Sural Nerve Entrapment: Week in Review 36

In this episode, Dr. Beau, Dr. Alex, Dr. Seth, and Dr. Daneiel discuss the journey of an elite distance runner dealing with foot pain. The conversation begins with personal updates and transitions into a detailed case study focusing on the runner's symptoms, assessment, diagnosis, and treatment strategies. Dr. Beau emphasizes the importance of understanding the psychological aspects of competitive sports and how they influence treatment decisions. The episode concludes with a review of the runner's progress and future recommendations for managing his condition effectively. In this conversation, Dr. Beau discusses the complexities of diagnosing and managing athletic injuries, particularly in runners and CrossFit athletes. He emphasizes the importance of individualized treatment plans based on the athlete's specific needs and circumstances. The discussion includes case studies that highlight the interplay between strength training, injury prevention, and performance enhancement. Dr. Beau also addresses the psychological aspects of injury management and the significance of patient buy-in for effective treatment outcomes.

Chapters

00:00 Introduction and Season Overview

02:51 Life Updates and Personal Anecdotes

07:06 Assessment and Diagnosis of Foot Pain

14:44 Treatment Strategies and Patient Management

20:58 Progress Evaluation and Adjustments

25:21 Final Treatment and Future Recommendations

28:56 Navigating Athletic Injuries

36:52 Case Study: CrossFit and Running Injuries

Transcript

Dr. Beau (00:01.294)

Yeah, it's episode 32 now. How long? The last one that was on YouTube was January. Is that right? January? It definitely wasn't this summer. Yeah. 30 episode 31 from what I saw. it's been a break. So over the summer, Alex went through puberty. Yeah. So welcome to the party. Now gross weight is much needed. 145 pounds. Yeah. It's going to enter a couple of bodybuilding competitions, lightweight division.

What else? just got done with Farm Fest. Yeah, I'm glad that's over for a year. And we're back with the theme or the concept for this season. And this season is probably going go through, what do we say, next April? Yeah, and before May. Every other week, do a week interview and we'll have a theme of what the injury or body part is. So this week, we wanted to focus on the foot.

And then we had two similar cases. We're going to be talking about those. then, know, any questions or anything that come up from comments online or anything like that, we may address those as we go. So I'm going to dive right in. Any other life updates? No, speaking of weight and he's going to be entering weight competitions or chop the interesting. wasn't talking. Yeah. So Samurai is gone, but also got a new taco.

So he drives around with his hair in the back of his truck now. Just not quite ready. it since January. I had a third kid. That's right. yeah. Yeah. he has more weight. Less weight, more weight. Same thing. Yep. my half Ironman got canceled. That's strange. I that I got hit by a hurricane. Well, you had COVID missed that triathlon and then. Yeah. was a good summer. Seth is our semi-elite triathlete that doesn't really do triathlons. He just trains a lot. Yeah.

Yeah, he's the biggie of triathlons. But if we're going off of weight, you mentioned he's entering like powerlifting competitions. If you want to do like the strongman competitions, the women's division, the lowest division you can do, which I learned from the patient, is 160. That's tough. So Alex still be a lifetime PB bodyweight. And you'd still get crushed by everybody. easily. Yeah, easily. Well, all of us probably would. What else? And I just have the crushing weight of life. it's just, yeah. That's heavy.

Dr. Beau (02:23.234)

Houseful of girls. Houseful of girls. They're actually pretty good this morning. Although Maddox went to bed with regular hair and woke up with like Jamaican braids. Interesting. Somehow that just happened overnight. Yeah. And that's never been a toss and turn and woke up with a braid. That's because you were awake the whole night. You gotta go to sleep to have those magical things happen. Someone on Monsters Ain't probably somebody from Jamaica came through. It was probably Alex. Jamaican Monster portal. Scare feet, scare feet, scare feet.

Yeah, shows you how bad I am at doing girls hair when Maddox told Sloan right before she went to bed, hey, can I have a braid so my hair is not my face? And Sloan's just like, I'll do like 18 Jamaican braids in like 10 minutes. And it takes me like 10 minutes to do a ponytail. you done the classic social media with the vacuum, suck the hair up with the ponytail? I pretty good at the brush it up type deal without her crying too much. But it's usually just the crying that gets me. And if she has like syrup in her hair or something, then go brush it up.

And he always has everybody here, know? tough guy to go to bed with. That's daily, that's daily. All right, let's get into this first case. So, theme is foot, and then we got more specific. You'll see what we run into here with the diagnosis. But 17-year-old male, I say elite distance runner. Elite is, he just threw down what, 1456, a couple weeks ago. And this is a previous patient of mine, which also plays into how I handle this case.

But he came in two weeks ago with pain across the top of his left foot. And he was like, it's not so bad that it's stopping me, but he's just, he's a runner. He's an elite runner. He's type a like that's the, what you get usually. So he's worried that was state three weeks out from that initial meeting. So now we're only a week out. They actually have a meet today, right? So they're at Scottsboro today. I'm not going to say that.

but he was just worried. And I was like, okay, let's take a look at it. He notes that he thinks it's due to wearing spikes and racing more. That's just kind of what he thinks. And previous history real quick, saw this guy two, two and a half years ago now had legitimate like left hip instability issues. And he'd always had left foot pain to the point that he had like a classic like turn Dellenberg couldn't balance on that leg, but can balance perfectly on his right. Like stuff where you're like, whoa, how'd you

Dr. Beau (04:48.622)

I could wait with this for so long. But he came in at that point for left hip pain. So now this is the top of his left foot. So I'm already kind of thinking some of old stuff maybe. Pain is worse after running, but he never really has pain during your run, even workouts. he's, you know, it's been going on for about two weeks at this point, which into cross-country. Heard it's going upstairs or doing a heel raise. And as I said, he's three weeks out from a state meet. Pertinent things to note, he's already committed.

to the college of his choice. Why I think that's important is if I was in his shoes, I would feel massively de-stressed if I was already committed, going to a D1 school, got a scholarship, but he's also wanting to do Nike Nationals. So then he's like, he has also asked me like, do you think I should do that? And I think his parents were not wanting him to for, I don't know, variety of reasons. So we kind of had to tackle a bunch of things. It's like, he's got a little bit pain in his foot.

