'll be able to do a single leg calf raise without you formally, like actually working on the single leg calf raise. And it's just because they've kind of developed that mind body connection again, and they can do that. So I no longer ascribe to that mindset that you have to check this box before you can go onto this box.box. I just am using it kind of as like what their, their baseline is and like what their numbers are to track their progress throughout this whole recovery timeline. Um, but so we'll do like, you know, balance. So we'll do balance. We'll do double leg calf raises. Like I said, we use like the dynamo to see like, You know, we do both bit me and street need to see their force output to see like how strong they are in the soleus versus the gastroc, even though you're getting activation of both of them, we now know it doesn't matter if it's been a straight.So there's a lot of research now that says that it's not just soleus working and when that knee is bent, you know, so. I think that's important to know. Um, but we also do, um, we do like a Y balance test. So we'll be doing, you know, different like movement patterns. I do squats, um, single leg squats to a box to see like how strong they are, um, to work on, see their quad too.Cause we don't just focus on just the Achilles. We want to make sure the whole leg is strong enough to handle the demands of what they're going to be doing in the next phase, doing hamstring testing, you know, quad testing to see that those force outputs. I'll be doing, let's see, we'll do single leg, leg press till failure.We do wall squats, um, which are brutal. Single leg wall sits just all this data to kind of see, like, are we, are we, we can muscular endurance or we, we can shrink, like what kind of problems do we have to, and that's what I need to put in their next phase to make sure that they're ready to handle. Whatever they need to get back to.And obviously like, if there's somebody that does more like rotational stuff, okay, like how well did they do in the rotational elements of the testing? You know, so all of this is just information. It's just data. And then like you use that to, to start facilitating our next program. But I started jumping right around.Probably that 12 week mark. And that's what I said. I re ruptured at like 14 weeks. So I'd already been doing like two weeks of the jumping stuff. And I was doing like band assisted jumping, you know, band assisted Pogos. It wasn't anything crazy at all. Um, like, you know, going like lateral, like front to back side to side.And then just like, like I said, the basics. Like how am I able to push through the ball on my foot while I'm doing broad jumps? Am I able to push through that part of the foot as I'm doing like box jumps or a vertical jump? Um, am I able to like land toe heel or am I leaning just heel and not, you know, using anything in that, that forefoot?So all those things, um, that's kind of like the first basic steps. And then you kind of add a little bit more like less ground reaction time. Um, so you can do a little bit more true plyometrics and then like kind of progress that way. But after I re ruptured. Funny thing is I just got, I put myself in Cal girl boots, which is kind of crazy.I don't know. How long have you been practicing clinician? 15 years, 15 years. Okay. So I'm 10. So I don't know if you remember, but like one of my first like, um, mentors, he used to always put anyone that had Achilles tendinopathy or tendinitis and like cowboy boots for guys or like heels for girls to like shorten that range of motion.And so I. I remembered that and I was like, why don't I just do that? Instead of like being in this like clunky boot all the time. Why don't I just put myself in my cowgirl boots, which put me in about 20 degrees of plantar flexion and let it be in the optimal environment for healing. So I did that for like four, four weeks.And then I moved down to my weightlifting shoes for like two weeks. And then I went back into the same program that I was doing formally and I didn't have any lag. So no, I had no downtime. I just picked up where I left off. Awesome. Now, Um, you were treating a full patient caseload in cowgirl boots. Yes, and I was weightlifting.So I would do like cleaning jerks. And there's like, I had tons of videos of me like doing jerks in my cowgirl boots. Like, yep. Is that the secret to building that massive following that you have on Instagram? Yeah, it's cowgirl boots. So you should probably get yourself a pair. That's exactly what I need.Um, okay. That is, that's definitely not what I need. Um, okay. So Now, my head almost exploded when you're talking about doing depth jumps, let's say, before they can do a heel raise. How do you, there has to be something that makes you comfortable allowing them to drop off a box. Um, so what is that level?There is, there's this one meta analysis and I mean, I can send it to you later, but it basically shows that like, there's all these different activities and how much force goes through the Achilles with all these different things. And so, you know, there's like certain elements that have way more, um, force through the Achilles.Then a jump, whatever do like, especially like a single jump by itself. So I'm like, okay, well, and through this continuum, I feel more comfortable initiating this before I do this. So you're just using like the, the evidence to your advantage when you're prescribing exercises as well, and dosing those exercises appropriately, you know, so, um, horizontally displaced things are going to be way more, um, way more demand on the Achilles complex.So we're going to be like. Not doing as many repetitive horizontally based plyometrics at first, right? So vertical, not nearly as much demand as, so I'm just, you know, I'm using research. Smart. Okay. So that makes a lot of sense. So my head doesn't