From Shoulder Replacement to Training: Week in Review 54
Take a look at a case where a patient thought he might need a shoulder replacement, boy, was he wrong.
Full Transcript
Beau Beard (00:00.366)
We were talking about what you can and cannot do in physical education class nowadays. And we were talking about dodgeball, how they, I guess, I thought you couldn't play it, but it's just the foam. Well, I mean, then again, that was 20 years ago. Yeah. I mean, they least like, we did. And then it like, I know it like a band or switched. But did you guys ever play, I don't know what it was called. I mean, probably different PE teachers call it different things. The gigantic ball, giant, like bigger than me.
And you would have like, was kind of like, threw the balls at the big ball to try and get it like, it's like, could also pick up the big ball and run at people and you would just launch people and people concussion to get launched on the basketball floor. the goal is to touch the big ball to the back mats under the hoops. know, destructive. Steal the bacon was a big one. What was that? There was a rubber pig in the middle of the gym floor. Everybody lined up on each side and you had a number. They call it the same number on each side.
Yeah, we played or know something like with a bowling pin where there was like across I don't know Yeah, Oh PE games which they did bring back or they are bringing back the what presidential fitness test good I don't know if it'll still be the same because what was it? tried to sit and reach push-ups sit ups pull-ups mile mile See, we just did like a body fat. Remember they did the calipers. They did calipers. Yeah, we didn't do like full pull-ups We just did like a pull-up
hold. I think there was an age where you had the hold. Actually no, when we were kids, girls could hold, had to do pull ups. Cause you want to hear the sad bow beard story when he got chubby after breaking his leg. how I remember this. Middle school, sixth grade. Cause I got out of PE the rest of that year of fifth grade and I just literally sat in the room and read books. Yeah. Yeah. And then the next year going to PE and still just like got chubby. didn't do anything. And I still remember the first time we did the test cause it was twice a year.
Yeah, something like that. And you're on the pole bar and we had like two elevated stages with the lower gymnasium floor. Like, and like you went up on the stage to do pull ups and they're doing stuff and you know, elsewhere. So you're like up wherever I can see you and I'm just can't even like budge. Yeah. And they're just like, get off. was another one. think that was on it. Really? Yeah. We, we use like expo racers to like,
Beau Beard (02:20.558)
be our markers and then you'd grab them and like bring them back. Eventually, they became the beeper pace pace or test. So you had a certain amount of time. There's a distance. I don't know how far it was. There's like 20 yards. The distance, the distance stayed the same. The beeper would decrease in time between. Oh, get back. And you went as long as you could. And some people would go a hundred and something. There's like a standard like 40 for men and like
30 something for females. then I think about doing sit ups on a hard gymnasium floor now and I'm no, I got something like crushed. I'm just like, God, I guess a little kid backs. You tell me you've done sit ups over there. My tailbone just gets, yeah. And that's a rubber. I did it on like a foam, like a curl down today. I was like, I don't like that. All right. Onto the real time. So Ethan has a quick update from his case last time. So give us a rundown on that.
Yeah. So last time we had talked about my patient, I was starting to do some shoulder extension stuff with him and it was going well. He enjoyed it and we had seen him, I think like three more times and each time it would be like no different at the beginning, but then I could get it back to like where we started. So then last visit, we were kind of just discussing like, like we should probably get like an image just because
One, he was kind of asking about it and two, was like, well, we're getting to the same point and there's been no astronomical change, but he enjoys doing the exercises. And I got the report later yesterday and I expected there to be some type of like rotator cuff stuff, whether it be actually a tendinopathy or tendinosis. And that was like the first thing they impressed. So I wasn't like crazily impressed by that.
They also talked about like a mild long head biceps, tennis and a vitus. Um, so I was like, okay, he didn't really have pain with anything but that. So not really crazy about that either. And then they said a suggestion of a small slap tear, but I haven't looked at the image. said a suggestion. Yeah. It's a suggestion of a small slap tear, better characterization with arthrography. Can we pursue it? That's just a funny way to say it. Cause they're it's their impression. They're saying that's a weird way. Yeah. Yeah.
Beau Beard (04:38.67)
It's just a weird way of saying it. And then shoulders suggesting. Yeah. The biggest thing that I expected to find was some type of like AC joint degeneration because in supine like abduction passively, he always gets stopped roughly about 90 degrees and then it gets really pinchy. This is the guy who had restricted all range of motion of shoulder. Right? Yes. Yeah. And like when he goes through like shoulder abduction standing, he has to like go into flexion to get to the top of abduction. So I kind of was like thinking there may be something and they said,
moderate AC degenerative arthrosis. And the last one was mild thickening and increased signal of the inferior joint capsule with mild periscapular edema, mild synovitis and the rotator interval findings are nonspecific but can be seen in the setting of adhesive capsulitis. So I haven't gotten to look at the images yet. Not that bad for the impression. So what's that change for you then? It's
going to change just like what my expectations are I think in certain ranges of motion. And then if he's wanting to get more than we're going to talk surgery potentially. No. And one thing I'd say is like, again, their suggestion of slab tears, mean, that's smaller. They, I mean, it's, you know, somebody reading the image. We don't know off that image. Like that could be something. Even the moderate AC stuff, like I bet I have moderate AC stuff. Like, you know, I've had AC sprains on both sides, football and weightlifting stuff. So.
All of that, that's what I saying, all of that, I don't think any of that warrants this kind of moving out of abduction. So then I'd be, I do agree, change the expectation, like time. like, you probably need your shoulder move and just in general, which my case will kind of mirror that. But then AC joints, if that is the driver that gets tough and that's where like, so Ethan is the only one in the office, Well, Sloan, that doesn't do dry needling, but dry needling in that joint is one of those like.
power moves because you can like decrease pain, literally start to ebb and a change. I wouldn't want somebody to shockwave my AC joint. I mean, if I had to, I would, but we're going to work on getting the needling certified. That's just like a thought of like, if you're like, that is the thing that you think's like getting it stuck. like there, it's a hard area to get moving. Yeah. And if I need to, I would just have them come and see one of you guys for the day, just to get that aspect done. But if I want to look at the image too, just to see like if the
Beau Beard (07:03.894)
impressions don't match the findings or if there is something that was missed too. When you said something, so I did a webinar yesterday with Ben Stevens and a group and somebody asked a question of, or she was kind of saying that I expect like 25 to 30 % functional change in visit. Like that's like just your expectation. I want to see it change. And I go, what do you, what are you basing that on? She goes, well, ART tells us we should have somebody like 85 % better in like three to four visits. like Ben and I both kind of smirked and we're like, you know, what's better mean?
