Running Injuries and Blood Flow Restriction with Patrick McGlade | Koopcast Episode 88

trail and ultra runners what is going on what's happening welcome to another episode of the KoopCast happy you are all here with me today on this episode of the podcast i have one of our cts coaches and patrick mcglade and it's all about this bridge from physical therapy and rehabilitation and back into running which is a topic that i've talked about a lot on this podcast and we just happen to have one of the coaches in our stable that works in a physical therapy clinic patrick is a physical therapy assistant at next level sports performance in golden colorado where he works with all different types of people and athletes from coming out of a surgical rehabilitation setting to high performance setting and he sees athletes across all of those spectrums and in addition to that he is an also he is also a coach with us so he happens to have a extremely unique perspective on this whole transition of healthy runner to injured athlete going into a rehabilitative setting and then coming back out again and so we have this wide ranging conversation on everything related to that including one of his specialties which is starting to pop up more and more in the literature and more and more in practice and this is using this technique of blood flow restriction

in a rehabilitative setting i really enjoyed this conversation practic is a great guy he's an avid ultra runner he's a he's just a good person all around with an incredible skill set so here we go i'm gonna get right out of the way here's my conversation with patrick mclean well thanks for joining i appreciate it i know it's hard to like carve out time in the day when you're bouncing from patient to patient to patient as we're talking about earlier but like i said i appreciate the time yeah thanks for having me on um what what i want to try to convey to the listeners a little bit is really through your experience in your eyes from a very practical standpoint kind of what you do and then use that what you do as the basis of the learning lessons for the listeners out there that don't get to interact with a coach or in a clinic or with physical therapists or people in orthopedic orthopedic setting on a day-to-day basis because i've said this on you know numerous numerous podcasts for years and years and years and also to my athletes and also we've talked about this in a coaching group we're kind of collectively the whole running community collectively really terrible at preventing and staying out of an injury cycle despite all the technology and all the science and all the good folks that try to keep us on the right side of the line we kind of suck at it if

we if we're looking at through an oddest lens and so i think the more people that i can bring to the forefront to like help navigate this i think the better off we will be it's never gonna be perfect but the better off we'll be so to start out with you have this dual rule role in the clinic and as a coach and the listeners will be familiar with a lot of the coaching side of it because i've had coaches on the podcast before so why don't you start out with kind of going through like in the clinic how what that setup looks like and what your roles are sure sure so um to start i work in outpatient orthopedic clinic that specializes in in sports medicine so we see on the day-to-day we see a wide variety of patients from high-level athletes to older folks that are getting over their their total knees or total hips um and basically everything in between um and so on the day-to-day it gives us a good a good view of of people as a whole and the types of things they're dealing with um and how it can how it can relate to what they want to get back to and so we do traditional physical therapy um but we also have sports performance in the clinic and um i don't know if i mentioned this already but i work

at next level sports performance in golden colorado and so we're in a community with pretty high level athletes and even our our weekend warriors are are people looking to get back to a pretty high level of sport whatever it is um and so the sports performance side of things helps bridge that gap between traditional physical therapy and making a full return to everything they want to do safely we're starting to see more and more clinics that are like this that are trying to have a lot of different types of services underneath the same umbrella in an effort to coordinate the whole chain of events and i remember when i was interviewing you kind of coming on board we were kind of describing some of the some of the challenges but also opportunities that that system kind of has where you know traditionally when somebody gets post-surgical they get into you know post-op types of physical therapy there's a gap between that post-op physical therapy and then what we would call return to play and that gap was kind of left up to the athlete or the individual to kind of figure out and it was always this weird area where coaches would try to come in and fill the gap and then some physical therapists that would come in and fill the gap but we're starting to see more and more of these outfits that start to offer this more of a continuum of the athlete from having a surgery or having a

traumatic injury having physical therapy and then kind of getting back to play and then you guys have the additional benefit uh of having a sports performance lab which is kind of even an extension of that in in your experience how like what do you think about that continuum right because it's not i would say that's not common in every practice and what do you think that some of the advantages of a clinic like that can kind of offer in terms of have being able to provide services to the same athlete and sometimes underneath different providers from one point to the other yeah that's a good question i think because you're right we are seeing more of these clinics pop up where they're they're offering everything under one roof and i think some of that is a realization that that we're treating the entire person and while we might look at at their ailment from a physical therapy side of things there's more to it than that and so you're seeing some of these some of these clinics pop up that offer nutrition services and you know the the blanket wellness term that you might see um and so it it is gonna tap into a much wider array of things but it's all relative or or it's all necessary for treating the the whole person um as opposed to just saying well this one thing or this one discipline is going to fix you

and um and just sticking to that and and and just being glued to that one one piece of it but to that to your point or to uh to the question on on the gap of of traditional uh physical therapy and a full return um that was one of the reasons that i got into coaching in the first place um because i saw that gap of of you know we get to this point in in the rehab process and there they might pass a strength test and might be cleared to to do some to start doing some running and you know traditional post-op running program might consist of 30 seconds on 30 seconds off for five minutes and that might build over the course of 12 or 16 weeks depending on the the individual to the point where they're running 15 minutes at a time it's like well that's nice but there's a big difference between running 15 minutes at a time and running even a marathon right never mind some of the longer distances and so um that's when i started diving into to some of the research on what you know how do we actually safely bridge that gap where do we go from here um and so one of the things that i did was create a running protocol for that next step then i realized it was basically essentially just a couch to 5k program so i threw that out and then realized that it was much more individualized than that and

