What Is The Best Strategy When Surgery Is The Only Option?

Full Transcript

Beau Beard (00:00.622)

Well, we're back for episode 46 and Colin who is in shadowing from Logan might have a special intro for us by the time you've heard this you would have known already but we'll see. if I look at this guy I just can't. I don't know, can't take it seriously. over there smirking out with a mustache drinking a cordial of some sort. But what's been going on since episode 45 all the way back in May? Oh boy. Yeah.

Two or three months in the life of Seth Grahame and Alex Collins, a lot that goes down. May? We moved. We moved. On July 4th. I can't remember if I had done my half Ironman before the last episode or not. What day was that? It was May 9th. May 10th. No, you had. Yeah. Just kidding. I don't know if you debriefed. It was pretty miserable. Check the calendar to see exactly when the last one was. I bet it was close to that.

Whatever Mother's Day weekend was. It was that week. Oh no, April 17th. It was our last one. So I did a half Ironman. No, how'd go? Yeah, was pretty miserable. Our swim got canceled, double red flags. The bike was like a time trial start. So two people went every five seconds for bib numbers going from bib one all the way up to I think there was like 1800 people there.

It rained and hailed on the entire bike. The last 15 miles, you went straight into a headwind of 40 miles an hour. Yeah. Then I had to go run after that. Sun came out, three loops. Back half was super hot. Front half was 40 mile an hour winds as well. Half flew off a couple of times. Yeah. Then we got done, thankfully.

And half the field didn't get to finish because they canceled it because the second round of storms came in. I think 1800 started and I believe only like 700 actually got to finish. Yeah. mean, driving. So we drove down to watch him race because we were at the beach anyway. And we stayed in Pensacola drove to PCB that morning. Y'all were, as we drove in, y'all were on the bike. I was like, he's biking in this right now.

Beau Beard (02:22.03)

And as we, it almost was the same timing because I was watching him on the live and we were driving up as the bikers were coming on the course, probably mile 35 ish and just seeing their faces. said, Oh buddy, this is a long day. And then we got out on the course watching them run. I was getting pushed over by the wind standing there. you guys seen Caddyshack? Yeah. The, the scene or the, um, what is it?

Minister is out there trying to play the last round. He's like, I don't think that hard stuff is going to come down for a while. Like leaning into the wind hitting it. The frog comes out of the hole. Yeah. It was pretty good. A lot of considered. I think I got like 50th overall. It isn't terrible. I think it was like eighth or ninth, maybe in my age group. I don't know. We'll take it. And correct. you done another triathlon since then?

No, he retired. Wasn't great for morale. It mentally just destroyed me. Still training. I feel like I'm a pretty mentally strong guy, but that was just like four hours of just like, think of all the weather elements except like snow and like, that's what we went through in four hours. It just was not ideal. Next triathlon he's going to sign up for is Nordic Man. So get the snow element down, you know you got it in bag. I say we should do a Spartan race all on the bike.

like carrying it through the... about it. I don't know. Just think about it. Got a clip in for that one. Yeah. And I guess we should introduce Trent McKeown over here. So he's our intern for the next, what do got? Two more months of the year, something like that. From, where are from? Palmer. Originally from Ohio. Logan. And this is also Colin Sargent. So his dad, Tim practices in Huntsville, which if you're not familiar with Alabama, is about two hours north of us. And I've known Tim, I don't know.

Seven eight years now. He's been to our clinic for a couple continuing ed things and are you going to practice with your dad? Do you know is that a bad question asked right now? Yeah up in the air. We'll just leave that one for that. Um Yeah, and you're in your last trimester, right? And then Trent's gonna go back to Ohio and work with Derek Ressler Yeah, and I've known Derek for quite a while too great guy and The mustachioed man. Everybody knows Alex. That's just telling about triathlon. I'm not gonna introduce myself

Beau Beard (04:40.814)

Any more updates? We'll have Troy probably on the next episode. Troy Briscoe coming in from Parker. He'll be here Tuesday of next week because Monday's Labor Day. And yeah, so we'll have another podcast for the next season. Oh yeah, this season. So we're going to do 10 episodes of the Week in Review starting with this one, this episode 46. So I 10 episodes every other week and then we're going to have farm cast episodes with interviews on the off weeks of Week in Review.