I kind of told her, go, yeah, you want to see change in visit, but you don't know how much of that's just like neurologic trickery. You know, we talk about top tier stuff changing, like, but even if you change ranges of motion, it's all about the next visit. And that's what you said. He kept coming back the same, which is a really, really big point to realize for people listening that like, even if you make change in, what are you seeing? Probably that there's not the degenerative changes of the main blockade. It's part of it, right? Yeah.
It's how your brain's interpreting all of that change and how you've changed movement over time. And you're like, okay, my expectations changed because now I've solidified that, you know, thought process via imaging. And I'm like, okay, yeah, I got to get his shoulder moving better. But it's like, how do you get his shoulder moving better where it's not painful? Yeah. And that's the challenge with a lot of rehab is like, yeah, we could just shove him, you know, we could send him to, you know, traditional PT and just start going in range and mobilizing it. That might take eight weeks where you'd like, maybe we could do a little faster. Maybe can't.
Yeah, I've thought about like just doing like a dead hang to see if distraction helps at all. But I also don't want to load him because like it's kind of like what Greg Ross is like, you don't want to load without full range of motion because then you're just like doing somewhat of like, but at the same time, like you need to do something to keep that range of motion restored after the end of visit. Yeah. And I think it I think when Greg says that what he's saying is don't load for like motor programming. So for like training, right. Whereas we can use load to mobilize a joint.
Like we were using, you know, for your rib cage, we were kind of loading it to get more exposure of like an eccentric load with those tissues. So I think it's also, what do we think's restricted? So if you had like a bony restriction, I don't know if loading it changed anything. I feel like, it's like tissue or, you know, actual like tension, like neurologic tensions, like load might actually improve it. And Greg does talk about that. He's like sometimes loading somebody, the stability thing gets better, right? Whereas we don't have to do this like four by four, like step up, you know?
Beau Beard (09:26.126)
So that's, I mean, that's just all kind of clinical like trial and error stuff. Yeah. Cool. So we'll give maybe another update on that guy after, um, you since made him hang from bar for seven minutes and see what a shoulder does. talking about shoulders, I have a shoulder case, which I talked a little bit about on a case of the week, but I thought it would be good to talk about cause I've seen the guy more times than I know case of the week. It's like a three minute, you know, real, but I'm just without giving any information.
beside the chief complaint, I'm gonna walk through our little system just like Ethan did with his case and then we'll kind of like peel back the layers on it. So this guy came in and had a primary right shoulder complaint with a secondary left shoulder complaint and then a bunch of other stuff. And he comes in and says, my shoulder has bothered me on and off over the years, had shoulder surgery on both sides, I think two on the left, the secondary complaint and one on the right, maybe two on the right as well.
Um, but he's like, was throwing football with my son and like the more I threw it, the worse it got. Um, I was swimming for awhile. It started hurting it. So I've kind of stopped swimming. Uh, and I was like, well, how's the day to day goes day to day. It's not that bad. Uh, he's an oral surgeon to some of the positions he gets in. Um, he's like, it might be my neck. He also had a laminectomy in his neck, like three weeks before I saw him the first time. So there's that kind of going on. Um, but he's like, it's sleeping on his horse. Common complaint with shorter stuff. And this guy's, uh, upper fifties, right?
So he's had all the imaging, had all the surgery, he's a physician, which is part of this story. And we go about our business and I'll go through the checklist instead of just giving you my exam. So does he have an injury? No. Does it move? No. So how does it not move? We're talking about his shoulder. Slightly limited inflection, not gross. Like a lot of us, like the top just didn't get there. You lay him down, you're like, it seems like his lat is just kind of really locked up.
internal rotation, like a lot of people that grew up playing baseball and stuff like that. That's the biggest restriction by far. Other than that, everything pretty normal. So does it move above and below? No. Tough thing, the first visit he was three weeks post-op, so I can't get in there and like, hey, let me really joint play your neck. Very limited at that time. He had full flexion, very limited extension. This is active, like top tier rotation was slight limit of both ways. I did lay him down. His rotation was totally fine when I do it.
Beau Beard (11:51.982)
And I didn't take him an extension that day and it's next again, he's three weeks. He had a little paresthesia from the surgery. was like, let's just leave that alone. Um, so can he move it? No, cause his shoulder doesn't move. So it doesn't matter at this point. Um, ish. Yeah. He has better internal rotation on the left. Both are kind of sticky inflection. It's just kind of like a, I'm a hit, say like a normal dude shoulder, like just done that full overhead slightly here. The left's better because he's a right-handed athlete and then everything else is okay.
Extra rotation, okay. Extension, okay. You know what mean? I think that's just like a theme. So can they move it? He can move what he has, but technically no, because he doesn't have full range of motion. So that would be like great glow net loaders, just like, well no, that's because he doesn't have full. And then again, because of that, can he apply said movement specific skills like swimming and throwing? No. So needs-based assessment, pain audit. Here's the interesting thing, none. No positive orthopedic tests, can't reproduce pain at all in the clinic.
He might have had slight weakness on Uregesons, but remember he had paresthesia from a laminectomy three weeks prior. So was like, I can't, I can't put that into there. No pain though either. Right. And it was just like, giving up. And he's like, he's a physician. He's like, I think that's the paresthesia. So was like, yeah, probably. His activity, is it showing up? Sorry to interrupt. Yeah. Is it showing up later? Like later into the session? Well, remember he had stopped swimming.