He wants to know how hard he should be training to be able to do Nikes. And then also he wants to, he wants to win state. Do you get, what do you get last year? Second? Was he fit? He didn't win last year. No, he didn't win. I thought he was fifth, I think last year. No, I mean, not only does he have a chance of winning state, like he could set a state record, potentially. Cause this race will be, top three will be a very quick race. And it should be a fast course. and then whether it helps or hurts a couple, what last week, a couple of kids really ran.

super fast times on a fast course, which could deflate his confidence could inflate his competitive side. I've seen him kind of grow over the last couple years and he's way more competitive, but he's still like I literally asked him because the race he's doing today. He won't be racing anybody. So he's racing clock. And I was like, what are you going to try to do? He goes, well, I'm going to put down a faster time than I have like another PR so I know that I can.

And I was like, well, that's going to take a different race strategy. And he goes, yeah, I just don't want to blow up. go, how many races have you blown up on this year? He's like, none. go, you kind of need to find where that limit is. If you're going to be able to push and not following somebody. So if you have to lead a race or something like how you can figure that out. So again, all those psychological components plan to how I'm going to treat his foot three weeks out from state and things like that. so again, I've seen this guy numerous times for check-ins and that initial hip thing over the past two and a half, three years. So top tier, I didn't do one. I'm just being honest, comes in three weeks out from state.

Dr. Beau (07:06.84)

paint on the left side or top of his left foot. I'm not, you might be like, shame on you for not being, you know, fall on that rubric, but whatever. I do watch him walk. Obviously he's having pain in his foot. This is nothing new for this instance, but he has left early to mid stance. He just hangs out in like mid foot eversion or pronation, right? Like that left foot versus right just hangs out on the, you know, medial longitude and large. And then he has a lack of great toe extension on the left, which plays into that. If you're already in pronation, it's hard to kind of.

you know, vault off that. So I'm aware of that, but that's how it was two and a half years ago. Maybe we should work on it more. Maybe it's part of it. Maybe it's not. I also restructured, not necessarily how I wrote up my exam, because this is actually how I do my exam, right? I had it ordered different, but this is actually how I do it now that I have gotten into it a little further. So then they're going to sit down on the table. You start palpating right away. He has a latent trigger point and I'm getting on the

boat of Fibularis, I guess I get rid of Peroneus. Is that what we're making the move to? And say Riz, is that what I gotta do? I went backwards to Peroneus because I learned it as Fibularis. you actually did. So now I like back on the- Peroneus is better. Let's do a poll when we put this up. Hearing Peroneus doesn't sound right, but you gotta go with it. Yeah. You just don't want those peroneals getting triggered. Peroneus almost sounds like what Ron Burgundy would say. Like I'm working on my-

You definitely don't want to make this mistake and say you're right, perinatal, right? I had some perineal. I virtual console put in. Hey, I think I'm having an issue with my perineal muscle. And I was like, wrong virtual console. Acupuncture. Sure didn't point. Would Logan Basie come into the equation? What's that called? Something zero, isn't it? What? Anus. Acupuncture point. What point is that?

the look of we should know this. Not yet. No, we should. Yeah, we should. look it up. Let's go price prony longest latent trigger point. So it's a mean trigger point there. Non referral into that site. But it's you know, and you'd be like, are you looking at the dorsal foot the pronies group you got three muscles in there. Tertius just covers the dorsal foot. So that's especially somebody that hangs out in that everted pronated position. Like the lateral musculature is just hanging on.

Dr. Beau (09:33.262)

that's kind of how you're stabilizing. And you'd be like, aren't they hanging off passively the inside? Yeah, it's both of those. So in my opinion, little overactivity of the lateral compartment and a little underactivity of the medial. And again, we're looking for synergy like grains on a horse, usually on those. Do you find that same trigger point on the other side? It's tight. So he's a runner. And this is where it's hard to know, like, well, is that a latent trigger point? Just tension. It's way more snappy than the other side. And what I was initially looking for when I was palpating that was what?

on superficial pronial nerve to see if it's pronial nerve, should be pronials. We learned it as superficial fibular nerve. Well, common ask Dr. Dooley, who I would say is the authority on anatomy from my perspective, we'll ask her what she says. But I was looking for that nerve. And again, you can palpate that on almost anybody. But again, strumming that doesn't create symptoms on him. So I'm like, Trigger point there, then tenderness to touch over the dorsal aspect of his foot in particular, like

kind of the joint line of the tail and a vicular joint on the dorsal aspect there. So just like, yeah, that kind of hurts. But I mean, there's a bunch of stuff that are tendons, muscle nerves, bunch of stuff, right? That's it. No swelling, no redness, no irritation like that. You're looking for lace bite, like dumb stuff. Like I say dumb stuff, like stuff. They're like, you're tying your shoes too tight. And how are going to find that out? Usually like some, you know, marks there, you know, bruising or something like that.

So range of just general range motion. He does have decreased ankle dorsiflexion on the left. Again, think of how he's using his left foot. The stuff's probably going to be different on that side. So it is different. It's a soft tissue restriction. In my opinion, around gastroxal, it's just like you're hitting soft tissue, you know, a restriction from an orthopedic standpoint, there's nothing classically positive, but we go into pogo jumps. You can tell he doesn't want to do it, but it also does hurt. So he's kind of like, don't like, I don't want to do it. And then he had told me a heel raise heel raise.

bent knee and straight knee both create symptoms. And then I have him do his right and it's sluggish compared to that. So you can just see like, I can't do it as fast as Poppy. Can't do it as on the left. can't do it as fast on the left, which I'll skip ahead to the special test. So then we did a soleus endurance test, which we're looking for like, can you do a, you know, just quick count of 20, 25 reps. He can do all the reps. It's just super slow. Like he has to sit there and think about it. He's, he said a one out of 10. Yeah.

Dr. Beau (11:56.198)

from a neurologic standpoint, he's a covert positive for cerebral nerve sliding dysfunction. So what's that mean? If you imagine if we put him into an inverted ankle position, right? And you could either slightly internally rotate that leg or cross the body. Like I know Seth's going to talk about, he would have this, Patrick Aranturn was in there with me. He would have this like jump. Like we would hit like about 70 degrees and he'd like, and then I did it a couple of times, he'd do it. And then we were all like, does that hurt? And he's like, what you talking about?

And even his dad's like, yeah, you're like jumping before we said it. And he goes, no. And then if you did it a couple of times, it went away. You're like flossing it basically. So I was like, eh, is that covert? Because he's showing something there. And it was a little bit reduction in range of motion compared to the right. But it's covert because it can create symptoms. Jumping in its hip. He's had hip stuff. So I'm saying sliding dysfunction now, if we wanted to differentiate, that distal, is that proximal, is hip. I'm not going to go that far because it's covert. Like, I'm just like, OK, it's some info.