have to explode over that. Um, okay. So, so now having been through the repair and doing it conservatively, God forbid you rupture the other one.What would you do? Okay. That is a really good question. I think it depends on where I'm at in my life. So where I'm at in my life right now, I would do a non op route. If like, You know, I, I don't know if there, when this is going to be released, but you know, my husband just had a stroke for those that are listening.And so, um, I'm primary caregiver to him as well as we have a one year old. So I have a small child at home, so I, there's a lot going on in my life that I would not be able to have the downtime. To be able to have a surgery, you know, cause there is going to be some weeks that I would be non weight bearing.And right now I just not feasible. It's not realistic. So right now I would say non op now, if I'm back to, you know, my former self, I would probably choose operative route again because outcomes are still way better for those that do the operative route. And there's less. Risk of re rupture, even though I did re rupture, it wasn't a full re rupture.Um, nine, only a 90%, which I know is close to full, but still it's that 10 percent matters guys. That 10 percent really matters. Yeah. Um, so yeah, that's what I would choose. Okay. And then how did you go about choosing your surgeon? So my surgeon, he's the best, um, Achilles surgeon in this area. And he's just one of those like people that's just like fun to be around too.So I just knew that I knew the moment this happened, like it was literally 10 PM on a Sunday. I sent him a text message. Cause I, you know, I already knew him and, and we'd already had, you know, several patients that we had shared. And I was like, Hey, this is what happened. I sent him the video and I was like, any way that you can get me into the office.And he was like, come tomorrow at this time. Then I went in, you know, and then like two days later I got surgery. Yeah, it makes it easy. I also love that. He's kind of thinking outside the box, like either I only do internal breaks or this is what your radiograph say. So I need to do it this way. It sounded like he took a lot into, into account.I think that goes a long way for a surgeon. And this is important to our audience of physical therapists, because so often, especially if you're a good PT, you. You are getting the question more and more now of what surgeon should I choose as opposed to when I first started. Thank you for pointing out that I've been doing this for 15 years.It used to be, we only got patients from surgeons rarely the other way. Um, so I think those are like great qualities to consider when you're sending someone to surgery. Like I think about. If it's an elite level athlete, how many elite level athletes is this guy see in a given week, right? Or, um, what is his, what is his communication going to be with the team's physician stuff like that?What is his communication going to be like with me? Um, cause that's invaluable. So, so a lot of things to think through. It's great that you already had that relationship. Okay. Let's shift gears a little bit. Stacy, I want to go from Achilles repairs to Achilles tendinopathies. Okay. So, um, patient comes in with Posterior heel pain, walk me through your diagnostics and how that's going to guide treatment.Yeah, I think the first thing is obviously the subjective information kind of tells a big part of what's going on, right? So if it's posterior hill pain, there is a big difference for those listening, um, between insertional Achilles tenopathy and non insertional or mid substance Achilles tenopathy, and you treat them.vastly different at first. So somebody that has, you're stealing all my questions. This is great. Yeah, we want to treat those those patients vastly different. So the posterior heel pain, that's somebody that has an insertional Achilles teninopathy and that we know that it's just getting a lot of tugging right there on that insertion.And so we want to put them in that heel elevated shoe. So we want to make sure that we put them in this optimal healing environment. Like I said, I like to have people in something that's a heel elevated for about 12 weeks, and then I'll start weaning them down. So that's kind of how I do it because it doesn't really like change their whole life.You know, if you put them in something that's a, and then we're talking about an eight millimeter drop or higher. For that heel elevated shoe position. That's what I usually prefer. Obviously, like if there's somebody that always wears twelves, that's fine. Just keep staying in that. This is really important for people that like have the barefoot lifestyle, which I'm a big proponent of Evo barefoot and I love them and I wore them previously, but I couldn't wear them for a long time post op either.Cause I had insertional pain due to those anchors that were in my heel. So, um, So I just asked them, you know, obviously like location of your pain, like how long has it been going on is something that's more acute and it's something that I do think that maybe we don't need those full 12 weeks, or is it something that is like chronic?And we're in that three to four month or beyond, you know, timeframe that like, okay, this is going to take a while. And so I need to make sure I set realistic expectations. Could tinnitopathy these take forever to heal? Like you and I both know, like two years is. It's probably a realistic timeframe for someone that's had a chronic tendinopathy, like, okay.So, so let me jump in there. If, if you're laying out, I assume you don't tell them this is going to take two years, but maybe you do. No. Okay. So how often do you see those patients? So they have a really chronic tendinopathy. You start them on a heel lift. How often do you see them? And what are you doing in those sessions?It depends on the