He had stopped throwing, so like all the things and he really wasn't working out, because he'd even peeled that back. He was like, and more of the story here, he has like a year of sick leave available to him if he's about ready to maybe switch jobs, switch like from a teaching center to a private center. And he's like, I could like get surgery on my shoulder and you know, do whatever and have all the sick leave and have his time off.
And he goes, so that's why I've just like stopped everything. He's like, I want to get this under control because I has a six and a 10 year old and he's a little bit older dad. So he's like, I want to be active with him. So like, he's not having a lot of pain day to day cause he's not doing a lot of surgeries right now. He's not doing workouts. And then that's why he said it's really sleeping. So we didn't really have an in office pain audit, right? Functional audits like glenohumeral internal annotation, glenohumeral reflection. I'm sure there are cervical spine stuff there. I mean, I've seen multiple visits, but after that first visit I was like,
Beau Beard (14:10.594)
I'm just running with that right now, right? And his T spine was stiff and extension, surprise. So diff die, I'm be honest with you. And we told him the stats that we all know, you know, that he, does he have rotator cuff tears? Yeah, like he had, he's had both of them operated on. Have they maybe retorn? There's didn't probably like, you know, the stats two and a half, which is a weird stat for a guy over 55, two and a half full thickness tears.
So I would just say like osteoarthritic change, degenerative change of the shoulder and I put stiffness with a question mark like that's not a diagnosis, but like your shoulder just doesn't move. You try to move it and it hurts. I know if you're like, that's kind of sloppy. Not when you have no positive orthopedic test and no real pain or, you know, generator like, well, that's not showing me that a tendon necessarily is bugged. His labrum feels fine. He's just stiff at end range. So then we could say, okay, that's some sort of capsulitis, whatever, right? Who cares what the diagnosis is called.
So treatment focus for this guy is improve his shoulder range of motion, improve his T-spine motion. And then obviously that goes into motor control. Can he move it? And then specific skills in particular, swimming. Cause that's one of the activities he wants to get back to.
System to matrix, healthy or unhealthy, healthy, is he in pain? Yeah. And I put 90 % MSK, zero peripheral, five centrals, because it's chronic. I mean, he's been dealing with shoulder stuff forever, so he can't not put that in there. In functional medicine, I would give everybody 5%. But we literally already talked about diet. He's like, I'm interested in anti-inflammatory stuff that you've mentioned. I was like, yeah, that might help a little bit, because he's got degenerative change and he's had 15 knee surgeries on one side. Yeah.
So that's gonna help anybody, right? Like nobody's perfect. So it's like, yeah, we could discuss that. So that's the general picture. Now here's more of the background. And if you listen to this case of the week, he came in saying his best friend or a good friend is the guy that's done his shoulder surgeries and basically said, we've done all the surgeries we either can or that we know that we could to help your right shoulder. So you're just looking at a shoulder replacement.
Beau Beard (16:17.078)
He's telling me this before I get hands on and check these, you know, range of motion. So then I go through this exam and I'm like, and I hope everybody, when you're hearing this, you're like, no injury. Does it move? No, it's stiff, but it's not gross. It's not as bad as Ethan's case. Yeah, they can't move well above and know, T-spine and below. Technically, if we're talking shoulder, like he's not having pain day to day except sleeping. It's like, wait, you have a 30 degree loss of internal rotation, maybe a max 15 degree loss of flexion.
bilateral, a stiff T-spine, had neck surgery, so you don't even know where that lies, like how much improvement you might get off that. And I literally looked at him, I go, what? Shoulder replacements are gnarly. And he even knew, go, you know, the success rate on those is pretty low, because like with some shoulder replacements, they ask you like, what range of motion do you want? Because like you might not get all of them. So we have a runner friend that he's like, I need to be able to do this. So they set his shoulder so he could run. He doesn't have abduction beyond here at all.
And he's my age and he had that surgery like six years ago. So imagine that. And they're going to have to replace that joint for him. Probably that's it. So I was like, I was just trying to be as nice as I could and try to make it humorous. was like, what are we doing here? Again, why I brought this case up was he's a, he's a surgeon. He's a, uh, oral facial surgeon. So it's not like he's a lay person. It's not that he's just a physician. He is a surgeon.
He's coming into me saying, I'm about ready to have a, he literally was going to take a year off and just like shoulder replacement, rehab, take the time off, start the new job. And I was like, holy cow. What if he would have done that? I just think that's like the kiss of death for this guy. Maybe he does awesome. Maybe he's the outlier and I don't know what the percentage on that. think it's 30 % success rate. So then I kind of had the little uphill battle. Well, how do you explain to him succinctly that like your good friend who I'm sure he trusts is wrong.
Cause I would say succinctly wrong. not maybe some knee stuff. like, you might be headed towards replacement. Let's see. This one I was like, there is no way. And now he's fully bought in. So we go through that first visit and I'm just going through range of motion stuff. And I just said, Hey, because of his neck surgery and I didn't want to push him too hard to make a shoulder angle. Let's just start working on your T-spine first, right? Off-load gets you moving. Makes sense. Adjusted them. I think we had him do some foam rolling and some like start position stuff. Super easy.
Beau Beard (18:45.326)
And he's very body aware. So he comes back and he goes, I feel like I'm doing it pretty good. was, he's like, I feel that area working. Cool. I'm going to move on. Then we start talking about a shoulder. go, I don't think you need like rehab stuff for your shoulder. think you need to start loading your shoulder because your shoulder seems pretty okay. And he goes, what do you mean? go, do you have a pull bar? goes, yeah, I got a door, like one of those doorway ones. I go, let's just go out here and hang and see how it feels. He hung for like 30 seconds, no pain whatsoever. Not even the pain where people come off.
He's just like, yeah, that's okay. was like, okay. then I, yeah, go ahead. On the T spine, did any of shoulder audience change after working on his T spine? No, like in his shoulder internal rotation, I think it's trophic. I think you're, that's a long road, right? That's why also knowing functional anatomy pays. So what is the end range of overhead flexion, internal rotation, right? Are you going to gain that much? No, but you're going to gain a little.