We got the first few interviews already set up. So we have Kyla Brown coming on. We have Courtney Conley coming on. She has new book coming out here pretty soon. And then a couple other people are working on. So yeah. And if you have any requests, drop a comment. Make sure it's along with a five star review. If it's not, I'm not going to take your comment. So that's how it goes. Yeah. Anything else? Let's get rolling. So we don't have a...

specific case today, what we do, we have two cases that I just thought were pertinent to discuss in terms of both the clinical side and then also just some general knowledge on approaches to surgery, both before, during, and after, even though none of us, don't, are you guys surgeons? No, didn't take that board exam. I did surgery on Seth's eye on a run one time. How'd that go? I got the bug out. I tried to give somebody stitches on a school bus at like 3 a.m. Didn't go awesome.

We'll just leave that for another time. That's one other story. So two different patients. So one is a now 52 year old, really competitive Highlands game athlete. So behemoth of a man. And I think I said behemoth of a man, which is actually correct. Huge guy Highlands game. So Highlands game is from what I understand, two different shot puts. So it's two different weight rocks or stones. The sheaf toss, which is basically

a balestrawl with a pitchfork, the caber toss, which is a telephone pole toss, hammer throw, but it's a rock, and keg toss over a bar backwards. I think that's all. So this guy is going to compete in Worlds 2026. So last year he got invited to Nationals and does some local competitions and we started working on a shoulder.

Beau Beard (06:57.87)

And if I back up a couple months prior to me working on a shoulder, had an SC joint separation from one of the events. And that can always preclude some bigger shoulder pathology. But anyways, we started working on a shoulder and about five, six visits in, I'm like, Hey, I don't think you need surgery, but we need to have an MRI and a, know, at least an MRI. If you want to do an MRI and an ortho consult, I don't think that's unwarranted. Sent him to our conservative, um, orthopedic that we like to work with locally here.

And he actually recommended surgery for what I knew he had going on, which is slap tear and just some other degenerative change in his shoulder. So he goes in for surgery. So we'll leave that one on the table. Our other guy, opposite shoulder. So that was the right shoulder injury. This is left shoulder injury. This guy owns a Taekwondo studio. So extremely physical, has to show people how to do different things. We're working on his shoulder for a while. In my opinion, his shoulder was really good. Like functionally, it was good. He had pain with lot of things, but like he didn't have any weakness. He wasn't...

There were very few things he wasn't able to do except lateral raises, which I tried to say, just not do this for a while, but kept going. So then same thing, he got about maybe six, seven visits in and he wanted an image. And I was like, yeah, cause he's worried that, you know, if something gets too bad, he won't be able to do his job, which I can appreciate. So I send him for an ortho consult cause we brought that up and he goes, I think I'd rather do that. And he, I think more or less said he wanted surgery when in the office.

And again, slap tear and some milder gender change. So both these people have basically the same surgery. And when I send them off, I'm not looking to like babysit these people. We don't do direct post-op PT in here. And we'll talk about what we do like to do. But here's how this went with both these people. Same surgeon, unbeknownst to our team, both of them are given four weeks of basically at home.

post-op PT via an app, right? So, hey, this is what you do, it steps up. Both of these guys are motivated, so they both did what they're supposed to do, and the Taekwondo guy probably went above and beyond just trying to, he's like, eh, stuff seemed too easy, I was doing a little bit more. So then at four weeks post-op, they both show up to the physical therapy office, that's two doors down from us, where they're doing post-op PT. So this is the first, I wanna kinda talk about these cases, and then, well, what can we take away from a clinical side, and then also,

Beau Beard (09:22.487)

a patient side.

So from a clinical side, it's did either one of these guys really need surgery? So, and again, I want you guys to weigh in on this. I think the thrower, the Highlands game guy, probably did. I think it would have been hard to keep going. The crazy thing was with him, the week before we sent him in for the ortho consult, he threw a PR. So it's like, you can operate around pathology. So that's a good clinical note to realize like function can remain high even though you're tearing stuff apart. There's a lot of aspects of that. The other guy, I didn't think he needed surgery at all. I was just trying to like...

he needed some like, you know, peace of mind and ended up in that surgical route. So is there anything that you guys kind of have a checklist or that is like a red flag ever like, ooh, this is absolutely surgery or, you know, if somebody comes at you like, hey, I think I need surgery and then you can like kind of talk them out of it based on some criteria evidence, anything that comes to mind. I was gonna ask you with the first guy.