needed to be um so that's what that's kind of how that all started i think so your earlier dialogue with all the services under one roof this has always been one of my issues with physical therapy as a practice and that's not to say that i'm an issue with physical therapists i have great friends that are physical therapists i lean on physical therapists a lot but a lot of times the that that those practitioners get tunnel vision not all of them but a lot of them they kind of get tunnel vision and they see a runner especially a runner that comes into their practice and like oh well you have tight hamstrings or weak weak glutes right it's kind of a catch-all for all runners and they start providing these tried and true kind of blanket solutions when as you mentioned there's usually more things going on not always but usually more things going on that need to be addressed but if if what you have underneath your roof is physical therapy everything looks like a nail right if all you have is a hammer everything else looks like a nail and by having all these other different disciplines underneath kind of the same roof it offers a like a broader array now sometimes that's not practical right you can't have 20 cooks in the kitchen but i think that there's a i think that there's a a kind of a blend there um so the color commentary on that aside let's kind of get like brass down to brass tacks with with runners right the audience that we're talking about are ultra marathon runners in which i know you guys work with a lot

there because we're pretty notorious for hurting ourselves in all manners overuse injuries traumatic injuries due to a fall and things like that why don't you run us through kind of the more common scenarios that you see and then how runners can go about addressing those if they're trying to address them uh kind of on their own accord sure so without you know getting too specific because you know i kind of feel like i have to put the caveat out there everybody's different everybody's injury is different you know if you're truly injured go see a pt go see your practitioner whoever you need to see in your your state um because every state is a little different you know colorado's lucky we were direct access so you can just walk into a pte clinic and say i want to see a physical therapist um but in other states you have to go to a primary care first and get a referral so um do your diligence on that one and uh and go see your practitioner if you're truly injured that being said um we do see a lot of runners and we see a higher proportion of trail runners just because of our location um and i think one of the things that we see probably the most of is our runners that have gone to other clinics or runners that have tried to fix themselves with the pretty standard exercises the bridges the clams the the squats the lunges you know basically all the exercises that

you're going to find in you know any running magazine out there and they do them ad nauseum and if somebody tells them to do 20 they do 50 because more is obviously better and um and then they don't get better and and i think there's there's a big disconnect between what someone might tell them to do and how they're doing it um so yes are clams a good exercise sure for the right person they can help strengthen the muscle groove and make you better at doing clams but the the thing that we see more of is that they might come in and have strength in a certain area but they don't know how to use it and so we will typically uh walk them through how to use that motion in essentially what's called a closed kinetic chain movement or standing on one leg if you're if you're talking about the glutes you know you can do uh clams all day but it's it's not going to translate to running strength all that well if you don't stand on one leg and try to do things while you're while you're stabilizing that area so um you know i'd love to give out you know a handful of perfect exercises but um you know if you're working with a physical therapist in your area you can just start the conversation with how does this relate to running how can i make this uh more applicable or how what's the next step in this

exercise and they should be able to tell you um yeah we're going to do this and then we we progress to this and then we start doing things like airplanes and rdls and and you know working on actual exercises that are going to help stabilize that that area uh within the action of running i feel like i was kind of trapping you with that answer because i knew you were gonna i knew you were gonna come up i mean we've had these conversations before in our coaching in our coaching group right there's no magic answer there's no magic uh exercise that will prevent injury that's what everybody wants and all the you know sexy titles in the magazines are five exercises to keep you injury free all that is total nonsense and i think that you starting out with here's what we see we see people take these five magic exercises and still not get better and here's why they're not getting better it's because they're not actually applying it to the motion i think that that's the learning lesson there because all too often you know runners will they want to diy it you know there's nothing there's there's nothing wrong with that if that's how you want to kind of figure things out yes you're left in more capable hands if you go to a qualified physical therapist but if you're trying to diy it just like you're trying to diy the electrical you know outlets in your house or your plumbing or whatever you can't just work on the drain you have to work on the whole drainage system you have to work on the whole electrical system and so physical

therapy or like fixing injuries is kind of the same way you can't just do clamshells and expect them to translate in any you know we're picking on clamshells a lot now it's a fun to find another exercise monster band walks that's my favorite yeah that's my favorite one you can't just do these single exercises and expect them in most cases almost all cases to have an appreciable effect for the end user over long periods of time most of times they'll have a little bit of a short effect and then you have to be able to translate that in order to have a long-term effect absolutely and i think you know for if we're talking about you know broad statements or big general themes that we can apply to to almost everybody you know most of the time within the course of rehab i have the conversation with with anybody it doesn't even matter if they're a runner but i mean almost every endurance athlete we have the conversation be an athlete first be be strong be mobile be healthy take your entire body your the the mental side of everything get everything in order and all of that is part of training and then your chosen sport is running or endurance biking or swimming or soccer or whatever but be an athlete first and and really understand where your weaknesses are and a lot of times physical therapy can help with that but there are other disciplines that can help with that too and um you know once you get those in order then you you bring those strengths to your chosen sport and um and those are the things that