I did because of that little jump, like he was like, you know, snapping around it. did openers and closers. So I laid them on his right side and just opened up his left side, flip them over, you know, it's closing one side and opening the other did both sides. No change in that test. Right. Closing didn't make it worse. Yeah. Nothing made it worse. Nothing brought on symptoms. Nothing also changed that little jump, right? If you did it a bunch of times, it would start to go away. So, then we did perform two sets of 20 press ups just to

check to see if it changed anything, then change anything. And we're also doing, I should have mentioned, pogo jumps in between those. So I checked the sero nerve, neurodynamic test, same, get up, pogo jump. And again, it's hard when somebody's like it's a one out of 10 or two out of 10, he's like, yeah, it's the same. Okay, cool. Already talked about special testing was the soleus endurance test, can do it, it's sluggish. So it's not like I'd want it to be, but that also could just be pain, right, that he doesn't want to do it. So with all of that,

I have to kind of say, well, it's the dorsum of his foot this first visit. So my pain audit is pretty easy. Pogo jumps or heel raise, right? Functional audit is still that trigger point. mean, that's kind of the, we could say reduce strange motion. I think that's been like that for a long time and probably it's kind of like his left side versus right with dorsiflexion. Treatment focus, foot intrinsic stability, motor control, right? So I think how he uses his foot and he even, he's the one that said,

Dr. Beau (14:18.798)

I think it's from wearing spikes and my foot has a harder time doing things than the right side. And I think when I have less stability or help from a shoe, this stuff happens. was like, probably it's a call. So my diff die would be, know, if entrapments the right word or not, you know, that's up for debate, but cerebral nerve entrapment, sliding dysfunction, pathoneurodynamics, something the nerve is irritated. now.

You'd have to ask me at this point, because I'm arriving at the diff die, because I have three visits in, you'd be like, well, how'd you end up on serral nerve? It's the top of his foot, right? So winding up serral nerve was the positive neurodynamic. He's got restriction in dorsiflexion, which what is serral nerve? It's a concomitant of what? Medial and lateral cutaneous, serral nerves coming together and kind of coming down over the musculatinnous junction of solus and gastroc. That's kind of where it's going to

you know, be most exposed. Obviously the diphthi fifth metatarsal stress fracture. I he's kind of having dorsum lateral foot stuff, no swelling or anything like that. then I kind of have to skip ahead. It was dorsum of the foot and then it goes to lateral. So it changes which plays into the nerve thing. and then trigger point referral. There was no referral when I was palpating, but that doesn't, maybe I sucked at palpating that day, right? But he had that trigger point that could refer there for sure. Okay. So treatment on the first day.

Stecho parallel to I'm sticking with pronious pronious longest just kind of knocked down tension, which it does quite a bit. Then we immediately go into five months sideline with the focus on the foot being the fixed point, right? The lateral aspect of his foot being the fixed point, not the side of his knee. And again, it's not that you're right or wrong. It's actually different positions. Remember there's RT two and there's, you know, four different RT, you know, two, one and two.

we're using the foot. So what I tell everybody, imagine that if you're laying on your side, like that foot would be pushing down to the ground. So like, we're just using the side of the foot, right? Is the ground. And when he does that, like he feels in his hip though, like more than if we use his knee, which is kind of the goal. And we work through that for two reasons. I'm, you know, kind of hopefully doing an isometric of those pronious groups. So I can knock down more tension. I'm working around his hip that probably needs some input and feedback. yeah.

Dr. Beau (16:38.158)

And then we go back and so you have his foot slightly inverted is what you're saying. So it's neutral. Okay. So it looks like it's even because he's working to keep it neutral. That's what I was curious. You're planning him to. Yeah. So I just tell people like put your foot flat and imagine you smash in the ground if it was underneath your foot right now, because they want to almost like traction down into the table a little bit. Yeah. And I'll push their foot down on the table for the first few reps too. But again, common mistake if you're looking at like a low oblique set.

These people just pivot around their knee instead of actually keeping their foot down and creating hip rotation. And at that point, the knee is the fixed point, not the foot, but the foot's a good guide. coach. Then the Arkansas Walmart headquarters calling to put my bow beard products out on the fishing. Do you want me to answer it then? Yeah, I got a new fishing lure coming out. Perfect. Heck yeah. I'm excited for you. Yeah, that's cool. Then we did hang stance.

We found some cool stuff on the second visit with hang stands, but we're just working on getting this foot into a better position. The reins on the horse synergistic play between the lateral medial compartment. That's the big thing. What's the timeline between visits? We're still on one right now. So we're just, I'm kind of going through the treatment there. And then we worked on supination curtsy because again, I want to draw up the medial arch, you know, and put it in a better position, a centriated position, and then have him work around that, you know, for right now it's in the coronal plane.

But a supination curtsy is basically, looks like kind of a curtsy lunge-ish type thing. You're just moving around your foot with your legs staying neutral and kind of working on for him, really keeping the ball of your foot down and not letting the inside of your foot kind of escape. You're working on like that foot doming shape. Is that what you're really working on for the supination part? And like we were working on this with another patient yesterday. Big mistake is people get into that position. They think we want this massive arch and they're actually loading the outside of their foot more, which is probably what he's doing when he like runs them.

ground and then like has uncontrolled, you know, pronation version. So we have to be really aware of like, no, we want you to load the inside of your foot and then be able to like keep your leg neutral and move across your body and eventually rotate and jump and land and all those things, which is tough for him. And that's all I sent him home with. So you have a next to curtsy, right? I'm doing it. And I even told him, go, I told him after the first visit, I go, I'm going to leave it up to you if you want to come back. And a lot of people like, why would you do that? Because he's a type A kind of like,

Dr. Beau (19:03.95)

He'll do it. Well, he'll do it, but also I don't want him to like buy into an injury scheme. And I think he has nerve irritation. So if he was better, even though we might say, there's stuff to work on from a functional standpoint, I think it's better three weeks out from state with somebody that's like hyper-vigilant to be like, you're doing good. Like go. Yeah. You've been fine for the past couple of months. Like just go. So that's what I told him. If you need me, I'm here. If it's still bothering you, come back in. He showed back up, you know, the following week. Are you, are you having him do that?

mostly before he runs, after he runs. A of times throughout the day. Again, you're gonna have not an isometric load, but guess an isokinetic load of the pronius group on the side. the big goal too would be, let's say that nerve, because again, the lateral cutaneous branch of serral nerve like basically goes on the medial border of pronius longus and gastroc, right? So it's like right in there.

And then it kind of connects back in with the communicating branch back into that medial branch to make Searle. So if he has much tension, like that's our patho neurodynamic scenario, whether it's entrapment or whatever you call that. so if I can dump tension, that's my goal. now I'm hitting two birds with one stone. Let's say I didn't pick up a trigger point referral or it is the nerve. I'm doing two things at once now, right? I'm offloading muscle to get the nerve moving. I'm slightly like kind of moving that nerve around. That's my thought.