person. So it depends on like, um, how often they can get into my office. Am I seeing them in person or online? Because we offer both services, right? So I just make sure that I educate them on it. Okay. So the attendance need load to heal. Like that's the only language that a tenant understands is load.So, and how much load you need to, to be able to tolerate is going to be based on what you need to get back to. So. Yeah. We're going to start you on this, this recovery plan, and you need to load a tenant every other day. You need to have that day of rest in between. So it doesn't matter if you come work with me in person, or if you're doing your program on your own, you got to make sure that you're loading it every other day.So whatever that looks like for you. So I kind of just set those expectations that this is what, how it has to be just from a tendon loading perspective, from a physiology perspective. And so, and make sure that they know that that is, What's going to get them better, faster. I don't care if they're working with me in person.Honestly, my schedule is pretty, pretty crazy that sometimes I'll just see a person and I'll evaluate them and then I'll create them an entire treatment plan for the first like month. And then I'll have them run it on their own for those, like, you know, every other day program. And then they come check in with me in another month.And then I reevaluate and see where they're at reassess. And then I give them their next month of programming. And which is really nice because they have everything laid out for them and they can send me messages. through our app about like, you know what's going on and like anything that I need to modify based on their life.Um, but at least they know that the framework of this is how it has to be. And this isn't me just saying this. It's just, it's really what physiology and research is telling us is most effective for this pathology. Yeah. So do you, do you encourage any mobility work in that patient population? So if it's somebody that has that like heel pain, that insertional heel pain, we are not doing any ankle mobility work except for going into plantar flexion.So I will encourage that in range plantar plantar flexion, because most people do, even if you have a tendinopathy, they will also still lack that very, um, The very top of that range of motion. So that's what I see very commonly too. So we'll do some, like some mobs, some like posterior mobs, um, some like PA mobs on like, you know, that calcaneus trying to get a little bit more plant reflection would, I do like to do this heel on the wall calf raise to kind of encourage that top end of that range of motion too.So we'll do things that are like mobility ish, but only in the plant reflection, if they have that insertional heel pain. Now, if they have that mid substance stuff. Then if they have a deficit in mobility, then heck yeah, we're working that mobility, especially if like the other side is drastically different.So I just want symmetry in a lot of these things. So if they're, they're both limited on both sides, well, do I expect them to have more range of motion on this now injured side? No, I'm not going to be pushing it. I might just switch gears and have more of a strength focus in that person's program versus mobility, but you know, whatever they need to be able to do for their sport and their life, that's the mobility that I try to get them to achieve.Why are you more comfortable pushing mobility in mid substance versus insertional? Yeah. For the, for the insertional, it just keeps tugging right on that. So anytime that you do ankle range of motion into dorsiflexion, you're lengthening that tendon, right? And so right on that insertion, you're getting more pulling right on that, that spot.So if you have an insertional problem, it's just causing more irritation, more friction, rubbing right on that heel. And it's actually further delaying your recovery. So that's why I want to shut it. And the friction makes sense to me, right? Because, because otherwise you're still tugging on a diseased.Tendon, even though it's mid substance, but I think you're more, the difference would be the friction, which is probably causing the inflammation or the disease process. Yeah. And a lot of these people also have Haglund's deformities as well in this insertional Achilles tendinopathy. So it's kind of like now we're also having to combat that as well.Cause now their shoes and like, you know, like the back part of the shoe, all that stuff matters as well. Do you ever get into mobility with insertional tendinopathy? Not at first. Nope. But if they have to like get back into doing that stuff, then we have to get back into it at a certain point. Now, how long out, it just depends on the person.So some people, if it's an acute injury, I can start, you know, kind of getting back into some of that dorsiflexion stuff as early as like two, three, four weeks. You know, if it's not something that's super flared up, if you catch anything early, it's so much easier to treat it. Right. So you get them to like, just chill for a little bit, getting that heel elephant shoe.Get it to calm down. And then we'll do like a graded progression back to doing more dorsiflexion type movements. I love that. Because what, because what you're doing is you're creating these buckets in which all the clinicians listening can kind of put their patients, right? So, so far I heard, um, location of pain.That's how you're noting whether it's, um, mid substance or insertional. You're not doing in office ultrasound, are you? Nope. Diagnosis ultrasound machine. So that that's, uh, two buckets that you've created. The other two buckets are chronicity, chronic or acute. That's also going to dictate any other buckets I should be looking for as I begin this assessment.Um, the other thing would just be segueing into