that when we can really shift that mindset a little bit to um to get away from just thinking of training as solely running and you're incorporating strength exercises you're incorporating some mobility some foam rolling you know all of those those things that make you a good athlete um that's where we see people really take off and do well so let's peel the curtain back on that process a little bit so you have an athlete that comes in and we can come up with any sort of generic injury right you guys have an intake process to try to determine what those strengths and weaknesses are on a physical level and kind of on other levels take us through like what that actually looks like because you and i have talked about it and i've always found it like way more comprehensive than most people will think because most people are like oh well let's just test for hamstring strength or let's just test for glute strength or like whatever these stereotypical weaknesses are with runners peel the curtain back out on that process a little bit because i think it's important for the athletes to understand how comprehensive that actually needs to be sure so to be clear i'm a pta so i don't do initial evals so the first thing they're going to do is let's say this is one of my athletes that are injured and they're in the area i can bring them into the clinic so the first thing they're going to do is they're going to see a dpt uh doctor of physical therapy and we're going to do an entire eval and the eval is going to really break down

their entire body they're going to let's say they come in with knee pain they're going to look at ankle mobility they're going to look at all the muscles surrounding the knee all this muscle surrounding the ankle all the muscles surrounding the hip they're going to look at core strength and then they're going to put them through some functional movements and see how they move and functional movements being what being things like squats walking um depending on how injured they are um i will watch them run um on their next appointment um but we're going to go through all those things and then we take all of those tests into account with the um you know with their injury in mind and where their pain is and what types of things they're having more pain with or less pain with what makes it feel better what makes it feel worse um you know all the kind of standard questions that you'd expect from a doctor so that and all of our um all of our appointments are a full hour so they spend an entire hour going over what this person looks like as a whole and then when they set up subsequent appointments typically um then i step in and like i said before depending on how injured they are i might watch them run and if it's just you know for example if they're just having pain after mile 10 okay well then we start to dive a little bit deeper into okay what's your training like

what kind of surfaces are you running in what kind of shoes you're running in what are you training i mean what are you training for you know how soon is this race because you know that the people aren't coming in with six months to go to the race it's always six days before the race how do we do this exactly all right awesome game plan um so then we just take a much deeper dive into what they're looking what their goals are and how we can take their current status and bridge the gap uh between that and their goals and then so usually between the the initial eval and you know because i usually step in that second appointment and that's where you get a little bit deeper into uh running analysis or um you know based on they might have been given a couple of exercises at the first appointment um that's when we can really start to paint a good picture of of what this rehab process is going to look like how fast do we think this is going to go um and you know if we think it's safe for them to do the race that's so the you just mentioned one really interesting point how fast the process is going to go because every runner if those of you that are not watching the youtube version patrick's got a shitting grin on his face right now because he knows where i'm going with this every runner that has ever been injured always wants to know when can i start training again right and is it two days is it

two hours is it two weeks is two is it two months and physical therapists and physical therapy clinics are typically adverse to try to answer that because you're looking into this really hazy crystal ball and you never really you know you never really kind of like know the answer so but yet the the desire to know that still exists either because there's a race on the forefront or we just want to know when we can start to enjoy our physical outlet anymore i'm not going to ask you how long injuries take but i want i want you to kind of explain the process of how you navigate that time frame with an athlete knowing that you're not going to be able to get as precise of an answer as they probably want right so the majority of this question i i think comes down to patient education and educating the patient on tissue healing time frames figuring out what's what's actually wrong you know because if we're dealing with with a bone injury that's way different than than dealing with a minor muscle strain so we're usually not very quick on the well let's pull the plug let's stop all running let's take a bigger look at this what's actually happening what's that's my dog she makes an appearance every

once in a while this podcast i think somebody just delivered something to my front door continue continue patrick the users will be used to this by now um so taking a look at at the big picture you know what kind of time frame are we dealing with is the race next week or is the race in in three months and we have a little bit more time um and then trying to get to the source of the issue if we can dive into their training and i can look at their training logs and say well i mean looking at what we're doing here this looks generally unsafe but it also depends on on what is working well for the patient you know i've had patients that for whatever reason they couldn't run at an easy pace without pain but they could do a track workout right and so it's it's it's more playing to okay what can we do during this this time safely and how can we keep you moving it's not necessarily let's just shut everything down blanket statement because that's not always the answer um so most of the time i would say it comes down to just educating the patient on what we're actually dealing with are we dealing with a major issue here are we dealing with a little bit of soft tissue um problem are we dealing with just kind of a muscle imbalance that you know certain muscles just aren't working the way they need to and you know we can run up to a certain point while we're getting those muscles online but uh but we just won't progress past a certain point um and so it is variable for everybody i i think that the part that you mentioned

where you're trying to keep them moving is an extremely important aspect for the listeners to take away because you know we'd like to have these like forks in the road these really hard forks in the road should i run or should i not is the pain getting worse then i should not run is the pain getting better then i can run more and the reality is is you have more tools at your disposal right sometimes it's speed as you just mentioned that's the tool sometimes they feel great running fast sometimes they feel great running slow can you bike can you swim can you do all these other things and this notion that you don't necessarily have to shut everything down sometimes you do but you don't necessarily have to shut everything down for every single injury in a better rehabilitation path usually is find what can work because that actually assists the rehabilitation process i think is a good learning process for every single athlete because a lot of times it's like running or nothing right especially for runners it's like run you know run or nothing um i want to pivot to another area that you mentioned and this is looking at people's running mechanics and i know this is something that uh that as well that you do in clinic and something that in the running community we've kind of gotten a little bit over obsessed with um in terms of trying to create like perfect form what what are the key things that you're looking for when you put somebody up on a treadmill you're kind of looking how they run what what are the for you as a practitioner that is trying to