That's all I send him home with, a couple times a day, do it before you run, warm up, if you're in pain, see if it takes symptoms away. That's the coaching. Do you worry because he's a type A person that he's gonna do that a lot and then he's not gonna have a sore hip that affects his running or? No, because it's body weight and if he did have a sore hip, hopefully he's like, I suck at that. If he did, like, cool, it'll go away in a day and then it's like, you know, it's easy. So the big reveal on this is visit two.

So he comes in and notes his pain is reduced, but now it's moved mainly, like he doesn't really have pain on the dorsum, so it's like on the lateral aspect. So it's like over the top of his fifth met and like around the side and even like kind of underneath. So it's all around. So the diff died, now you gotta be like, ooh, this guy have stress fracture reaction, you know, makes me a little bit nervous, but the same thing doesn't hurt when he runs in particular, if he does a hard work, I was like, I don't feel at all. And then it goes afterwards, it'll hurt. And we get more of that story in the third visit.

Dr. Beau (21:28.526)

So we go back in, you know, a second visit, it's always assessment and treatment. So palpation of cerebral nerve slightly reproduces symptoms at that like musculoskeletal tendinous junction of the gastroxylulose group. It's like right in the middle of your calf, like right before it turns in your Achilles, you push there and he's like, you gotta start feeling that out into the lateral part of my foot, which is good for me, but really good for him. So it's like, hey, see, this is what we thought it was. Yeah. Now the neurodynamic test that was positive four is negative.

So that's not present at all. So now I'm thinking, it's probably was a patho neurodynamic scenario and the nerve stays irritated for a while. The nerve's still irritated. Let's take care of business. No jumping now? He's not jumping when you do that? Yeah, we're jumping. And mean, again, still has slight pain, but like he's like, it's a one. And then sometimes he'd be like, I don't even know if that's it or I just don't want to do it. That's literally what he's telling me. So I'm like, that test kind of sucks now. No, sorry. When you're doing the neurodynamic test. no, no. Yeah. So it's just clear. Like full range motion.

Totally. But yeah, pogo jumps. I threw out because it became just, I don't know if you actually know if it's better if there's pain or if you're avoiding. So it came down to kind of like heel raises. Like how are we doing them? Do you have any pain? Move right into hanging stance. Now here was the kind of interesting thing. So we're getting to hanging stance and he's been doing supination, curtsy and panchanger's foot. When he gets in there, if you can imagine a foot that lives in midfoot pronation.

And when he tries to like load the ball of his foot and use the rest of his toes, A goes into that, you know, compromised buckling of the distal joint of all of his metatarsals. But then his pinky toe is like, I would call it a dewclaw, but it starts to like literally turn like purple. It's like he's having occlusion, like from a vascular standpoint and like, then you do like not capillary refill from the bed, but just his toe. And I mean, it's totally different than the other four toes. Patrick was still in here in turn where you're like,

So we go over to his right foot, totally different, right? You can stand there. so we're doing that and I go, well, now we can use that as more feedback, right? Like obviously the neurovascular bundles that's running between your fourth and fifth met, like it's getting compromised because you're just crushing everything as you go over here and then try to probably overuse interossei or something to like stabilize instead of like, abducting and all that stuff. That's gonna be really tough change in two weeks, which is why I approached it the first time like.

Dr. Beau (23:53.294)

Yeah, there's stuff to work on. Let's just get you out of pain. You know, and that sounds lazy, but it's the best option, I believe. So that was kind of cool for me to see. He definitely could tell the difference. Then I was like, maybe we can change that. And then we really have a different kind of test to look at. Because of that, I started working on diagonal single leg deadlift with foot loading because imagine I have his left foot down. And for those that aren't familiar, imagine a single leg RDL and you're leaned against the wall towards the leg that's down, right?

I could put a video up because what's that do? He has to keep the ball of his foot down, but it's biasing weight over to the lateral aspect of his foot. So it naturally gets his foot down and he's basically just doing the same thing as, know, a curtsy. He's just loading his foot and moving around now. When he does that, he gets a way better setup for the transverse arch. Like you see kind of like vaults that fourth, fifth met space. Really cool. So, and he didn't have the like a color change in his pinky toe. It's like, yeah, perfect drill.

Still want to do the supination curtsy because you got to like feed those in. So I go just mix those together, like make them a little random. like a couple reps of this, a couple reps of that. And that's what we send them home with. Diagonal single leg deadlift, supination curtsy. Third visit, we got even more data. So I said pain is only occurring after a run, especially workout. So again, doesn't ever hurt during a run, just each push it or after being sedentary for periods of time and then moving in. But he knows it's, I think he works at a fast food restaurant, Republics. I don't know, it's not.

But if he's up moving and working, he has like no pain. So it's if he sits down and gets back up and then he'd be like, is it tendon? You know, there's not a tendon that wraps all around the side of your foot. So now I'm like, okay, that's probably you're just moving the nerve and desensitizing it throughout the day and it doesn't get a chance to do that. So again, let's say let's back up to first visit, we had a covert aberrant finding on a neurodynamic test. Rule of thumb for over positive would be what?

not doing any flossing usually or send them home with that. Now we're into the third visit. I'm like, dude, you have just just nerve irritation, opinion, like the peroneous trigger points gone. I'd say dorsiflexion is probably about the same. Heal lifts still reproduce the symptoms. But what we did is if that musculatinnitus junction just voodoo floss the snot out of it, and then I had him do heel raises, which does two things that helps you do a heel raise because you have compression, but he's like, I have zero pain. Now, again, mechanisms there just

Dr. Beau (26:18.286)

pushing on some make it easier to do, but also you're compressing that nerve and giving a much input. And he was like, yeah, that's nothing. So I was like, okay, to me, that's going to again, concrete what we think is going on. and with, because of that, we, went in and because he has just kind of resting increased tone where that sero nerve drapes over that musculatennis junction, I just went in and kind of dry needle parallel to it, almost like a steko ask dry needling, right? Just going in along that channel.

you know, promoting some like kind of input. When we put in a couple of those needles and again, we're not on the nerve, we're in the muscle next to he's like, yeah, I can feel like pain in my foot, like on the side of it, which kind of crazy to me, because you're not in a trigger point that should refer you're not also on the nerve. And he would only you know, he'd poke it in, then he'd be like, Yeah, I feel it and go away. And like, did that for like two, three needles.