like, what do they need to get back to? And that can kind of determine the pathway that we're going to go to. And if this is like somebody that's. In person or online minimum effective dosage for any of this stuff is two days a week. So what does their lifestyle look like?How much time they really have to rehab this? Like, so now are we doing a two day week plan or a three day week plan? Like, how does that look? Okay. Um, that's really helpful to, to outline. Okay. Then talk to me about if that, we talked about mobility. We talked about, um, some measurements you, you measured range of motion.Um, are you measuring strength? I would assume, right. And you're using, um, force plate analysis perhaps, or you're using some type of force measurement. Um, we talked about 10 deck, any other measurements you're doing as part of that evaluation? Um, I look at like global strength too. Like, so we're looking at like their, their lower extremities primarily.I actually do a full body assessment on everybody that comes in my door. It doesn't matter if they're coming in for a pinky injury or a toe injury. Like I'm doing like a head to toe, like. I do like a really quick objective measurements on like everything. So we're looking at like gross ranges of motion, like active.So active range of motion. And then I kind of like dial down to like, okay, now it's maybe more of a lower extremity injury. Let me do a few extra little special tests to kind of isolate in this area. Um, I'll look at calf raises. So like how many calf raises they can do, like one side versus the other. And then the heel height of their calf raises.And then I use a metronome. Um, to kind of track to see, to make sure that they're going on the beat, which sucks if you've ever done that. But for people that have Achilles tendinopathy, it really can help truly isolate those actually like flare up at like two reps versus those that can kind of fake 25 reps.And you're like, Oh, they have full strength, but they really don't. Yeah. Yeah. I mean, you mentioned metronome and that just makes me think about some of my return to sports stuff. It's a great tool to use when you start thinking about ramping up speeds because you can play with it and you want to make sure that that gastroc soleus complex can function at multiple speeds, right?Whether it be, um, high rates or even some of the low rates will be problematic. So metronome is a great tool there. Do you ever measure circumference of calf or lower limb? Oh yeah. Yeah. Especially if I notice that there's a lot of atrophy and sometimes I'll even like if somebody is like, Oh no, I, you know, like if someone has like a really thick tendon and they're like, Oh, I didn't notice that it was thick at all.I might just like give like a quick click measurement. Okay. Well this, you know, this tendon is this thick and the other one's this one, which usually is a key indicator of there's some sort of tinnitopathy at play. Maybe something that's chronic that's been there for quite a long time. Um, and then like maybe even like some extra scar tissue formation or like Just other things that play as well going on there.So yeah, I'll do some circumference measurements. I'll do like the figure eight of the ankle itself too, to make sure that there's no swelling in the ankle joint. And then I'll, you know, do various points above the calcaneus, you know, I'll do like 10 centimeters and then 15 centimeters. So we can get into that like soleus and the gastroc complex.Love that. Okay. Then what's your intro to loading day one? We're doing soleus calf raises, whether that's, if it's somebody that has that insertional heel pain, I start everyone in a planar flexor heel elevated position, so now we're just working that like top position. So just that the top part of the planar flexion, and then as they progress, then we're going to get lower and lower and lower until we're getting to those neutral ranges.And then get into that, those deficit ranges too. Um, but we're doing soleus calf raises where I have to do four sets of six, seven, Um, having people go as heavy as they feel comfortable day one. Um, and I tell them that my goal for you is to be able to get to one and a half times your body weight for four sets of six reps, three days a week for this.So that is, that is the goal. Okay. And, and you're setting that up on your knee extension machine. Is there any, are there any other angles you hit looking at that soleus complex? We do, we do different like three ways. So we'll, sometimes we'll do like toes out, toes, and then toes straight, um, toes in for that.Um, for soleus, that's kind of how we hit that because it can, you can truly have isolate that in that manner. We also do like out of the knee extension machine, like, you know, kettlebells on the knees. I like to do that with BFR. So then, you know, you get your BFR all set up and then you're like, you have the kettlebells because.BFR should be like 20 percent of your one rep max versus like, you know, one and a half times your body weight. It's kind of hard to hold two kettlebells that are, you know, half your body weight on each side, you know? Um, okay. Totally worthwhile. Then what are you talking about in terms of what the patient is doing with their toes during your plantar flexion training?Yeah. So sometimes I'll do things in like toe extended positions, depending on like how, like, you know, if we want to work on a little bit of toe mobility at the same time. So it just depends on the person, like what they need, but, um, I want to make sure that they aren't, you know, having that big toe up. So I use this thing called a mobile board.Have you ever seen a mobile board? So I love the mobile board to kind of like retrain like foot, uh, mechanics and to make sure that they're pushing through those, those four little toes versus just relying on big toe as