navigate runners coming from injury or trying to prevent injury in the first place what are like the key hit points as you're taking them through that process so to be fair most of the actually all the people that i'm looking at running are injured because they're in the clinic i don't that's the fact of the matter so i'm not having healthy people walk in and say my running is going great i'm training fantastically i want you to watch me run and tell me how to get better it just it doesn't happen um probably should though like how like where am i going to break down right anyway let's sit in the conversation and to that point i think it should like every other sport practices skills and running is a skill running is it's two and a half times your body weight landing on a single leg and then pushing off of it as hard as you can if you break it down that easy and so it is a skill that i think should be practiced um so to start yeah every every runner that i watch run is injured um or has a history of injuries or has recurring injuries or or has something that we're we're trying to trying to change now whether or not we change that with a gait pattern change that's individual because some people um some people the reason for injury is are training problems they're um they're not necessarily gait issues like load problems is that how you're describing that like

just training load i'm increasing my mileage too much i'm increasing my speed too much something like that yep yep they're uh they're they're training mistakes um so right off the bat i go into a gait analysis with the bias that i want to change the minimum i feel that i have to to safely get this person to alleviate future injuries um i i'm not typically into completely shifting and overhauling someone's gait um because the research has shown that most of the time people are going to find the path of least resistance the body's going to compensate pretty well and if we're looking if if ultra marathon participation numbers are any indication of it people compensate really well and they can they can do well for a long period of time on less than less than stellar mechanics and if you look at the last mile of 100 miler that's a pretty good indication of that um because gate mechanics there look let's do a gate mechanic analysis up on the boulevard at the leadville char 100 this year and uh basically i think we'd we'd have uh jim walmsley and jared hazen passing and that's about it yeah there you go everybody else total fail yeah um so you know i think i go into gated analysis much like uh

much like we treat uh coaching you know we're looking for the minimum effective dose to to change so that they can get what they need out of their their running gate and so even with that you know let's say someone comes in and it's it's just a horrible looking gate they don't move very well athletically it's you know they don't have control of their body we're going to be looking to make micro changes at a time so even for the worst hold on even for what you're saying i want to drive home this point even for the people that look the worst from a mechanic standpoint you're still saying that you're trying to change as little as possible at a time there you go at a time yeah yeah uh because if i tell someone to pick their knees up more and drive with their hip more and land in this position and swing their arms more and do all these things it running happens too quickly for them to absorb it think about it and and and do it all at once so and i think sometimes people get into trouble with that on their own because you know i'll have somebody come in and like well you know i i read this article and so now i'm trying to land more on my forefoot or now i'm trying to land more here land more there and it's like well first off you're you're looking at your feet the entire time to try to make sure that you're doing that and now you've completely changed what your upper body is doing on the gate front so you've you've

wrecked your posture you've you've completely shifted the way your weight is distributed throughout the gate cycle all because you're focused on one tiny thing that you read in in some article about where your foot should land uh what part of your foot you should land on so i i think you know and and you see this all the time in in training as well with your athletes people get fixated on one tiny aspect of the gate cycle and it's it's not one thing it doesn't actually matter all that much where you strike on your foot it has much more to do with where your foot is in or where where that contact is in relation to your center of mass at initial income at initial contact so um so when we're doing let's go back to the the horrific gate i'm looking to make tiny changes at a time just have them think about one thing and let's just think about one thing and then feel it and then i watch them and then okay so they fix that one thing they've fixed it without looking you know they're fixing it while they're looking up straight standing tall their posture is good and then we can move on to the next thing um so it's you know there have been very few people that i've that i've actually looked at and said i hate to say it but we need to start from scratch we need to go back to the basics and and start with a skips you know um but i think that's telling the fact that out of all the patients

that you've seen all the runners that you've seen very few have this completely new rebuild and more often than not it's really small things as you're going through that dialogue it's almost like training right where we ladder one thing up at a time and usually ladder down another thing it's the typical thing that most people will that will resonate with most people is volume and intensity as you bring volume up intensity needs to go down and as you bring your intensity up you want to do super hard intervals you have to bring your volume down and then once those normalize you can ladder it up and down and up and down and kind of teeter-totter them the classic coaching mistake as we talk about a lot in our group is increasing volume and increasing intensity and increasing the amount of intensity all at the same time that's a kind of a recipe for disaster and your dialogue about the foot strike i think is the same question where should my foot strike should it be heel strike should forefoot strike should i run on my toes which nobody can run on their toes except for ballerinas right we shouldn't realize that i feel it's the same that's in the same vein of what my longest long run should be yeah it's the same vein it's like that doesn't have any relevancy right now we need to think about the whole picture not just this one singular aspect right right but you know historically like books i hate to pick on born to run it was a great book i you can pick up born to run nobody i enjoy i enjoy the story myself like and of course i i was went out and got a pair

of five fingers it was 2010 let's do it but you know that was a great that's a great example of like one thing that that they picked one piece of advice one piece of equipment that and and this one this one target audience that was utilizing that and it completely shifted the the thinking on it um and there's just there's much more to it 100 it's okay to pick up i think now that we look back on it like everything has unfolded exactly the way that i said it would unfold during the middle of the barefoot mania is everybody gets caught up in it it's the new thing more books have been written about it it's the panacea for all of these running injuries and all this is make things worse to be honest with you at the end of the day like injury rates when uh vibram got sued i mean come on yeah yeah yeah did you see that in your clinic like people who transition to like barefoot or five fingers because i've heard this from a number of physical therapists of the like the aftermath of all of that you know i wasn't um i was still working in running stores at the time i wasn't doing this you were selling the five fingers come on man we didn't sell five fingers but but i i will say though it got the conversation started in the right direction okay i will that because i i there is a lot to um you know moving naturally and and using your body the way it's it's meant to be used and