Hanging stance again now we're moving into heel lifts because that's something he's had a hard time with because of the starting position his foot and being able to move over to his big toe already he's already on it so it's hard to generate force when you're already in that position. So just working through a more active version of what we've been doing. Hanging stance with heel lifts, capillary refill was improved so like pinky toes not turning purple that's better you know maybe that's a variety of reasons. Really stochotic movement.

So when he goes up, he's got these like ratchet and going down, like, whoa. And that to him, even though it's us, like, that's, you get that with a lot of stuff. Like to him, he's like, my God, which is kind of good. I was like, yeah, that should be smooth, man. So then because of that.

and seeing how much he responded to seeing like what that looked like. I was like, let's just work on that with like, you know, a squeeze and lift drill is you got a lacrosse ball between your feet, trying to cue up like, again, synergy between the medial and lateral compartment, drive through your big toe, did a bunch of reps of that, and then just sit on single leg. And I was like, be able to repeat that feel in a single leg stance. Which again, without being in hanging was again, like really like, you know, stochastic.

Dr. Beau (28:26.51)

So we did heel raises and then we finished with cerebral nerve flossing and I kind of preempted that with like, I'm going to have you do this a lot for the next two days. Just see what happens with symptoms. So I'm out of that like acute irritation thinking that there's actually a nerve entrapment or interface issue thinking it's just inflamed. still swollen or whatever we call that. Now he's telling me if I move around all day, it's better. Okay. Let's move around more specifically and see if we can abolish it completely. So teach supine, cerebral nerve flossing, right? Just, you know, like at 90 degrees, kick your leg out, you've heard it.

slightly planar flex. So now he has supination curtsy diagnosing like deadlift, just mixing those around or warmups and then sero-nerve flossing like pretty hot and heavy for two days, which I will see him tomorrow because he has a race today. So I don't know how he's doing beyond that. But I just thought it was kind of an interesting one from there's always a hundred things to work on, but then it's also a scenario driven of like

I'm going to be honest, like if he comes in tomorrow after his race and he's doing better, I don't want to see him next week for state. I think that's a bad move with his personality type. Even if there's a million things to work on. I know a lot of people would think that's stupid, but then what I will say is I don't want to see you next week, but I want to see in between then Nike or I guess he has sectionals next week. yeah, then Nike. Yeah. So three in a row, but I don't want to see him after all that stuff unless something flares up. Cause then we got out or indoor, just clean up stuff.

indoor because he's also got to get prepped for like college where he's going to get either spanked with higher intensity or more volume for both. And that's what I was trying to get him to realize like your training is going to go way up. And if this stuff falls apart, just in season with, I mean, they, what do you max out at 45 miles a week or something? Maybe he's got, don't know if his volume is high, but his intensity is pretty high. Right. And then we could, you know, we'll see what happens in college. I also know where he's going and kind of how they roll for the most part. But yeah.

It was just any of those things get magnified. So like we do want to keep working on it. Just not right now. I think that's the biggest deal with this case besides it having some like, I wouldn't say confusing, but it, the second visit, like, God, do I need to send this guy for an image real quick to just rule out stress reaction? Tough thing there is like, we know like has to be pretty far progressed for an X-ray. We're definitely not getting MRI. mean, you also saw symptoms change location in one visit. And that's what I kept telling him to reassure him like,

Dr. Beau (30:47.95)

In my opinion, it can't be an injury. I've gotten fooled though. Cause again, a stress reaction or fracture can cause a lot of pain, right? And then what we know now from nerve sensitization, the periphery, if something's going on, like a bunch of nerves could just be irritated and you'd like, the nerves are irritated and you do have an injury too. So that's something to be aware of. Yeah, that's a point. you're here, he wasn't having anything after easy runs though, right? It was just after workouts. Initially the easy runs where he felt like it was worse after. I just think that was the amount of time he was doing stuff, right? Just more time.

on his feet. Yeah, maybe not more time, but like dirt or, you know, the duration of effort versus like an interval and rest and stuff like that. I think there's longer time on the ground on easier on that. Yeah. When you run harder. And he also mentioned which I, I have a hard time reconciling this when people say it now, just from what I know. But he's like, yeah, if I'm on like trailer softer ground, feels better than concrete. And you know, like we've said, like we attenuate the impact force on that. So it's the same, but I mean, that's what he told me. So, you know,

I mean, I feel like they just get a different stimulus when you're not running on the flat concrete asphalt the question I should have asked, which I didn't, are you wearing a different shoe on concrete or versus trail? then maybe that's what's going on there too. don't know. Any questions on that one from, and again, I wish I had tomorrow's visit, but again, we can, you know, two weeks from now do a quick update on him and just be like, Hey, how are you doing the races? How's foot doing? that stuff. And off of the X-ray, if you're thinking about pulling that, are you doing bilateral?

No, no, just because like stress reaction fracture, I don't need to compare like normal anatomy from a joint standpoint. If I was looking like we had somebody a while ago with a Liz Franck like ligament thing, you have to there because like he has abnormal anatomy from a degenerative standpoint. Now, if you're looking at recurrent stress fractures, like we had a gymnast with a tibial recurrence, like at some point, like her second set of images, like if you don't do bilateral, you're a dummy because like

If we have the same showing up, it was like just how our tibia is and it's that's not the driver symptoms, but it's a new thing. So I'd say no in that scenario. but again, if he came in for the third time for fifth met pain, I'll be like, yeah, let's look at it. So we don't call something wacky. Yeah. Anything else?

Dr. Beau (33:07.298)

And if I'm being honest, this kid just needs to lift more weights too. he, he's stringy. So his, well, and what we also know with like strength conditioning, if we were, know, Hey, use your foot the way we want to use it, work on single leg stuff. That's also input. So if we have talked about all these motor control rehab drills, like working out is input. If you're aware and conscious about what you're doing or not just like,

you know, sticking headphones in and banging out reps and stuff. like that in itself is a twofold getting stronger being able to create more force, which also reduces impact and things like that up the chain. But then also it's just like motor input with that, you know, feedback loops. think people don't think about it like that sometimes. Which knowing that team, I I know they strength train in the summer. I don't know what they do during the season. I don't think I don't think anything. Yeah, I don't. Nothing's mandatory. Most things in high school.

I mean, like we can speak on experience. feel like we didn't really do any weight training because you had limited space. Football and baseball always kind of took, they kind of took precedence. We did during track, but that was because we had the weight room at the track that we shared with the football team and they were in off season. So we always had volleyball, basketball, football and baseball, all of those were going. So was like our weight room time was like, you might get in there once a week, maybe. Which I also know that they're

program that they get in off season is handed down from the strength and conditioning coach that runs football. So it's not even specific. It's literally that program. again, it's still something in their high school. Yeah. not. And again, should it be running specific? I don't know. But it should be people that are low body weight, low power out specific. I was going to say, most of the time when they do anything that they're having to load their body outside of the sagittal plane with extra weight than just their body, they respond.