well. And like to be able to go back and forth. So sometimes I'll put a band under the big toe to make sure that they're pressing down the big toe when we're doing like calf raises.Um, we'll also do sometimes like. Um, the band under the, just the little toes, maybe there's somebody that just likes to roll in and they just, they overpronate and there's little toes always come up. So, you know, like it just depends on the person. Sometimes people overly grip, you've seen those people. And then we, I see the people that also kind of like, they lift their toes up when they're doing it and they kind of like hyper extend like their joints.And I'm just, it just working with each person, everything is different. It's, it's not a black and white answer, but I'm just, I'm definitely having them barefoot when they're doing this stuff. So I can see what's going on with the foot and their mechanics. Um, and sometimes like I'll even like have a ball between their heels to encourage a little bit of that calcaneal inversion.So we're working on some post year tib activation, but everyone's different. Why, why do you think athletes are extending their digits when they're doing plantar flexion? You could tell me, then we would both know. I, I mean, I just think that sometimes that like, that's maybe how they were taught. I don't know if it's like a developmental thing.It's like some people, they really just don't have that mind body connection with what's going on with their feet. That's what I see a lot of the times, especially with like men. You know, it's like women tend to like be barefoot more, but like, especially guys that like, maybe just are always in shoes, they don't know what their toes are doing.And sometimes I'll like, especially runners, they'll have like the, they'll wear out their, the toes of their shoes. They'll have like little like holes in like that area. Cause you know, that they're lifting their toes up. Yeah, good point. That's interesting. It could be, I'm thinking, thinking out loud, uh, maybe they're avoiding using their flexor.Like maybe the line of their flexor hallucis is actually giving them issues posteriorly. And I think that's a hard thing to tease out. And maybe they're trying to get away from that. I definitely see over gripping far more, um, than I do like, like popping up. Um, and I think that's just a training. Do you ever do heel raises in a supine position?Yeah. Yeah. Okay. Um, cause we do that like more on like leg press machine and, um, sometimes I'll teach people at home to use their scale and they kind of use it as that biofeedback tool. So they're in that supine position and I do that first rep, you know, and they kind of like figure out what their maximal resistance is so they can get to, and then they back off or back offsets for training sets, but they're supine while they're doing that.True Sports Physical Therapy is growing like wildfire. We have 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 the 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. Okay. And, and how much, um, cause especially if it's chronic, they're going to feel some Achilles.Symptoms, how do you coach them through how much they should be feeling? What is too much versus, uh, you're not doing it. I love to use the whole, like, if you want to go above a six out of 10 on your subjective pain scale, then like, that's a good stopping point. And I think that, and when people are like, well, I don't know where that is.And like, you know, I don't know where that is for anything. Anyways, it's just. So subjective to the individual. So I tell them that like, if you, if it makes you drop, that's probably where that six out of 10 is. That's probably a good place to stop. So if you're having some pain, some pain is normal because you have to load the tendon and you have to get it stronger.And if you have not done anything in a long time, then you're going to have a lot of fear and sometimes fear causes pain, right? Then versus like true pain. And so there's just all these different factors at play there. Um, so I, I say pain is okay. And tendons, I'm okay with pain. Like whatever you're comfortable pushing through, I'm comfortable with you pushing through.Okay. I love that. Um, I, I talk a lot about how it feels the next day after loading. Do you get into that and how do you grade that? Yeah. So I tell them that if we don't return to baseline in 24 hours, so whatever their baseline is, that they come in at a five, five out of 10 pain, then I don't expect them to be a zero.You know, the next day, if they go back to their five perceived five the next day, and at 24 hours, then we know that we probably did enough. Maybe we didn't even do enough, you know, like that. But if we're like, you know, at a 10 out of 10 pain, the next day, we probably maybe loaded too much, maybe the dosage wasn't right.So that's when we start like altering dosage to figure out which exercise did it, was it just the volume that we accumulated in that day, or was it the extracurricular things that you did outside of our training session that caused this Yeah. No, I think that's, that's great advice. Then as you proceed towards plyometrics, eventually a return to run right with the, with these, um, Achilles tendinopathies, where do you start with plyometrics from a volume standpoint?Yeah. So, like I said, I was, we do pogos. Um, I like to do a lot of like assisted pogos at first. And we're looking at ground reaction time. So I get the, the four stacks under my SWAT racks. And then I had to have the band that's hooked to the SWAT racks and we're holding the band. So we're seeing that ground reaction times we're measuring it in real time.And then, so we're kind of looking at that and we're trying to like speed that up first, and then we start dropping the resistance. So we want to make sure we're under that 0. 