and strengthening your feet uh there there is something to that um whether it has to be slung as far as that pendulum obviously it's you know not the case um but there is something to it and and you know every now and then i still have somebody come in with with five fingers and they're like ah these are the only shoes i can run it all right man we'll go with it yeah well then why are we seeing you here okay i want to pivot to kind of another more coaching related topic so i i came to know you as you started with a coach for cts and you obviously you had this pta background but also a coaching background before you you know before you started working with us and i always thought that that was really interesting because coaching is ultimately an interdisciplinary profession we try to be jacks of all trades and at the same time we are also masters of none right we have to play in the physical therapy world we have to play in sports psych we have to play in sports nutrition and try to harmonize all of these different elements realizing that we're not as good as the dpts that you get to work with on that side we're not as good as the registered dietitians that we all get to work with but the more broad of a skill set you can have in any of those areas the better you can serve your your your athletes at the end of the day so how have have you been how do you think that that is synergistic within the athletes that you work with not only that you see in the clinic but also the ones that you're now working with remotely right you don't have the opportunity to to see them in

person you might be able to do it digitally but you still can't do it in in the in the kind of same way how do you think that those things actually transfer over so i think it's transferred in a couple ways and i think a lot of it has to do with the the team atmosphere of both both jobs so in the clinic we we utilize a team treat so that we get more hands on the patient we get more eyes we get more um more levels of experience more um backgrounds and and biases essentially on it and it works out really well and i think cts is is kind of the same way and it's honestly the reason that i stopped doing my own coaching thing and came to cts because i knew there was this this team of coaches that you know we've got that call every wednesday and it's it usually divulges at some point into just kind of a roundtable discussion on something and it's it's really good because it just gets that dialogue going and so they they cross over pretty consistently um because being in the clinic i'm constantly reminded of what's happening anatomically at the muscle level coaching wise i'm constantly reminded of what's happening on the cellular level and i wouldn't necessarily get that both way you know if i was just doing one or the other so you know obviously i don't have to talk about the the cellular level

with my patients but it is a good reminder to to and and i use this on both fronts to zoom out okay what am i dealing with with this athlete or what am i doing dealing with with this patient zoom in what's the problem what's the workout what are we dealing with today and then zoom back out and how does that problem relate to the bigger issue how is this injury going to affect them long term how is this injury going to affect their their goal whether their goal is to run ledville or whether the goal is to to be able to play outside with their kid it doesn't really matter because if you take that zoom out okay whole big picture zoom in and then zoom back out and both of them i'm using both in both settings or i'm using the same thing in both settings it can really help to to better manage what i'm dealing with and avoid that tunnel vision of okay well how's this workout going what am i doing this week with this person you know what's the longest long run what's the longest long run favorite question you know um it really helps to to be able to convey that and and then you know then teach the the athlete or the patient this is what i'm looking for this is why we're doing this um and so it helps them to understand too the the zoom in zoom out as you'd know but just kind of for the listeners reference i think that that's one of the if not the most important coaching skill that you can have if you

can zoom in on the level of the workout athlete does the workout you get your training peaks notification you look at it okay what are all the hero metrics okay we're going to go into the workout what's the normalized graded pace what's the heart rate what's the elevation gain loss and things like that zoom into that level and then zoom out to where does this workout fit in the picture of everything and does it still make sense do i need to change things going forward or can i keep them the same and then zoom back in to the level of a week or a few weeks does the architecture of these few weeks remain the same that process one it sounds super easy when i describe it but it's only because i've done it 10 000 times when you're actually in the thick of it and you're getting the workout notifications it's all too easy to ask what's my long run going to be next week and focus on that one specific thing and it's the same thing in the clinic right are my glutes week i'm picking on the glutes again um so i i think the skill is translatable and for the athletes that are like listening to this and and and trying to diy either injury recovery or training or kind of both that's one of the that's one of the that that is one of the most fundamental skills that you can have is to zoom back out zoom back in on the aq problem zoom back out on how it fits into everything else and then try to find solutions not just pinpoint with laser guided precision whatever is going on

in that one minutia of time right right and to that you know kind of on those same lines the the uh you know specificity is is really important you know like you've you've talked about and and being as specific as possible but being hyper specific isn't necessarily the best if it doesn't if it doesn't go towards towards the broader goal then then being as as hyper pinpoint specific as as possible isn't necessarily any better than just being globally uh globally specific can you give an example of being too hyper specific in the physical therapy world because i can give you one in the coaching world after that i know i'm putting you on the spot yeah no that's okay um i'm trying to think there was a um i don't remember the um the article but there was a professional runner and i want to say like the 2008 2010 time frame and they were talking about their gym workout and they were they were doing a gym workout and it was a time when when ultra runners weren't doing gym workouts and one of the things they said that they that stuck with me was that they were only doing squats down to like 30 degrees of knee flexion which isn't much at all right because you shouldn't do because that's that's all you're going to use for the running gate and so they were getting so so