Yeah, well, if you give him some like, some topical even like easy plyometric thing that they did like once or twice a week, that would go a long way. Which is crazy to consider that, you know, he's running 445s for a 5k each mile and be like, those are way going there. You might actually run faster. Yeah. Well, that's, I think that's something that across the board, if you saw, Hey, the big game plan for all, or I mean, female and male,

Dr. Beau (35:28.526)

senior high school runners that are going to run in college that the move into outdoor like towards the end outdoor you just start lifting weights and like don't put on a ton of weight but you want to put on some lean muscle mass and like get some power under the chassis to bulletproof you're going into college training over the summer and also get stronger before you increase volume and intensity. Yeah I feel like for college like intensity is not that much increased it's just volume I feel like is what goes up.

So then it's tougher to recover because you're dependent on how hard you had to push in high school. think that's the chat. So your, your story versus his story would be very different. What if we look at some of our other runners, like our guy that's at UK, like that guy never had to push here. And then when he got there, like he is not fast guy and all. Yeah. The intensity as programmed is the same, but the intensity went way up for him. He's like, Ooh, like I have to push harder to do what they want me to do. And then same thing for him. If you're the top dog and you have a program workout and it's like,

Again, he doesn't even know where his limit is. His biggest detriment right now is that for sure, from performance standpoint, for a lot of reasons, mentally and physically. Anything else on this? Because I know you got kind of a secondary case that's similar, right? Yeah. Do you want me to do the entire case, or do you just want little pieces? Give us the rundown on what was similar, but what was different. What led you to, is it same diagnosis? Yeah. Mine is same diagnosis. Give us the...

history of why they came into the office and then the pieces that were wildly different. Yeah. So mine would be a 23 year old female. She's really big into CrossFit. She decided that her best friend wants to go to all these different national parks. So there was a half marathon in South Carolina at some national parks. So she was like, yeah, I'll just sign up and do it. She's been training for high rocks, which she's competing for in a month, I think, over in Texas.

And then, so that's kind of like her main focus. So if you look at her, not so like your typical runner, she did this probably about 10 days ago from when I saw her. She said that the day after her half marathon, she started having like outside of like calf pain into the lateral aspect of her foot when she was just like walking around. The other piece was big like impact movements. She started feeling like zinging kind of like upper leg.

Dr. Beau (37:49.846)

And then just walking around, she felt it kind of like shoot down. So you kind of have like two different directions that it kind of runs depending on the impact. She has nothing if she does like squatting, like really no movements inside the gym bother her except like if she decides to go run or walk around. Outside of that, that's pretty much the only, that's pretty much my like main history piece. She said that she made the appointment on like a Sunday and then she saw me like two days later. She said the day after that she made the appointment. I started feeling a lot better, which is pretty typical.

that I wonder if that's actually named that effect. And you guys have people tell you all the time, right? I made the appointment as soon as I made the appointment, I started feeling better. Maybe that's how good I am. Over the phone, starts making a difference. placebo, but it's like an action step. Like you made an action on doing it and literally people say it all the time. Yeah. So almost every patient feels better. Yeah. Unless they smoke their back, pick up a tissue. High low back is not going to feel better. didn't, her top tier, I ran through it.

but it is no different because I've seen her in the past. It's the exact same. Main things for me that I was looking for, I guess, I'm not trying to bias it, but just how she moves overall, mainly flexion extension, because she's had low back stuff in the past where her multi-segmental extension was dysfunctional non-painful. So I looked at that. Both rotations are dysfunctional, but again, that's a lot of hip, I would say tissue is her limitation there for the external.

external rotation and then single leg stance on both sides. I call them functional, but if I wanted to get real nitpicky, I mean she passes the test, eyes open and eyes closed, but she kind of leans into her low back a little bit on the right side, which she's had right low back pain in the past and she has right foot pain. Well, that's something that I probably should have done on our patient because like you did have single leg stance stuff in the past, which would clear completely, which is the other thing I didn't say is like that stuff all completely normalized 15 seconds, eyes closed bilateral.

So I should have checked that to see, has it gone backwards? And again, I probably am ending up the same place, but it like be good again, like clearance stuff. And I'm not like dogging top tier SMA for the clinician. But again, I don't think I need that, right? I think the patient sees that like, big change, right? Cause it's harder to say like, hey, see how your foot's working different when you walk and run, like they don't pick that up. Yeah. And then even though she passed, I still dropped her, just again, based on her previous history.

Dr. Beau (40:15.926)

I still dropped her down into like a half kneeling in line lunge just to see if I took away the foot, how she would stabilize if she still kind of leaned into that low back a little bit. She didn't when she went down to her knee, but she still passed on both sides. And that was even after I had even had her like come up eyes closed and stuff like that. So really nothing on top tier that was really big. Since she had this pain after running my two tests again were the kind of the exact same of just a soleus endurance test.

straight leg and bent leg still kind of both reproduced her pain on the right side and it was also slower. She still got to like 10 or 15 until she was just like how many more do I have to keep going? I mean she was kind of crushing on me that her right side was just slower. So then she's like how many do I need to do? But there's no pain. Then I was like okay if she has no pain there next step would be something that's got some impacts the pogo jumps. Right side is not really that much slower than the left I wouldn't say. She just has pain and she's like I can kind of feel it there.

Which I would say is a better pain on it at that point, because you don't have like a performance or functional deficit comparatively. yeah. Did she get that zing? Yeah, she feels it on the out. Sorry. She feels it like on the outside of her calf, of, guess, if you want to like a third of two thirds of the way down or like peroneals all the way down, like into the fifth met, like that exact pattern. And she kind of like points it and like, it's almost like a draw the line with her finger. And then.

I'm trying to think of what else. Then I went to like my orthopedics, nothing reproduced it on low back. Well, first I checked her foot, nothing was there. didn't sprain her ankle, she didn't roll it during the race. So I kind of just made sure I checked all my boxes there. Was she tender to touch anywhere? She was tender to touch over again, where she like pointed to and drew the line. But I wouldn't say it was on the tendon. It was kind of like right behind the tendon, over the nerve. And if you compared it side to side, that side I would say was larger than the other one.