And do I expect to get full internal rotation on somebody that played baseball, football? No, like there's going to be a deficit. So I want to make sure he has full external on both sides. Gets a little bit better here, but shoulder flexion should be expressed fully, which I think is a lot of tissue for the flexion stuff. So I was like, your battle, right? If you can't completely, you know, wash his left shoulder blade and the shower, we'll be okay with that one. But he also needs to be able to move through internal rotation extension because he wants to swim.
So I told him to go try to swim and he said, I didn't really have pain when I think this was third visit. When I saw him, he goes, I know. Like pain has felt really weak in that, you know, like kind of in that catch position back or pull position back there. I go, well, that could still be neck surgery cause it's still feeling weird. But I go, also it's hard to express strength or power when that's the end of your range motion, right? And drew the little speedometer of like, if you're already at the end, like we're going to try to get a little bit more. So now like you got this, you know, keep explaining all this stuff to him. And literally it came down to last as I go.
Hey, I'm going to show you a crab press, which if you don't know what that is, we were talking about, you know, PE. So remember doing crab walks and PE, just crab press and like extension. go, we could move you into bench dips and dips, but like we got to start someplace. And he didn't get far at all. I his, he's making a V at his hips and his torso. So he goes, I'm so scared of my hips like yours is like, Um, it's like, we want you, you know, three sets of 30 seconds of hanging or, maybe even four, if you can tolerate that, you know, a circuit with our, you know, um,
Beau Beard (21:10.414)
crab press in there and then we can work in, you know, just we showed him kind of a rotary press. So he's not pressing straight up overhead. He's kind of leaning like you're in a getting ready to a windmill, right? And I even had him put his hand on his knee. So he's, he's basically pressing. If you had him in the position like this, he's, if you're watching the video, he's in abduction, inflection, right? Standing and left hand off. He's pressing right left hand on his knees and like a hinge and he's just pressing. So he ends up here, which is very amenable to his shoulder. Cause he's not.
pressing into the end range, we can start working. And he already had what all the scapular kind of thoughts from the start, like the down and out, and he knew all that. So was like, hey, when we're hanging, you can work on some active stuff, like shoulder blades down and out. When you're pressing, shoulder blade down and out, right? When you're crab pressing, shoulder down and out, right? So I'm just honing a motor control thing around scapular thoracic joints, worked on this thoracic area first. General range of motion with loading of a shoulder.
And I think that's as fancy as I'm going to need to get with this guy. And then it's literally I turn into a coach. I don't think I'm a rehab guy. And that's why I told him, I go, I need to get you out of my office as soon as possible. And he was like, yeah, and a weird joke. And he's like, yeah, I agree. But I go with a really strong game plan. And if you aren't going to follow it, like you got to become a gym member because you got to start doing this stuff. And he's all about it. And he wants to start lifting and doing some more active stuff. And, know, so again, multiple things with this case, I think one of the important things is
what he was told versus what we found an exam. So like, don't get misled obviously by like, this guy's a physician, he's telling me his, you know, friend told me he needs shoulder replacement. And then you start being like, ooh, and like what you find, I this one's apparent, but what you find is what you find, right? And make sure you iterate and communicate that correctly. Second thing is,
kind of, you know, Ethan said this like expectations and you you asked us like, well, you know, it change in those audits? Not really. And I don't expect T-spine too, because I think his shoulder is legit stiff, right? My stiffness diagnosis, that's going to take time. And that's why I told him, go, you're, this is a month's journey. That's why you need to get out of here, not rely on me. Cause we're not going to see change in visit usually. And we're not going to see visit or visit, visit change. That's going to be, you know, months.
Beau Beard (23:24.674)
And he was like, yeah, as long as I know I'm getting progress, not getting worse. And I go, I hope through that pain in your shoulder at night gets a little better, but it might get a little worse at first. We'll see. But if you're not having pain doing these activities, we will go with that all day long. And he totally understood. And then we started having fun conversations about like, you know, anti-inflammatory diet and like peptides. I mean, you know, just, and he's bringing this up to me. I was like, yeah, whatever you want to do, but like, let's, let's focus on the basics. Is a peptide going to change your range of motion, your shoulder?
no peptide that I know of, even the Wolverine stack, you still gotta do work, right? Is the autoimmune protocol or anti-inflammatory guy gonna eliminate all of the need to do the work? No, it might make it less painful at night, which is awesome. So I was like, yeah, let's work on that, but make sure we're doing this first, and he's really diligent. So now I've seen him four times this last visit. We're taking a three week break, and I said, just do this stuff, and then yeah, we'll start being more aware of like.
Okay, his flexion changed or those trigger points, your lat changes, your internal rotation, seeing any change, but like how stuff feel, like how swimming, you know? And I reported anything to swimming. He had only swam between the third and fourth, because I just started basic stuff and I go, I need you to go swim, just see what happens. That's what he's like, I swam fine with no pain, it just felt weird. I was like, that doesn't make sense. But I bet that's also the surgery for his neck. So the one thing that was kind of a flyer after the first visit, right? We just did start position and some T-spine foam rolling.
all the cervical extension came back, which he didn't even realize. I was like, dude, are we not impressed? goes, I don't know what you're talking about. But he was at like, know, 45 and he to like maybe 80, maybe not 90, but like it was pretty, yeah. I think like he's had shoulder and a neck issue with a really stiff T-spine there. I don't guess you knew which started first. And we talked about that a little bit. But like how much would that T-spine be affecting how that's limited to cervical spine, which is then limited to shoulder.