hell-bent on this is the only range of motion you need for running so this is the only range of motion i'm going to strengthen it and it just it always stuck with me it's like this kind of ridiculous why would you why would you how does that make sense and so that is yeah yeah hyper specific is not necessarily better than like if you're going to do squats do the full range squat don't just do 30 you know baby squats at 700 pounds that's actually a really good example i'm glad you came up with that off the top of your head but we see the parallels in in in different formats where runners are trying to in in trail ultra runners are trying to accommodate for things that they don't have so if they're doing a climbing race they'll go run stairs or they'll do box step ups or something like that where they're trying to emulate this aspect of specificity maybe not on the narrow specific side but but because they don't have it the the one that i always point to in the trail and ultra running world and this is one of the first kind of pieces of exposure that i had to trail and ultra running so was with the bad water folks where where they were training for the bad water 135 and they wanted to simulate the heat that they would experience in death valley and it's always classically described as a gigantic hair dryer that is blowing into your face constantly through this notorious section between pan of the valley between uh pan of the valley and stovepipe wells which is typically

the hottest uh part of the course when the course was run uh during the day and it very much having experienced the race many many times now it is very much like that it is like a huge hair dryer and so these runners would say okay i want to i want to specifically train for this hair dryer effect and what they would do is they'd wheel their treadmills into their laundry room they'd shut all the doors they'd put on a space heater in the back and just heat the laundry room up to whatever temperature they felt was hot enough and then they would disconnect the dryer vent in the laundry room stick it in front of the stick it on their treadmill like literally with the dirty freaking you know silver hose that everybody knows it's got all the lint in it and everything they'd stick it on the front of their treadmill and turn the dryer on so that the hot air from the dryer was like blowing in their face literally like a hair dryer and i looked at that going that is a that is an overly specific way to train for this one element of the race what you really want is you want your body's capabilities to be robust enough to handle the thermal stress so let's look at some mechanisms that we can deploy sauna training training in a hot environment and things like that that isn't as stupid as taking the dryer vent and specifically putting it on your face to mimic that so there i guess my point with that is is there examples of all of that but the the learning point is the same is that you can get too hyper specific to the point that it's counterproductive and your example earlier that's a counterproductive

maybe not counterproductive but it's certainly non-productive squat maybe it's counterproductive in terms of time you agree on that yeah but it's not productive in terms of adaptation right right right well i had not heard the dryer thing that's wild i could go on and on and on about the bad water crew every year every year they get a little less extreme but when i was first exposed to it you know a couple of decades ago it was it was it was just weird and fortunately like me not being indoctrinated to it i think that was a little bit of strength i could look at it with a kind of a skeptical eye and go this is kind of dumb but like i said the the psychology is the same right i want to train for this specific part of the of the event i want to have a 30 degree squat because that's all i'm using and running i want to put the dryer vent in front of my face to simulate the hair dryer and it really has kind of an it's a it's an it's a novel attempt it's an admirable attempt but in terms of it being productive we have to back out and and and and look at how productive it it actually is and i bet you see that all the time in the clinic where people have just tried to like oh i'm gonna fix this because one plus one has to equal two right yeah yeah there's well and i think we're like we do a pretty good job of recognizing our patients that are going to do all of their exercises five times three times you know just dialing it in for them a little bit but okay this brings up another point though

why it's more not better in this injury rehab setting because a lot of people will look at rehabilitative exercises as a low effort activity it doesn't cause it's like if we were to add up the training stress score right it's not a lot they're relatively easy so if it's easy and i'm doing three of them why don't why don't i do five or six what's the error in that type of thinking and actually doing so a lot of it has to do with and i'm going to use a word that you use a lot for training i'm going to use load but instead of overall training load we're going to talk about like actual load at the tissue level and a lot of it has to do with appropriately loading those tissues and so if we need to rehab say and let's just use calf strain for instance like if we need to load that appropriately then we need to do a very specifically so that it's not overloaded because it's already compromised so i'm you know i might ask them to do a certain you know depending on the severity of it we might just be doing isometrics where we're just holding the contraction for a certain amount of time and then releasing and then holding the contraction for a certain amount of time and then releasing and so to do that just over and over and over risks overloading that tissue which was the problem in the first place right it was too much load for what that tissue could handle and it became

injured whether it was acutely and it was just you know a quick tear or whether it was over time uh with with you know too much training uh too much training load um regardless of the the initial problem um even though it feels easy i guess i guess that's the point that people try to like look past is like oh this feels easy it doesn't feel strenuous but what you're saying is is the load on the tissue is still enough it's still enough that's going to adapt exactly and and it's always gonna be a fine line between appropriately loading the tissue and also allowing for healing because we we have to do both concurrently and sometimes the healing has to take place in a completely unloaded environment that's where you get you know a lot of post-op you'll be non-weight bearing for a certain amount of time in those cases we can't put any load through it we have to adjust prioritize healing and in certain injuries yeah we're going to tell you to not run for a period of time and that's to prioritize healing but that that quote-unquote strenuous activity is now aggressively healing like let that tissue heal let yourself heal prioritize the other things in your life prioritize nutrition hydration prioritize sleep for god's sakes prioritize sleep but this is coming from somebody who evaluates people's running biomechanics by the way people somebody he's telling you to prioritize sleep coming coming from a