So a little bit like neurogenic swelling. And then lumbar orthopedics, just because again, she's had low back stuff in the past. I rechecked some of the things that reproduced her pain in the past. like Milgram's nothing. Straight leg raise didn't reproduce it until I had her cross her leg across her body. That reproduced it. With inversion? Inversion. Okay. Yeah, with inversion. Inversion, plantar flexion, and then taking it because I could do that like laying on her back.

Dr. Beau (42:42.764)

I could dorsiflex her foot, which she has restriction range of motion in her foot. Nothing reproduced it there. I could plant her flexor foot and invert it. Nothing there. As soon as I took it across her body, it got about halfway and she like jumped and she's like, yeah, you got to stop. Which again, isn't classic differentiation, but kind of is that like you have below the knee or, know, cause we know where that kind of comes out of the calf. So it's hard to say, well, ankle or knee, like lower shanks. Like that's good to know. And she also on that side really wanted to like do the straight leg.

raise for me. I don't know how to like say that any more than it is but like you take her left side her leg was pretty much just like limp her right side she wanted to kind of force it in the way that she wanted to and keep her knee bent. So I kind of just took that a little bit into consideration. Nothing with like her slump test either. So again I kind of rolled out a little bit of like low back disc stuff.

And then that was the only, I guess, orthopedic test that was positive with straight leg raise across. I even like banana'd her to see like if it was like reproduced anymore with like opening her. Banana means if they're supine and like their shoulders and their feet stay put, you'd move their hips to one side. like if they're standing, you'd be leaning one way and then standing the other. So you're like opening one side and closing the other side and then repeating it straight leg raise. So I just was going to see if that changed anything. It didn't, it didn't change, didn't help, do anything. Which is a good point. Like I didn't do that. I could have known with John.

I went into openers as a test and then retail. You're kind of doing all the same stuff and sometimes it's faster to do that but then you get full because if you hung out for 20 breaths in an opener you might get a different result. Again, that's where sometimes it's hard to be like, we're like, don't fall, fall to protocol, you can bounce around and then sometimes if you did fall, maybe you would suss out a pure McKinsey, a pure neurodynamic. There's merit to both. And then palpation wise, so I kind of went locally and then moved my way up. So if you start moving up to the hip,

She has like massive like tone in the right glute around like glute med piriformis area and then lumbosacral mutation which are all things that we had previously worked on probably like four months ago I think was the last time I saw her maybe. So I've just had her since she was already flipped over I had her knock out like three sets of 15 for some press ups just to see if we could do anything down below.

Dr. Beau (44:59.342)

She's getting her PhD in some like nutrition stuff and like anatomy things. So she was kind of curious on what all we were doing, why we were attacking her low back with her foot. Yeah, I did. I I asked her if I needed to get on the table if she was a doctor now. No, I'm just kidding. But I just had her knockout press ups had no change in any of the tests. So then I did.

Sorry, I gotta get down to my notes. Should we have the Lane Norton double blind? What is it? Double blind, placebo controlled, randomized, step whatever he yells every time, which also you see his newest article they put up today on a low back pain is not caused by loading. Terrible article, by the way, just cause you can read a research article doesn't mean like whatever, sorry. Side note. And then, if she had, since the only thing that reproduced it,

was that basically tensioner for the serial nerve for the straight leg raise. I had her stand up and put one foot up on the table. So I guess you're like a tensioner into like a slider, if that makes sense. So she has heel on the table, her foot's plantar flex and inverted knee bent, kind of like lean forward a little bit. And she's trying to extend her knee. And as she extends, whenever she gets to the point where she starts to like either recreate the pain or it feels to get like super tight, she slowly lets her foot go into E version.

So I used that as just – as kind of my like test but also like a little bit of my treatment because I was just like maybe she has like a really big like tensioner on that side since she has a lot of tone in peroneals and in her glute. I had her – I coached her to do that. And so I had her do 10 of those, went back to the pogo and she could pogo up and down with like nothing. So then I was like okay give me 10 more, went back to pogo, still no pain with that.

had her go on her back, straight leg raise across her body, that's completely gone. So then I put her again, just because I had noticed that she kind of like lays into her like low back, doesn't really like to load her hip, but she's in that single leg stance. And she has that massive tone, I put her in a sideline position to work on the tone of her right hip. As soon as I put her in the sideline position, I was like, just kind of pushed back into me just to meet my resistance. I mean, she's like already like shaking a ton, which to me was kind of my...

Dr. Beau (47:26.016)

where I'd like to head with her is like that right hip stability. But in her mind, she thinks she has something that's like seriously wrong with her foot, which she kind of kept saying the entire time. Like if she gets up, she's like, yeah, she has no pain, but she goes, I just don't think that that's like what's wrong, which is kind of cool. So it was the second patient I've ever been told that like they had changes in that I was wrong. Second? I feel like we've talked about this before. No, my fifth patient ever told me I was wrong. And then

That was during preceptorship. And then she was just like, I just don't think that it's like the actual nerve there. She's just like, it just doesn't really make sense to me. Then you should have told her she was no, she's talking about us. So you're right. So then I had her, so I just started showing her. was like, so you see how we like tensioned it a little bit and then showed her all the tests that we had just done. I was like, we have no pain with any of these. And I was like, if it wasn't this, this probably would still have pain.

And she was like, yeah, that kind of makes sense. So then she got back up to the POGOs and she goes, it's like still kind of there. And she, and so she was like, so what do mean to take her home? Cause she had to kind of like leave kind of quick. Cause she forgot that she had to teach in Tuscaloosa in like an hour and I had like 30 minutes with her. So I sent her home with those sero nerve tensioners. Actually, that's actually like what I sent her home with cause nothing else reproduced. She had, since she has that high rocks coming up and her main thing was she just didn't want to have pain cause she left and she was like, am I still good to be able to like.

load pretty heavy for my competition. was like, yeah, you're good to still do these things. Your nerves is pretty irritated. I like that's why I'm sending you home. Cause I was like, one thing I'm also seeing is does it make it worse? Right? Cause if it, if it makes it worse, I know there's either some tone that we need to calm down, like in like peroneals, we need to work on this hip a little bit more, especially if you're adding like your training back in since it's not really like half marathon focused anymore. but it also gives us a good, you know, way forward of what your next month's going to look like heading into the competition.

so she was like, okay. And then kind of left like, you know, not really like in my opinion, fully bought in on that one. so it was, yeah, I don't know. It's kind of, kind of, I only saw her one time. I looked, saw her yesterday. I see her, I think Tuesday, because I'm out, I think Monday, but Tuesday afternoon, I see her for like her second follow up for that. And the hyrox is when? That is late November. I think like, I think it's like a month out from like, to like this weekend, maybe. Yeah. So do you.