Well, and you know, he's in the position that like a lot of our dentists are in and stuff. And that's why he said he goes, dude, this has been coming for years. And I was like, I'm not saying your neck's not part of this, but even I guess at that point when I checked his neck range of motion hands on at four weeks was not bad at all. Right now, could he use some motion there? Sure. And does that, you know, if you have good range of motion, does that negate an injury? Not all the time. Like that's not what we're saying. But I was like, I just don't see Andy had no
Beau Beard (25:49.868)
Neurodynamic signs even after the surgery, right? So I'm like, you know, if that nerve still swollen, which you would assume it would be if they're doing, you know, laminectomy, you'd be like, or no, they did a neuro-feraminectomy. So they just cleaned out the neuro-feramina, which can really irritate nerve, which is you had the paresthesia probably, but no pain. I was like, dude, if you don't have any positive sign there, like, I mean, that's gotta either be a really successful surgery or it wasn't really the culprit. But the reason he had that next surgery was like,
superior angle of a scapula pain that he said it went away after the surgery. Sounds like, okay. We also, in our world, we would know like, okay, maybe that's not always the nerve being irritated. That could be directly the disc, like a cloward sign. So it's also like, we'll see where the cards lay, you know, in another month. And I told him that I was like, dude, we need to get way further from this neck thing to see how much your neck's involved for a lot of reasons. So yeah, that's a flyer.
But we'll also pick that up in swimming and stuff. Like if he's rotary breathing and he starts saying like, turn my head this way or whatever. Yeah. mean, we might even have to, you know, we're working on it. told him like, you you get in this catch position where you start like occluding your shoulder and it's like, that's going to be a no bueno for you. Right. So that's why we're really working on like the scapular activation for him. So you can learn how to pull from a shoulder blade and sort of pull from a shoulder. Cause that'll just, I mean, that's how you get swimmer shoulder, right? In essence. he done any?
like dry land drills for pre-swim where he's basically pulling. cause he's just, getting the pool 119 or something. No, but I told him, go, you might need some techniques stuff. You know, it's like anybody like he got the motion down here, but I go the most common thing in swimming is you're getting here and then you pull from there, right? And just pull through and your shoulders getting ground to pieces. Yeah. He's doing pull up from this position.
So that's why we're just doing a mix and I told him do what he can, but a mix of dead hangs and active hangs now. And I go, if you can get to where you're doing like three by 30 active hang, like, I mean, Rich was taught, Rich Olm was talking about that at DNS strength training. Like he has kind of, I guess, barriers to entry for like athletes doing overhead work on a bar. And like, that's kind of where it was like, dude, that's really good. You're not that far off, you know, three, four visits in with me and you've never done that. So I think that's huge. And I think that was good for him to realize, but he still even last phase like,
Beau Beard (28:11.586)
I just, I hope I don't have to have surgery. are we not like, like, come on. don't know. So it's a cool case cause it seemed he came in like, I'm gonna have, so he has his MRI reports and all this stuff. goes to you and you know, at the end of the first phase he goes, you want to see this? I go, not really. I go, it doesn't go the way I want, sure. We'll look at him because we'd be looking at a re-image cause that was like maybe eight months ago on the right shoulder.
And obviously he had neck imaging and stuff like that, which doesn't matter a whole lot for the post-op stuff to me at that point. Yeah, I'm not saying it's a cut and dry case because I got to see how this guy responds. But I've seen him enough now to be like, okay, think we need to because we always, know, in our assessment, we kind of say you have all these rehab tools, but then it's also should it be rehab? Should it be like directly to load management or is it like skill acquisition stuff and like he's directly in load management land and then a little skill acquisition already?
Like, can you start doing some different stuff on the bar and like how you're swimming maybe? And if you can do that, like God, that's, I mean, that's not rehab land. So I just think that's some people, maybe not, I think would still do rehab on somebody like this. And what I mean by that is spend like six day visits working on their shoulder, doing rehab stuff. I bet you it's just going to take you three times as long because their shoulder probably needs a big challenge because you've kind of ruled out the necessity of doing, you know,
five months shoulder rolling and seven months hinges and all these remedial things. And not that you'd be wrong for that, but I just, again, why did we try to create a system like that? So you can be more effective, more efficient. If I can get there faster and safer, right? Or as safe maybe. I I went in technically and that's for myself. I could have spent eight visits doing rehab stuff. like, probably could just have him like start hanging. I mean, that's kind of like my patient, right?
visit seven, been doing a lot of just like table work and not loading them yet. So like, he might need that because how painful is your shoulder though? I mean, he says it's painful, but he still does like all of his day to day activities. And it's like, he wants to be able to throw the ball with like his nieces and nephews. And he's like, I can do it. It's just not great. Like he knows that it could be better. Yeah. But like he doesn't look like he's like in excruciating pain when I get into that painful point of ranges of motion.
Beau Beard (30:33.454)
If he like, if he throws or something, is he pay for it the next day? Or is it just like a little bit after during or? think if I remember correctly, it was a little bit after. I don't recall ever there being a point of like the next day is worse. That's one thing I always tell patients. know, if you do, whether it's a rehab exercise or you go do something that would like, if we want you to get back to running and it hurts during or a little bit after, but you're normal the next day, like back to normal, like you got to keep going. Yeah.
It's that next day or the couple days after like, Ooh, like I'm worse than I was. It's like, okay. That's telling us something. It's not necessarily like, back off at all costs, but is it how you're doing it? Is it tissue pathologized? Is it a pain response? We're trying to figure out what's going on. We're not being idiots and just push through it. But like if I get this guy and he, so at some point I'd have to make a decision on that piece of advice with some people, right? I'd be like, Hey, if you're worse the next day, like back off. But if this guy starts to do like,
bench dips, he's like, my shoulders kind of talk to me. I'll be like the next day I'll be like, okay, let's just see. Because what? He's not gonna do bench dips every day. It's a workout. So I'll be like, okay, take, you you're not gonna do that for two or three days. Do some hanging, do some, you know, mobilization stuff. When you do it the next time, is it still, you know, the same? It might be sore the next day and it goes away in a couple of days. Cause the shoulder's not perfect. So like we shouldn't expect a perfect response from a non-perfect joint tissue, you know, XYZ.
So I think that's a good expectation thing too is like, we're not looking for completely pain free on people that we expect like trophic change over months. It's gonna, mean, it's a little work, especially AC joint. Those are notorious. mean, I do stuff and it still gets sore. know, mean, years removed from an actual injury. Nobody wants to hear that. That's the reality. know, any questions on that case specifically? And I'll give, I mean, we'll probably have.