25, um, And that's like the, really the true plyometric. And then that's when we start to go down in the bandwidth, um, assistance levels, how talk to me about volume, how many reps, how many sets, where do you start with that?So it's such a fear based movement for a lot of people, just like plyometrics in general, especially true plyos. So I start very, very. Very low. So I have them do like five and then like, that's what their first set. And I, I usually do about like four or five sets because of true plyos, you should be going a hundred percent maximum effort, right?We shouldn't be doing a shit ton of them. We should be doing like a hundred percent effort for a few reps. So I like to do like, you know, five at first and then feel confident of that. Okay. And then now let's do five at a higher intensity more. So, so I like to bump up intensity before I bump up volume of repetitions.Okay. And then at, you know, near the end of their, um, before they discharge, we'll be doing resisted files too. So now we'll put on like the weight vest and we'll be doing those same things because we're graded exposure to those different movements too. So your tendon is able to tolerate more and more volume to be able to get you back to whatever you can or you need to be able to do.Yeah. The, um, the great thing about this conversation, you have so many things that I want to pick your brain about. You're also my fastest talking guest, so we can cover a million topics. No, it's a, it's a pleasure. This is the way my brain works. Um, this is going to be the only pod I listened to at 1. 0 speed.So thank you for that. I'm so sorry. I speak so fast. You're doing a great job. Us on the East coast. I love that. So, um, keep going. You do you Stacy? Um, I'm from DC. See you. I can tell, I actually thought I heard a Baltimore O in there, so like, I can tell you're Oh, maybe. Oh, maybe. Yeah, I could hear that. Um, okay.Well, we need you back here. Get your ass back here. Um, okay. Tell me about your business. Tell me about how it started and your biggest challenge in business to date. Okay. So I started my business in 2017. So I'd been practicing for a couple of years, um, in a PT mill. It was, it was a very much a sports orthopedic clinic.So it was really like, I loved what I did. I just didn't love the setting and the environment that I was in. Um, I just got so fed up with the way that things were going. I was pretty dissatisfied with, like, I had to juggle four patients all the time, you know, like on my schedule, like every hour of the day, I felt like I was not able to give my all to each of my patients.So. One day I literally, without any sort of like side hustle, no plan at all. I was just like, I'm done. So I just quit. And so everyone was like, what are you going to do? And I was like, you know what? I want to kind of like blend my background in. I used to be a personal trainer, sports performance coach in the DC area.And I want to blend that with physical therapy. And everyone's like, You're crazy. You're never going to make money in a one on one model. And I was like, maybe I, maybe I am crazy. Maybe it won't work, but I would hate if I didn't try. So I wanted to just try it. So I decided to kind of like start also at the same time.I was like, this is the model that I want to create, but I also want to create online fiscal therapy. 2017 unheard of, no one was doing it, but I like saw that that was the direction that our field was going. And I wanted to make sure I was on the forefront of that. So I created all the platforms and stuff for online physical therapy.And also for, um, I was looking around for in person physical therapy places that I could start opening my practice. So I started in a CrossFit gym. Um, everything was really, really small at first. I was a solopreneur for like the first, what, Three years. And then COVID happened, everything had to shut down.I was in a gym. So the gym had to shut down, but my bins could be open. So it was kind of like a weird time. Luckily I had all my online systems in place, so I could do more online stuff at that point. But I still was like, I don't know how long this is this pandemic is going to happen. So what do I do? So I started looking for brick and mortar places and I found a place opened, um, started like hiring employees and we've kind of just been growing since.Now, when we talk about the biggest struggle as a business owner, I think it was going from being a solopreneur to being an entrepreneur, to being able to hire more people. I started out hiring people as independent contractors, because that's how I thought that I would like things to be best for me if I was in their shoes.And this last year, earlier this year in 20, 24, I completely restructured my whole business and turned everyone into an employee. So that has been the hardest thing it's because everything was kind of set as an independent contractor for so long that I wasn't, it took so long to kind of like, To steer the ship in a different direction and to change kind of like our systems, our processes, even from a business standpoint.Now people coming in, they don't know any other way than the way it is now, but the people that were here before, it's still, it's like, there's still things that are lost in translation. Why'd you go independent contractor? Why was that so attracted to you? Yeah, I think it's because when, when I did find the brick and mortar, like I said, it was very sudden.So I found the brick and mortar and I had somebody that she was like shadowing me. And she was like, Looking for a job. And I was like, Hey, do you want to, you know, a job? And she was like, yeah. And I was like, well, shoot, I'm in the process of setting up a brick and mortar and I'm bringing an employee at the same exact time.I was like, what's the quickest way I can get someone up, you know, to being like part of the team. And