physical therapy clinic there's a lesson in that right there for sure and and i know i'm a little bit of a hypocrite on that i've got a seven month old um but that's not being a hypocrite that's just accepting the situation i'm periodizing my uh like my sleep there you go yeah um so you know just prioritizing different modalities uh at different phases in the rehab process um there will be a time to push the load there will be a time for you to to uh to really aggressively strengthen that muscle uh but that time might not be right now yeah a lot of runners when i advise them to go into a physical therapy clinic it's kind of the same run a show where they're typically having to do that because we've had some air in the training process right too much load too quickly too much load overall kind of whatever it is sometimes acute injury or whatever but they have been used to pushing themselves hard physically immediately preceding the need to go into somebody like yourself somebody uh involved in in your clinic and then what the clinic is saying is okay we're going to give you these super easy exercises that are magically going to fix you and the delta of effort between what they just went through from a training perspective and what they now have to go through from a rehabilitative or physical therapy perspective the delta that is typically so big that it's easy for the athlete to look at that as not going to make a difference because it's not as

strenuous right and what i always say is it's just like just let it play out you're gonna have to trust them just let it play out i know we focus on pushing the training and doing things and blah blah blah blah but you're just gonna have to like let it play out and realize that relatively compared to what you were doing it might feel easy yeah yeah and that's where i think i think that's one thing that next level does really well here is we will always try to discuss with the patient what can we do because this piece of the puzzle has been removed you know a hard workout a hard running workout doesn't feel like anything else i mean as a runner myself i i know like i want to run but there are times when we just need to remove that piece of the equation and we can work with you on what what we can do we're going to push you as hard as we can um within the confines of of the limitation and i mean there's there's times where we have people um uh that are non-weight-bearing and we've got them you know sitting on a box doing rope slams and i mean doing uh blood flow restriction and that's one thing that we use a lot of actually and so i do think there are very creative ways to get a workout and we'll find that way uh it might be weird we'll make it work but you're trying to provide an outlet right i mean it's absolutely it's

it's go ahead oh and and just try to find an outlet for them outside of the clinic whether that's on a bike or in the pool or um you know we had somebody get into uh too aggressive what they call it it was like it was like competitive quilting or something it was it sounded ridiculous but then they described it and i was like geez that sounds like it sounds like almost uh almost like carl melzer's uh speed golf yeah there you go take an activity that you wouldn't anticipate aggressive but okay last topic man i really appreciated that dialogue that was good last topic you just mentioned it blood flow restriction i know that your clinic has been your clinic has been doing this for longer than most clinic or longer than a lot of clinics out there i'm not sure you know the space that well it's not new and people have been tinkering around with this both in a performance setting and also in a rehabilitative setting for almost 20 years yeah a little while now yeah but it seems that it's continuing very it's almost like a slow grind being more and more adopted as a standard run a show in a rehabilitative setting most of the users are not going to be familiar with with this but they're going to be curious about it because it's going to pop up more and more more of their friends are going to go and kind of experience it yeah so let's just walk walk the listeners through the whole thing what is it how do you guys use that particular modality and what do

you like what just what do you think about it and what are the practical applications sure so to start out uh bfr as you'll hear it uh spoken about is blood flow restriction and what it is is essentially a tourniquet that you put on one of your extremities one of your arms one of your legs and you inflate the cuff to a certain percentage of complete occlusion ideally the research has shown that uh for the lower extremities 80 is going to be in that therapeutic level for the upper extremities 80 is super painful uh so they go with 50 and that's therapeutic so you'll see a pretty wide variety of uh of tools to do that um some of the most popular and the cheaper ones are they essentially just look like narrow blood pressure cuffs with a little dial and you just pump it up and then you start working out and and so yeah you pump up this this uh this cuff and then you do uh an exercise with it on with air with air you're like literally pumping it up like those like the Reebok shoes back in the day exactly exactly the machines that we use are made by a company owens recovery science and ours look a little different they're this unit that uh first finds the complete occlusion rate or the rate at which no more blood goes into the extremity and then it backs off and then it keeps you there so it's constantly adjusting because as soon as you start working out things start pumping

up that and that 80 or that 50 is skewed it's it's no longer in the right range or in that therapeutic range and that's one of the things that that is kind of a struggle when somebody comes in and like yeah i'm in the gym i've been using bfr cuffs and it's like well what are you using them for you know why are you using them what kind of cuffs do you have how are you making sure that it's at this therapeutic level and and most people are just like i just go until i can't right um and that's not necessarily the well actually volitional failure is the the desired goal for it um strangely enough but we can get to that uh so so the machines that we use uh like i said are made by uh this company owns recovery science and they have done extensive research on um the the even things like the width of the cuff so these are going to be wider cuffs they're going to be more um more comfortable um as comfortable as bfr have you tried bfr oh yeah yeah a long time ago actually like long long long time ago before it was ever really that popular anywhere yeah yeah um so they're gonna be a little wider it's it's pretty wild stuff um the first time i tried it i was an intern here and the guy my my ci tj he put me through it and i was i mean i run hundreds i was like oh you know this will be you're just putting this little cuffer on my arm really yeah yeah what's that what's that