Did he, the high ones game guy. Yeah. Maybe you already said it. Did he, whenever he was doing, when you did orthos on him, did he buckle? Did he have weakness with all those? So you would have no, no, no weakness. But also if you look at these guys shoulders, they're like his biggest sess head. So we can bulletproof around pathology with muscle and that's going to be hard to know, well, is he going to fail now? I mean, he had a, you know, I don't know.

Basically half of his labrum was torn off the posterior aspect of his glenoid fossa from a slap tear when he threw a PR. So he can just manhandle that stuff. When we talk about his post-op, I think that's part of what's made his post-op PT a little tough for him. That's just a little bit different, but yeah, no buckling. The other guy that I didn't think he needed surgery, again, maybe mild weakness, but due to pain, he just didn't like doing, know, like resisted external rotation at 90, empty can, but.

Beau Beard (11:14.51)

He was one of those cases that I talk about where the taekwondo patient, all of the orthos were slightly painful. So it's not indicative of like us to sync pathology. What became clear was the position he hangs his shoulder in the things that were painful and some, you know, some of the positive or P test, Oh, you definitely have a slap tear. Like we just know now, do you need surgery? Probably not. Like you, we should rehab around that. In my opinion, he just, I think he just got gunshot. Like I don't want to not be able to use my shoulder, which lo and behold,

PT took way too long and you know, he still is not at a hundred percent for how far out is he now? 18, 19 weeks or something like that. So pretty far out. It makes me, I was thinking of a patient that I have who plays, she's a semi-pro pickleball player. and she had already had a rotator cuff surgery when she first started seeing me, I think maybe second trial of care. came again during her, during her season.

and we ended up, she wasn't going to have surgery during the season. wanted to just keep playing. then knowing that she was probably going to have surgery at the end of the season, which I did send her out for it because for some of the ortho tests that I was talking about, she had weakness, and pain, but it was the same in all positions. Like whether she was seated, same with supine, like she would still buckle. So sometimes if I see a difference in those same tests where they can't resist seated, but then they go supine, that's fine.

they get more stability from the table and then, okay, the likelihood of that, the integrity of the structures in their shoulders is there, they just can't control it as much when they have sitting or standing. And she had a good outcome with that surgery. yeah. Yeah. I think for me, some of my criteria is how much is their everyday life getting affected? I think that was like the Taekwondo guy. His, his tipping point was I can't do a lot of things just because of pain.

And then he goes, like, I'm not throwing punches, I'm not demoing stuff. And I think that's where he's like, I don't like that. And he's like, what do I gotta do about it? So I'll have that one as like, I guess it's like my number three-ish. weakness and pain is another one. And then if I've changed, like at least the audits that I'm like going after, and those have gotten better, but their everyday life and or pain level has not changed.

Beau Beard (13:41.432)

I'm like, probably need to look at something underlying here. Cause like you can change stuff in office, but that protective pattern just comes right back just over and over and over again. They have to weigh the option of like, the patient like actually doing stuff outside of here, but it's still the same change. Like the patient base listening to this, like what's that saying with an audit? like if we're saying, you know, how your neck moves or how your shoulder moves or like muscle, like tension or trigger point like goes away or gets better, but you're still having all this pain and can't do things like that's showing like.

or improving function around or at the area of complaint and you're still having the same amount of pain and dysfunction locally. And it's like, like that doesn't make sense. Like that's indicating more of a patho anatomical, like a legit injury. And then what Alex was saying for those that may not have caught it, like if you were, if you're in a orthopedics office or somebody's office and they're doing, you know, you're sitting on the table and they're going through all these resistive range motions and all these things. And then you lay down your shoulder blade is on the table. So it's like,

you know, now it's like somebody holding me and they're testing my balance. Like it's going to be better. Now the table's holding my shoulder blade. You might be like, Oh, that stuff's way better, which could indicate, Oh, it's not a pathology. It's how you're using your shoulder. You know, how are we define that? You know, is kind of a little bit more nuanced. Sometimes the weakness sometimes is like tough to like suss out and people just because like some people are just like super strong like that guy. Other times it's like they've already created set by the time they hit us. I feel like they've already created a good compensation tour. Like when they like

do resisted ranges that's supposed to be testing certain muscles. They've already compensated with another one and they're just like, yeah, that hurts to do. But yet it's like, if I'm going for super spinae, right? Like they're just going to get super like trap heavy, right? So you almost take that muscle completely out and it's like, that's it. This lady was a little different too, because unlike these two guys, her shoulder strength was not nearly the same as what theirs was. So her ability to compensate and use other muscle groups to stay was a shoulder was not going to be nearly, which now we work.