I didn't have time to go through all of the, the steps to be able to hire people as an employee. And so I was like, this seems pretty easy. Let's just do that with the thought at that point was. Okay, let me reassess the business in like a year and let's like switch things if I need to, but things just kept happening so fast at that point that it was, it's so crazy that like, I just, I think I hired 10 people in that first year.10, 10 what people, how many therapists, how many admin, who are you hiring? Within, within the first year I hired One, two, three, four other physical therapist and like, so, uh, an office manager, a biller, a like indifferent front desk staff, a brand manager, 10 people within that first year. It's just like, it just happened so fast.It was like, I was constantly having to like onboard somebody and train someone that I didn't have the time to set time aside to be able to like, really do a deep dive and like. What does the business need for the future growth of the business? And I needed to do it back then. And so I doing it this year, it's just one of those things that since I went on my maternity leave, I had time to reflect and I had the time to just sit down and be like, What do I want this business to look like?Where do I want the business to go? And I figured that like, in order to be able to grow together as a team and be able to get to where we want to go, I had to change things. So that's why I did it this year. What, well, congratulations. That sounds like a huge shift and undertaking. What does an independent contractor, what did it look like?Yeah. So everyone like, so I pretty much was doing all the, the hustling still, I was bringing in, you know, majority of the patients, which is like, so anyways, it's now looking back and I'm like, Oh, I was working so hard. It was like, they were living the dream and an M an employee, like. but like getting the money of being an independent contractor.So, um, I was still doing all the work because I had the platform and I had like, you know, the connections to bring patients through the doors and stuff like that. And I was just paying them, you know, each for each patient that they treated or assessed or whatever. So I would just pay them like per hour, pretty much.per hour that they're treating. So like per patient, yeah. Okay. But it wasn't like they're there from nine to two. So they're getting paid from nine to two. It's you treated from nine to 10. You were off from 11 to 12. So you're not getting paid for 11 to 12. Is that the way it worked? Yeah. But generally speaking, most people, like, um, the average, like even during that time was like 30 to 32 patients per week.So they're getting paid for, for that many hours. That's okay. Gotcha. That's amazing that you were able to do that. Good on you for being such a marketing genius. They were able to generate that many patients. That's awesome. You mentioned in order to get where we want to go, we have to make everyone full time.Um, where do you want to, where do you want to go? Dr. Stacy? I think we just want to impact. As many lives as we can. So we want to be like the go to people for, you know, bridging the gap between rehab and performance and performance doesn't have to just be sport, right? Like whatever you want to get back to, we want to help you get back to those things.So like my husband and like, you know, his stroke, like he wants to be able to get back to lifting, but you know, There's nobody that like after he does outpatient rehab there, that's it for him. There's nobody that like bridges that gap from like, okay, this is where you're at functionally and you're fine.And your insurance is going to drop you and say, you don't have any more visits. How do I get all the way back to where I want to be? So I want to be that person. I want to be that person for everyone. It doesn't matter what you have going on. If you don't even have to have an injury, we want to be that person to help get you to your goals.So, and that we want to do that not just locally, but we want to do that globally too. So, like I said, next year, we're going to be opening up our second practice here in Scottsdale, Arizona, um, which is a different kind of area of town. Geographically, Phoenix is massive. Um, and then like, you know, maybe in a couple of years I want to get back to the East coast.I want to get back to North Carolina and that's like where me and my husband met at Duke university and we want to go back there. Was that where you were a gymnast? No, I, no, Duke doesn't have a gymnastics program. I was a gymnast at Illinois state university. Okay, did you go to Duke or no? I went to Duke, yeah.Duke PT? Yes. Okay, I won't hold that against you. The reason I'm smirking like an idiot is because as you're, as you're talking through things and the way you think, how Intentional and maybe type a you are you sound like a Duke girl. Thank you. I think that's a compliment, right? Yes. Yes, you're welcome.We've had some some great new grads. I'm just a College Park, Maryland guy. So I have issues with Duke but Clearly produce a great product. Okay, so but So back to my original question, how big do you want PhysioFix to be? I think I want it to be as big as it needs to be to be able to impact, like, it's just going to be whatever the natural course of the business goes.And that's kind of how I've been this whole time. It's like, okay, this happens. Okay. Let's kind of pivot. Let's like create a new path and new, like. Yeah. Yeah. Yeah. So right now I'm kind of creating different paths that like each of my employees can like go on. Like, do you want to be a director of this?Like, you know, site, do you want to be an owner operator of your own like facility, but I want to make sure that the brand doesn't become diluted when it, if it increases and has more, um, like more locations. So