Dr. Beau (49:50.976)

What's your confidence interval that you're right? 98%. So then if you're 98%, then it's all management, right? She doesn't think it's that. You think it is. She may be like, want an image or she goes someplace else. Do you have anything else that you're thinking on how to manage it? Not better, but just how do you keep managing it? Yeah, the next time she comes in, just in my opinion, work pretty locally of just calming out some trigger points if I can reproduce it.

Like she seems like kind of person that likes things like locally worked on. Maybe not fully just like, let's work on your right hip because she's again, I would say above average if you're talking to CrossFit. she kind of has this like she's, feels like she's good at moving her body, which she does move pretty well besides like these one things. And then,

I guess working on the right hip and then linking that with her low back a little bit more since she's already had that in the past. And again, I kind of pulled up and like showed her like why she could have the like low back with the foot because I brought up the Expo study that we kind of always like throw out and she wanted to go look up that research herself because she like likes to do that research. So she wanted to kind of see it firsthand. See how you weaponize what she's like not being trained about how she's going about getting trained.

It's like a little bit like there's this article and that may literally, that can change your pain. I you know, I know that sounds wild. Cause I showed her, was like, mean, even if we, if we take this study, you know, there's 30 % of all foot cases have some type of low back components. I'm like a third out of all things that come with the have foot pain could be coming from your spine. And I was like, you've had low back stuff in the past. So I was like, dude. of you listen to the Ron Hruska podcast with Winchester and them? So you had a really good point on there.

Because they're asking like how do you know if you're on the right key link with all of the stuff that you do? And he goes almost regardless of key link if I don't start where they think I should start doesn't matter what you do I think there's a really good point here that like it's not trying to pull the wool over their eyes But like let's say you you're not like I'm 98 % sure what it is Which means you're also you got symptom relief, but then who's to say we can't just like fool them by like

Dr. Beau (52:08.11)

You know, what if they mentioned they're like, you know, did she ever mentioned what she thought it was? Like stress, you know, she, she she said she's like been rolling her calf a little bit. So she has, that's kind of helped it a little bit. like, who's to say she has a trigger point, know, lateral gastroc perennial group, whatever. Stecho the snot out of it after doing neuro dynamics, get a pop around. And I know that sounds like you're being sneaky, but again, you're still decreasing tone, which is probably playing into it.

And we may be like, that's not the most important thing, but it might be the most important thing to them. And then we have to, we don't have to talk our way around managing the case. You're literally doing what they want you to do, which doesn't hurt them. It helps. Or if it's a net neutral, I, you know, a crew scatter, like a point of like, you just like, they'll literally tell you what they think's going on, what they want you to do. And if you start there, you're going to have, what did he, how do you say it? I can't remember the exact terms. We basically said you're going to have better outcomes.

overall and he goes, that's a clinical like thing that you should be working with, not just like a placebo higher. He goes, that's a clinical like buy-in changes the game. It's like, that's a good thing to note if you're like, you know, I was notorious for explaining what was causing their pain and why I had work there. And you know, you can get good buy-in like that, but I think it's a lot easier to not have to like fight that battle in the first place. And then if they ask questions, why are we working on our hip? Like, I think there's some hip involvement and it just might be easier.

Yeah, that's what I mean. Five minutes into like what Seth was saying, I was like, he's going right down the right target, doing everything right. And then on those patients, you can almost hear their hesitation at some point. And then you kind of think, OK, if I don't give you a foot drill, even if it means nothing, if I don't show you how to load your foot, because nobody does everything perfect. And then so as soon as I show you that, but then I'm like, now I'm going to do all of this. Then it's like they think those little foot and sometimes it hits right like.

The other patient came in like, think when I wear shoes with less stability, like my foot has a problem with that. And then I was like, it's nice when it does agree 100 % with what you say. But when she's like, man, I worked on my calf and you're like, yeah. mean, cause I mean, she's worked on her calf. She also said that she's been rolling out her foot and she's like, it's kind of been helping. So I mean, she's kind of nailed all the soft tissue in that area, a decent amount. Show me over the nerve reproduces her pain. And she also was like, I guess the other thing was she was like, yeah, when I'm like sitting down, it hurts like walk. But also if I just like do my foot like this and kind of turn then it like.

Dr. Beau (54:28.694)

really kind of gets it. So I mean, you have like two options, or you have like a muscle and you have a nerve and the trigger point didn't reproduce it, you come off of it and it's like, I think that would be a good tip for all of us with anybody listening to this clinician, just like whatever they literally tell you they think it is, unless it's wildly different, or they've been misinformed, and that's leading them astray, but whatever they tell you they think it is. And then like, you know, we always ask questions, what have you done to tell up through what previous treatment we had, things like that. I think then you can like be like, this is like, you know,

they're the buy in is there because they're like, you're treating what I want. Because imagine if you went to a restaurant and you know, they're like, yeah, I'd like this. Like, nah, I think what you really want is this. And they're like, this is the best. This is the best restaurant. Right. And you're like, yeah, and they're like, I want this like, we're the best because you're gonna get that I think like there's a conflict, you can be awesome. And you might be right. Like, that's the best wine pairing. Like, no, I that one. You know, whatever. It's like, it's good.

Well, you go back to years to where like now you don't have to check all those because you've showed him the wins in the past. Yeah. And again, for me, I should have checked it just now. Like, his single league balance is worse. Like good to know when he does get further in training, it does get worse. I think that is happening, but like, don't know if it didn't check it. So that's more for me. He might see that. I think he already knows that. And I, maybe that's not good to show him right then. I can't bounce. I'm going around state.

Hey, I literally told him that first, let's just calm stuff down, get you right back out there. That's, know, and that's why I was like, see you later. I don't hope I don't see you next week. totally different scenario if he comes in and you know, a has different injury or be at summer or something like that. Cool. Any other questions or any more on that case? And again, we'll do like a quick five minute update total on these two on the next one. So we can see one or two more visits on there and then at least one more visit with our guy here. Yeah.

We won't know what the next cases are because we're going to be deciding those week before the weekend reviews. But the cool thing is in the upcoming shows, whatever the case or body area injury that we're bringing up, we'll have discussed and gone over either the concepts of the legitimate injury and the previous week's doctors meeting. So we're going to have way more info and might even be able to shoot some videos of stuff specifically those cases. So it'll be a little more in depth. But again, leave us a review, leave some comments, let us know what you want to hear. If you have any specific questions, we'll try to address those.

Dr. Beau (56:49.902)

any closing remarks? All right. Well, I'm having a fun time. My crotch is vibrating. And I mean by that is somebody's been trying to blow me up. My phone's down here. we got to go. So see you next time.