we're working on strength, but I think I could have done that then because she had, I mean, she had partial and full thickness tears of all four rotator cuff muscles. And I think there's two notes here. We always talk about most orthopedic tests where the orthopedic tests are actually worth a damn are testing like integrity of a tissue or a complex. So if you think of classic knee ones like ACL, like you'll have a, an appreciable amount of movement on like an a drawer test, right? So if I,

Beau Beard (16:02.104)

do like a laboral shear test or something like, it's not just a pain. It's like, do you actually feel like they can't do it? Because remember the five out of five on like muscle testing is not like, can they hold it for 10 seconds to the initial response? Like everybody, like I'm can win against anybody if I just hang on them for a little bit. It's that initial, like, can they, and then if they give up, that could just be pain growing or it could be even central, you know, not even anything local causing pain. So it's also not like I'm going to hang off you for three seconds. Like, you buckled. It's like, no.

Initial like half second like press. you did fine. Cool. Yeah hers was I mean I put two fingers right so that's yeah, and that's well if I'm looking for integrity is I will change the fulcrum So instead of being way far out I'll move closer and be like can they still hold it if they can't I'm like yeah There's something wrong with that tissue there. Absolutely. So Last piece on the orthopedic tests. We all learn the names of these tests I forget them but we learned the names in school the names and the positions don't matter and I've even seen like

Bill Tortorillo and Robert Lardner, like if they're doing shoulder or peak tests, like multiple angles of the same test, trying to denote, that like a certain part of subscapularis and things, which I think you'd probably get too nuanced and maybe get lost in the weeds, but also understanding what am I actually testing? Not just what's the name of it and how do I do the test? Like, okay, what is that? Purely infraspinatus or are there other things that could help it and also be aware that like that's not in ice, nothing's in isolation. It's just a, it's your best guess.

So for the patients, takeaways, how do know you might need surgery? You literally can't do something like an inability to, whether that's due to extreme pain that changes quality of life or inability to do it, or in particular, if you didn't have pain, like a re-buckling. So if we have somebody's knee that's buckling out from underneath them, you go to reach for something, it's dropping. Now, is that in your shoulders, is in your neck? That's maybe where you need a workup. And then the other thing, like Seth said, it's just like, are you over it? So we'll ask people sometimes like,

hey, I know this can be rehabbed out. Maybe the timeline's much further out due to their just overall health status, their inability to stop doing something that's kind of picking the scab. And then you have to have a conversation with like, do you just want to have surgery and get this thing done and then do post-op PT because the dirty little secret, which I should have pulled up this research, most, if you look at a lot of the research on surgeries and then surgeries with the post-op rehab program,

Beau Beard (18:23.95)

Post-op rehab program standalone without surgery kind of outperforms. So then we have to ask, well, is it just the post-op rehab, right? Eight to 12 weeks of dedicated care. And then we see most surgical sides end up being better than the non-surgical side. So whether it's a knee, a shoulder, an elbow, hip, you know, like, should we have just done pre-hab and seen what happened? Which I'll hit on that point real quick. So I looked up, I'm gonna see if I can get this podcast sponsored by Consensus. So this is sponsored by Consensus.

But I just typed in, so consensus if you're not aware is an AI aggregate of, I don't know, 200 plus million peer-reviewed articles and it just basically says like, hey, this is what all these articles say about your yes or no question. So I said, does improving general fitness improve post-surgical outcomes? This has very quick like 18, 18-ish articles that it looked at. 56 % yes. Most of us would say, oh yeah, that makes sense.

Now, I think also this is just general exercise. If we did specific prehab of like a shoulder or something, you're going to have way better outcomes. Where I think we, or I do a lot of this is like, know somebody's going to go in for a joint replacement because that's just one of those scenarios where like, I'm not really working on an injury. It's like, you're in a bad spot and like, let's strengthen stuff up and do as much as we came before we go in there. just like your recovery is better, but also like the things around that joint work better.