At least one more week and review maybe two before I can give a legit update on that guy cuz I want to get pretty far out and I might take videos of him doing some of his stuff and like post them alongside these on social media so you can kind of see what we're talking about Yeah, he'll be a good one. I have a question about just like the internal rotation in general It's not necessarily specific to this case But imagine like he was like an active baseball or football player really we expect there to be a natural bias towards external rotation and the throwing arm
Beau Beard (32:57.07)
Obviously you don't want to take away what they have or like give them too much internal rotation because then they can't control it. Like where is the divide of how much you should be focusing on the internal rotation in an athlete like that versus just like knowing that there's going to be an asymmetry side to side. Just the arc. mean that's what we're taught right is a total arc of you know what 150 to 160. I think the arc is present that's for you.
pay homage to it. Because again, then you're basically taking them beyond the physiologic boundary of their shoulder if you you know, based on what the if the humerus has already created torsion, you know, because I can start as early as age like 910. It's also whatever sport they're going after. like, let's just put this together. I mean, this might be rare. Let's say you had an elite, you know, swimmer that also plays baseball. They start losing this range of motion, then this guy needs to like be back here and
Really be crying you're kind of not pulling all the way through here except it's gnarly on your shoulder But right here and he's like when I do that He has this tendency to put his shoulder in a more optimal position to be an internal rotation, right? Cuz you just like move it. So your relative range of motion is bigger at that point Then we go after it, but then what are we asking them? What's your primary sport? Are you gonna play baseball and call it? Like, know what? mean, you're starting to ask questions of like which one can we hedge bets on? Could you do both? Sure. Is it hard? Yeah
So then we're like, I just want to be able to play baseball for my school team, but I would like to get a college scholarship. So, okay, then I need you to work on this a little bit. And like, if your arm gets sore throwing, like you're done, you just put boundaries on it a little bit. I'm trying to think of other things where it would play in, but that's what you're having to weigh all the time is like goals, right? Like where are we trying to get them versus like, I'm getting it normal. Again, you guys have for me told the story of like Sue Falzoni with the.
She tells the story of the first time she got an MLB job and the first player she worked on basically didn't have terminal extension of their elbow. And then she goes in she's like, I'm gonna get you that. And does give him terminal extension of his elbow. And I think, I don't know what the timeframe was. Couple of days later, that pitcher comes back and goes, whatever you did, undo it. And she's like, why? He goes, I can't hit the strike zone to save my life. So he was an off-speed pitcher that was using all this torque around his wrist and elbow to move the ball around, which had created stiffness, which probably is not good for a healthy elbow.
Beau Beard (35:18.424)
but for the way he pitched, that's what he was using. She gave him the extension, what do you do? Range of motion gave him all this wacky feedback. And she was like, that's where you gotta realize, like, so that's why when I, you we had a pitcher come in not too long ago, speed or off speed, like what's your top pitches? What are the pitches you struggle with? What have you struggled with when your arm hurts? Like you're trying to figure out what are they trying to do with your arm and like what's pissing it off? And then that, like you go back to, okay, now I see how it moves. I see your total body, okay, it makes sense.
So then if I give like our guy didn't have the picture that was in here, terminal elbow extension because of a surgery, didn't have before at a greater loss of degree. And he goes, I really think we should leave my elbow alone. go, I agree. I think it would be bad to like, could you? I think so, right? But I think that might be really, really bad for that guy to like, you know, say, Hey, just take two weeks off, get it back and then go back to pitching because why he's created stiffness as a compensation. If we keep bleeding that out of him, he's going to just completely blow his elbow up.
Yeah, it's not the best thing in the world. But even said he goes, if I could just get three years of pitching, OK, that's your goal. We got a stiff elbow to work with it. So those type of like compensations or oddest, young students or even docs in general may find those are ones you want to leave alone. Yeah, and that's tough because again, so say I get a stiff elbow and a 14 year old pitcher. No bueno. Sit your ass down. Don't play. Let's get your elbow wire. What are you doing throwing wise? What do you lack that's making you do that?
Because I mean, we know what we're gonna run into. We don't know, but we can kind of guess a little bit. So again, it's kind of goal and it's situational awareness, which we talked about again of like, okay, we're in this situation. It's the exact same scenario, different situation. We got a high school freshman, a guy that's in AA that could get, or AAA that could get called anytime, totally different scenario. But that, I bet you that freshman and his parents and his coaches want him to just,
keep going just like the major league and not my office. I mean honestly like that's where yeah. Yeah. Cause again, we've had people do that. Right. Youth athletes that say, I want to keep going. I'm going to do it. Okay. You're out of my care. Like you can go see somebody else. Cause that's, I think that's some people would see them and just believe them along. We'll keep, you know, do an arm care and keep your elbow feeling good. I feel like that's negligent cause you're, you're just now waiting for an injury and
Beau Beard (37:45.356)
You know, some people are like, that's what it's normal in sports. No, it's not. Not for you, Zach. It's normal nowadays. It's common nowadays because of how we run youth sports. It is not normal by the long shot. I I have my own, you know, I'm sure we all do like coaches pushing you too far and the injuries you dealt with because of just like volume or, know, and going back and like, God, what the hell. But that's how it goes running. I mean, huge. Yeah. Anything else in general?
on like just kind of themes around that. I think we touched on some good stuff like the end visit versus visit to visit, you know, expectations, real expectations around what you're finding, right? Like trophic changes versus like neurologic shifts, being confident with what you find and then communicating that. I mean, that's absolutely huge. We talk about that all the time. you know, this, let's say this case, let's say I would hem hawed a little bit. I'm like, let's see how it goes. And I don't take the shoulder replacement off the table.
That's, mean, I think he makes his own decision. That's what we're, he ultimately, he needs to make his own decision. He's a duality physician. Like your health is your health. What we're trying to do is say, this is my opinion. Are you along for the ride? If they're not along for the ride, like your job's real tough. Even if they do see you for care. It's just tough. Cause every time they're asking in their brains, like, don't know, you're trying to get them fully on board. And then if you see any pitfalls, you're trying to get a.
of their questioning of themselves. Being like, hey, it's not going the way I want it. Because he might come in and think his shoulder's doing better and you're like, no, it's not. And if he's not painful and it's not changing, it's a situation again, okay? You can keep working as long as you're feeling okay, but I don't see any changes. So I either need to change, in my opinion, what we're doing, what you're doing, activity wise or X, Y, the diet comes into play, something like that. But I want to see changes if we're talking months.