I want every. All the values and all like the mission and stuff to still remain true that we still like produce, you know, the same high quality care.We promote that movement is the best medicine that we use shrink training principles to guide all of our treatment plans. And like that kind of just stays ingrained into the culture of the business. So I don't, I don't foresee it being like so big that it's like, um, Um, you know, like an ATI, I don't want it to be like a chain.I don't want it to be like that. I think I want it to be small, maybe like, you know, a few locations, um, maybe in different parts of the country, depending on like where people like eventually want to like end up. So we have a new therapist that just joined our team that he's from Virginia. So if he eventually wants to move back to Virginia, then you could take this and then we can bring a location to Virginia, you know, like that's completely like that.He knows the, the vision, the value, the culture, like all that stuff. And I just think that that's what's most important. So it will grow, however, it needs to grow. And I know that's not a great answer, but I have the vision that like, if it needs to be this big, I have a plan for being that big, but if it's going to be like smaller, then I also have a plan for that.Yeah. How, how'd you know when it was time to open a second location? How do you know when it's time to hire another therapist? Yeah. So when people are at a certain percent capacity, that's how you know that it's time to hire. And you also have to like, what percent? Seriously. What percent? And for how long?Used. You start hiring before way before you think that it's time. So once you start seeing the trends kind of like changing over like week after week, month after month, I start looking for somebody when someone's at about 70 percent capacity, because I know that it's going to take that long to find the right candidate too.And then by the time that they're like 90 percent capacity, okay, we're like, we're absolutely busting at the seams because people don't have any more. Like right now we don't have any evening availability. There are so many people that need evening availability. We don't have anybody, you know, so it's like, we're ready for somebody now.Um, but I've been in the hospital for the last couple of months. So that's, that's how you know that you're ready to hire somebody else when it's time to open up a second location, when you have somebody that's ready to open up the second location with you. So like, I won't be spearheading that location.You know, I'm going to be training one of my team members. Uh, he's going to be, he's already like This is what I want to do. And I was like, I want to help you do that and let's figure out the plan. And then let's figure out the trajectory and like, when we want to open it and then let's work backwards.And so we have the plan and we have the date in mind and it, you know, there, it could be a little bit, a couple months, either direction. Right. But this is ideally the plan and the, he is the person that wants to do it. And so now it's just having the right person in the right seat to get you to that goal.I love that. Where do you get all of your business acumen and knowledge? I've read so many books. People always ask me for like the books that I read. I will put a list together one of these days and I will send it to you because sometimes the people like, um, I mean the, uh, why did zebras get ulcers? Have you read that book?Have you read like outliers? Loved it. The four hour work week. That changed my life. Yeah. Yeah. That's really awesome. There's just so many books and like, Um, I'm trying to remember one of the, Oh, the jab, jab, jab, right hook. That's why I got really good at marketing. So if you've never read that book, add that.Okay. I will. Did you ever read the E myth? Yes. Yes, I have. That I read that in grad school. I didn't know what the hell I was reading, but those, those principles and for our work week. Really like, um, shaped a lot of the way I look at business. Um, and I think that's what we struggle as clinicians so much to get the hell out of the business and work on the business.I think that's so difficult for us. Um, that is certainly hammered home in email. Fine. I'll read jab, jab, jab, right hook. And then we'll do a book club podcast. How's that? That sounds great. Um, Stacy Barber, you have been a pleasure. Thank you for talking fast. Thank you for doing what you're doing over there in Phoenix.Cause it's awesome. Let me know when you're back on the best coast and I would love to hang out. That is, that would be great. I'm sure I can learn a lot. Thanks for teaching. Everyone that's listening about what it is you do. How can everyone find you? You can find me on Instagram or any of the social medias on the physio fix.I also have my own personal page. It's called doc. Stacey Stacey with an IE, by the way, cause everyone misspells my name. Um, but yeah, if you want to connect there, I I'm more than happy to connect to answer any questions that you have, or just kind of help you, you know, if you're a clinician figuring out like what you want to do with your career.I love kind of brainstorming those things with people. Yeah, well, it's awesome. Thank you for being open to it. We say, uh, in my neck of the woods that your husband should have a refusal. And I should have a full and speedy recovery. It's so impressive what you're doing there. Um, let us know if we can ever help you in any way.And thank you so much for helping us today. Thank you to everyone listening. Bye bye. Bye bye. Bye. It's the True Sports Physical Therapy Podcast. Tune in. You might just learn something. Catch all of the full episodes on all streaming platforms. And as always, the link is in the bio.
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