different oh you get completely like noodle leg and it was the closest thing i could like get to feeling like you do after 100 miles but anyway um so then we take you through a protocol an exercise protocol um typically it's uh it's 75 reps uh 30 a set of 30 followed by three sets of 15 each of the 30 second break in between uh that's what the research has has suggested is um ideal at this time um they're always doing more research on it um but in the clinic many times and it it works on a on a on several physiological levels but in you know to give a really just broad overview of why we use it we use it as a bridge to essentially overcome a catch-22 many times people are having pain because they don't have the strength to do something but they can't strengthen because they're having pain and so you can take the load down from what they need to do to strengthen down to a much lower level so that the actual joint or tissue can handle that load but your body still thinks it's going through this monster workout and so um so you still get a lot of strength benefits out of doing a much lower load at much higher reps and so we essentially use it yeah to to uh to get over that catch-22

um but it's not the end-all be-all it's not a replacement for traditional strength training uh we use it in um we use it concurrently um so you know many times we'll we'll have somebody come in you know twice a week we'll do it with them once and then the other day will be a traditional strength and so this way we we tackle both and uh and tip and we end up having some pretty good results with it i felt that this this kind of mode it's we're trying to figure out whether it's more applicable in the therapeutic side or more applicable on the performance side because you'll also see people use it from a performance perspective particularly in like strength training power lifting and things like that right right where they're using it adjunctively in addition to their normal lifting routines they will do blood flow restrictive types of sets and reps and things like that to kind of like super boost their you know their workouts or their overall like kind of architecture most most runners aren't going to care about that there's been some speculation that you can use it in the endurance world and that's another podcast for another day but since i'm since i'm talking to you i want to mainly focus on the rehabilitation side to like really simplify it you're able to get better kind of improvement out of whatever thing is dysfunctional by using a lower load so you could take any lift and let's just say i'm lifting something at 20 pounds normally and it hurts well we're going to put on this blood flow restriction device and you're going to lift it at 10 pounds it's reasonable 50

right you're going to lift it at 10 pounds but the effect that it has on you is like you are lifting 20 pounds so you've reduced the risk you've reduced the pain and you're still getting maybe all potentially all of the benefits of lifting of lifting that higher weight and as you as you mentioned you're using it as a bridge to eventually get it back to that 20 pound weight exactly exactly because there really isn't a true substitute for traditional strength training and there shouldn't be we're not looking to eliminate it uh we don't i mean i don't think anybody would want to put strength in a pill but um hey man they're trying yeah that's another topic yeah i guess cpo is a thing but um the uh yeah so we use it as a way to get past that that initial that initial point and how give give the give the listeners a little bit of a uh of an idea of how frequently you are using that in a rehabilitative setting like is this something where it's like super niche and like really isolated or can it be more broadly applied no we use it for a wide wide variety of patients um we'll we use it a lot we deal with a lot of acls um and so we deal with it um i mean we we've gotten pretty creative with who we use it for and strangely enough because it feels like the craziest workout of your life

um and strangely enough some of our most diehard like i gotta get me bfr today are some of our older patients and the people that like that have had a couple joint replacements and they used to just really get after it and now for whatever reason they can't and they're like i gotta give you a bfr today it's the outlet it's the outlet that you've always been talking about right you're trying to find some outlet it's the same thing yeah yeah so we use it for a lot of different things um but some of my favorites are the are the non-weight-bearing people um that you know they're kind of down in the dumps they don't feel like they can do anything you know we can't even have them you know bike or swim yet and we put bfr on them and we're doing quad sets and they're just sweating and it's it's awesome so um yeah we use it quite a bit yeah it's a cool tool i'm glad to see it finally get more acceptance particularly in the in the in the rehab world which you know i've had to play in a lot having athletes injured injured over the years because it can't it can't it can't be an effective tool if you're using it as a bridge and not using it as like a sole modality or sole substitute that's where you kind of get in trouble because you move back to weight bearing stuff and the gap is too big yeah yeah yeah absolutely cool all right patrick we're gonna let you go man that was that was actually really fun we covered a lot of topics man we threw clamshells under the bus barefoot running and everything like that i didn't know where that was gonna go man i appreciate what you do man um you

want to give a quick plug for uh next level sports performance and and where they can find you guys yep absolutely so uh like i said i work with north next level uh we are in golden we just moved to a brand new building uh three weeks ago uh it's just on the yeah it's pretty sweet um it's within running distance of uh north table mountain which is really cool yeah yeah so uh you can find us on instagram um you can look us up on google and uh yeah come see us cool you guys got a good clinic up there i'm gonna go next time i'm up in boulder which will be yeah some point when i'm re-recording the pieces of the audio book i'm gonna come check it out yeah please do awesome man thanks for being on the podcast today patrick thanks for having me all right folks there you have it there you go much thanks to patrick for coming on the podcast today if any of you are ever in the golden area or you just happen to live in the golden or boulder area go ahead and check out next level sports performance they really do a fantastic job with their athletes there and i think that came out throughout the course of this podcast where they treat athletes very comprehensively and use this head-to-toe approach where they look at all aspects not just their weak glutes they look at their life their training their sleep habits as we talked about and all these other components that go into keeping athletes healthy and out on the roads and trails as one final announcement we are hiring if you want to join our coaching team just like patrick and i

talked about during the course of this podcast we are in the process of bringing on a few excellent coaches so if you think that you have what it takes check the link in the show notes to directly apply to be one of our cts coaches or you can hit me up on instagram or on twitter and i will show you the right direction or you can go to train right.com and you can find the information there there are many avenues to which you can apply and i always love it when when we bring new coaches on because it's always a good process for me and it's a good process for our entire team to bring on some fresh faces that is it for today appreciate the heck out of everybody listening and as always we will see you out on the trails you