Cause I either suck at my job, you're lazy or this or the other. But again, being confident in that versus like, what if he came in in three months? He's like, I'm doing awesome. Been throwing the football with my son, having barely any pain at night. His T-spine stiff as bricks. He is back to lack of extension of C-spine and his shoulder's the exact same. I think you are an absolute con artist if you're like, dude, you're doing awesome. But I I bet numerous people would be oh, your pain's better? Cool.
Beau Beard (40:09.966)
And they're like, oh, you're feeling good. And he's going to have no, no positive worth being tested. I mean, I probably did that early in my career. Like, yeah, okay. Yeah, it's not great, but keep going. Chase some pain. Yeah. And not that I would like, but what would I try to do? Other interventions or like really be like, you got to get after that thing and get regressive, you know, and like prove if it's going to get worse or does it actually get better? Cause I think you're just waiting. He's going to throw that football one time and has pain and he's right back. And then he gets angry. He's like, I was doing so good.
No, you weren't. Not based on my criteria. It's like somebody coming in, we can't do this, but that's why we use the very first slide of our assessment as a thermometer. It's like if somebody came in, they're like, I feel awesome, and they had a 101 temperature, and be like, okay. No, you're not. But they may not realize that. You might feel crappy or something, they might not realize that they a fever. Low grade fever, especially kids. I don't know, I feel fine, I'm go school with it. No, you're not. We need to be that succinct with our criteria.
It's hard because it's based on like your hands and your skills, but the better you get, the more it becomes that thermometer. You're like, no, stop. We're doing this. You're a 14 year old. Sit. You keep going. And like that's how you work through it. But it's never, even if we have the thermometer reading, you could still be wrong. it's low grade. Yeah. It's probably a viral infection. Maybe it could still be bacterial. You're not a hundred percent, but you're trying to make the best decision based on information. Cool. Anything else? Negative ghostwriter.
All right. We'll have more PE updates and anything in running world. don't can't remember. The high school state meet. Didn't the Goug out put up a different time or did I say that was a while ago? Same. They're actually in the really a lot of this has been high school because pro is not like college is getting close to nationals, which would be next month, like probably two weeks. High school in Texas, you had.
He had two sprinters, which a lot of the sprints that they were when they did that, you know, when they did nine, nine, two and a win dated 1986 is still pretty impressive. Who is the relay team where the last guy celebrated? four by four. Yeah. They said it was taunting and he had just like put a five up because they won their fifth state championship or something. Yeah. I'm like, bro, come on. It also wasn't a close race. mean, like, yeah, the guy was behind it, but he wasn't going to catch it. That's terrible though. Yeah.
Beau Beard (42:32.95)
Especially for I mean, if you would have looked behind him and like, yeah, yeah. Yeah, it was not. It was also that nine nine two guys.
And then I saw there was a now not wind dated. was a freshman girl run 1101 and her sister is 12 and she's run 11 three.
think I ran 11 three and like eighth grade. This body never run 11 something. was the fastest sprinter on the distance team in college and he ran 11 like three or 11 four. was to say, cause we did like, you know, you do 140 and stuff for football. Cause we had like a speed camp thing and I to say I ran like 11, maybe 11 four or five, my going into freshman year and everybody's like, Oh, cause you know, like
We had pretty fast guys and stuff. So you're like, and I was like, Oh, so I know an eighth grader. Yeah. Well, I guess she could be an eighth or ninth grader and that girl could be a sixth or seventh grader. Yeah. Cool. Whenever you need a confidence kick, just look at what kids are doing now. And local, guess you had a, why do we think all these kids are getting faster? It's the shoes. I'm just kidding. Yeah. That's the water part of it is shoes. I mean, there's that has changed. I don't know, man. I feel like
Sprints of real explosion here in the last two sprints this year big time this year in last year's was last year Yeah, saw Alabama distance running blow up in like 2021. That's really when it started Like Ethan strand in his class And I won't say that times were crazy impressive from this last state meet But you you had so much depth from I remember we talked about it last year, but I was looking
Beau Beard (44:20.846)
I look at these through the lens of like when Seth and I graduated high school, the times that we would have run in the mile, I think we get second to last, right? Like 25th or something for breaking 440 or something like that. Which is wild. And even though the winner wasn't that much faster this year compared to the times that we were, I mean, I think they still ran like 410, which would have been not even happening. That guy also won JT from the Stavia. He won 800 mile, two mile.
and leaned for like 800, I think it was. And then they won the four by eight. Yeah, like super, super impressive stuff from them. Something's happened. Yeah. Which we also had a runner here locally, their carbon plated footwear exploded on their foot. yeah. Someone was telling me about that. Yeah. They ended up, when they sent me the message originally, they said somebody's shoe exploded and they ended up in the ER. And I was like, the stitches were falling. So it wasn't their foot. I was like, God, their foot exploded.
But I have a picture, I'll put it on social media here at some point. Well, I don't know if I have permission to do that. I should ask. But yeah, that shoe exploded. Yeah, and it wasn't old. I I'm assuming the carbon fiber plate just snapped in half and blew out the bottom of it. But yeah, was less than 50 miles, I think. We also forgot to mention Cocodona. Oh, yeah. That was probably the biggest update. Yeah, Sloan was out at Cocodona with our friend Shannon. Sadly, Shannon did not finish.
mile 203.4, I think that's what it was, came out that we'll, can talk about her case. Maybe next time we'll talk about just around that case a little bit. Yeah, it didn't finish, but someone got to, you know, see a lot of cool stuff. There's a YouTube video that Shannon Sloan got caught on for nine minutes. That's out there. We might put that up on the farm at some point. But yeah, Rachel Enshaken who's originally from Birmingham destroyed everybody. Like overall winner.
set the course record by two hours and 40 minutes and change, and then also finished and was like talking like me right now. And I'm like, I would be at the end of my race, that it was Alex, I thought I was gonna die. Even the 20 mile or that I felt good on, I still was like, ooh, okay. How much did she sleep? She took like three or four 10 minute dirt naps. Yeah. And you said she ran. She ran the last up mountain up.
Beau Beard (46:45.934)
Oh God, it starts with an M blinking on the name, it doesn't matter. But it's, mean, that's 10-ish miles from the, you know, to run maybe 15 up and then you come down and then you're down in the city and you're running through Flagstaff. She ran up the whole thing. I mean, it had a good clip too. Yeah. I remember seeing the video and it wasn't up the mountain, but seeing the video. It's wild. Yeah. I she ran the whole thing, the entire race. I mean, it's just, it's insane. I also saw a killing course who got first male and second overall, a full thickness terribles, pronies, longas on his right side.
because he was hobbling the whole time. I don't want to, I mean, he was kind of like, yeah, I'll be back. was like, that's going be a tough one. But yeah, that race was wild. And our friend that didn't finish already put herself in the lottery. So we'll see if she comes back. Cause she was in the ER for Rabdo, which I think everybody would have Rabdo. So if you know who, God, why am I blanking on his name? Jeff Browning.
Um, is ultra honor. He's in his fifties. He studied, he finished in the top 20, I think he was up there. I saw a picture of him finished. He is trim. Like he's lean or leaner than Alex. He had a gut and his legs looked like he was like, you know, needed like 14 blood pressure medications. I mean, this race is gnarly. Um, yeah. So just the water attention, I he gained like 30 pounds gross. he a hundred percent had wrapped up. You're never catching me doing that type of race.
So yeah, I'm trying to think of anything interesting. Our friend was hallucinating and seeing dogs as rocks as dogs and thought her toe exploded and fell off at one point and yeah, some other fun stuff. was one death. There was a death, sadly. They haven't released anything. I know it was a woman. They haven't released anything on like who or what or why. I'm assuming a fall like head trauma or something. I don't know. What happened with the campaigns? Oh yeah. So campaigns at mile 30.
I don't know, 35 ish or something like that. Took a header like, was using trekking poles and fell and said he couldn't catch himself because he the poles and like hit his head. He needed a gash on his head, his campaign. So he just keeps going. He's got blood running down his face. When he ran into another runner that had cut his head and they're kind of joking about it. I think he gets into the aid station, ran fast, like destroyed those next six, seven miles. was pretty wild. You just smash your head. Gets into the aid station. He's like, my, I can't, my right eye is all weird. He was telling his crew and they're like,
Beau Beard (49:13.952)
And James Gideon, his buddy on his podcast was like, Ooh, I don't like that. But he didn't say anything because it's camp. So he's like, so then he gets up and he, as he was running away, he's like, yeah, my eyes still weird. And they like bandaged them and they thought it was the blood inside. he's like, nah. So he said like four or five miles later, he started throwing up and he was like, I think I know he felt woozy, tried to eat and then started throwing up and like was throwing up a lot. Then he was like, my feet weren't
like weren't connected to my body. Like it just kept falling to me. Volst is UCL. Yeah, like collateral ligament off his thumb, ended up in surgery this past week for that. It all banged up, blew his shoulder out and all that stuff. Cause he just kept falling. Cause he was so clumsy and they pulled him a mile. 60 something for concussion protocol TBS stuff.
And I'm not saying it was completely, but if anybody's listened to the shit talkers episode, not this last one before, he was full blown, like wailing, crying. And he even at one point was like, I don't know if this is a head injury. I mean, he was sad about the whole, it went down, but I mean, you can tell something, something's off. He was better this last one, but it was kind of wild to see him in that or hear him, guess, in that light. And even he had two people on there with me. tell they were just like,
It's all good, man. Like it was weird, but mean shit happens. He's a person. So, but he's also, he started running. think the day after if you have a true brain injury, we all know that yeah, aerobic stuff's good, but like high impact, high climbing back up Mount Pisgah, maybe not the case, but campaign. He ran on a broke foot for a year and ended up fine. So he'll be okay. Hopefully. Yeah. He was like, I hope running never gets taken away from me. And like you can tell he was like reconciling. I'm getting a little older.
Cause he's like, I just wanted to run with the pros and that's, was trying to catch him and yeah, it's kind of Yeah. think it's 50, 58 or 56, 58, think. Also, did you see that Sage Canada filed a USADA claim on campaign's first 239 Eugene marathon.
Beau Beard (51:24.238)
Yeah, because they're saying when you go into a US TAF sanctioned race, you sign a waiver saying you would submit to any drug testing, even if you're not a pro, to any race you do that's sanctioned. So then him and Sage have been having a big debate online about him taking TRT and peptides, which he's very, he talks about going to Waze to Well and you know, all this stuff. then Sage was throwing shade at him because he's like, you shouldn't be able to take TRT and then go do that race. He goes, I'm very open about all of this. And he goes, I'm old.
I'm doing this so I can do these races. I'm not winning these races. And he goes, you're basically gaslighting your fans. goes, I tell them that I like had Brigham Bueller on the puck. I see his point. I also can kind of see Sage's like, should he get like tested? What's that mean? It's a non-official time. He doesn't care. Yeah. If he was the record holder for his age, which he's not, they'd be get stripped. The dude in multiple people said he didn't care.
But it's pretty sad that like Sage Canada is going on this crusade and then came called him out. goes, it's Sage's, I think my age now, maybe a little younger. And he goes, it's cause my time was pretty close to his last marathon time. But yeah. So go look that up. If you want some fun, like doom scrolling about Sage Canada being a nerd and what she is, um, great runner, but still a nerd. All right. Uh, as always, if you have a case you would like us to present or that you have questions on, you can always go to
The Farm University, scroll down to the bottom. There is a art of assessment kind of info form just like this. If you have any questions, you can get ahold of us on social media. See ya.