And then one note on that is you don't always have to just work the bad side. like generally working the opposite side and getting stronger overall has a neurologic effect, which is called the crossover effect. But there are studies too that if I'm going to have a right knee surgery, right knee replacement, and I can't do a lot because there's so much pain or dysfunction, working just the opposite side gives me almost the same benefit. Like you lose about 10%, which is kind of crazy. All right. Yeah. There's still local stuff to do, but that's what you're going to do. Post-op PT's get that range of motion and strength back.

So that's one thing we do like to be involved in is what could you do before you go into that surgery for maybe four six weeks before to make it the best possible outcome? Because what we don't want is a failed surgery or just your overall fitness or health is the detriment to you. So then, yeah, so that both of these patients started with an at home app.

Beau Beard (20:43.522)

They were motivated. I don't think that's the best idea ever. For a lot of reasons. These guys are the proof of why this is not a good idea. They did the entire four weeks at home. Guess what they're not gonna be able to do? So like mobilize their shoulder like a physical therapist or whoever it is, chiropractor, physio, ATC, I don't care who you are. Soft tissue, some of the edema relief things. Yeah, you can put ice and heat on it. Both of these people came out of that four week window.

like so far behind where they should be. So neither one of them had external rotation, one had overhead flexion, neither one had internal rotation and both still had pain. So then we talked to the PT and she's like, what is going on? It's like, you know, they did their work. I just don't think it's enough, right? Or it's not specific enough maybe. So then it's literally four weeks out, like they're starting at week zero, which I mean, makes perfect sense with our guy that's like 18 weeks out. So if he was supposed to be released at 12, well, he's basically released now at 18, 19, like.

mild pain hanging from a bar and stuff like that. So if you're a patient out there or PT or whoever, you know, conservative MSK specialist, and we think that somebody is going to be as good as you are by themselves at home, maybe that's just not the case. So whether these people are getting paid for what's called remote therapeutic monitoring, where you just check the exercise and get paid money, or they are just giving it to them because they think it's easier or they think it's saving them money.

Maybe they think they're doing something good for these patients. That's what I assume. I don't think it is. So if you've been given that as a patient, I would be like, no, I'm going to opt for just the post-op PT. here's the kicker. We always tell our patients, hey, they're probably going to sign you up depending on what the surgery is. So let's say you have a slap tear repair and you're a 35-year-old guy and that's all they had to do. You should be released in about eight to 10 weeks from post-op PT. So I always tell them, hey, about week six, we want to see in our office, just take a look at like,

how are things moving, but then how are the things around that area starting to function or not, you know, dysfunction. So we can start helping this along because that's kind of what gets lost on these cases is we get range motion back locally, we get strength locally, and then maybe the thing that led us to that injury or things that happened since that injury are not great. And then we get right back into the same scenario when we get released to, you know, baseball crossfit or whatever running. So that would be a huge deal for me is if you have somebody that's

Beau Beard (23:09.932)

And no knock on like a post-op traditional post-op PT or outpatient PT. That's not what I'm saying. Sometimes the things that got us there aren't worked on. We just work on the pathology, which I think is pretty myopic. So always have somebody in your corner in a team approach. You need the post-op stuff. I don't want to do that. I don't think anyone's going to do pendulums and soft tissue and put you in a game ready. I don't want to, but we're trying to make sure you don't get back there and you're actually better than you were. Any comments on that in terms of like,

trying to think, there's no specific what we're doing. We're just coming in. If somebody had shoulder surgery, hey, what's PT saying you're at, like progression wise? Are you on track? Are you behind? Are you ahead? When are you supposed to be released? Check in with me maybe every two weeks until you're released, then I'm gonna see you three or four times and hopefully you're, we're good, right? So we always say we're just kind of cleaning up the ends there. And on that same vein, one thing that tends to happen in post-op PT is sometimes it's not.

challenging enough. So we call it kind of like you're undercapacitized. You're in like rehab purgatory is you got out, you were cleared and maybe it's not movement dysfunction or something that was leading to it. You're just not ready. And you get thrown back into the gauntlet thinking, I was cleared, right? My return to play criteria was maybe not as hard as it should have been, or there was no RTP because I'm an adult and doesn't play a sport. And they're like, you're good. And you go back out and start running or gardening and you're like, God, yeah.

doing something that are like, ooh, we didn't test them hard enough to say, you were good to go for that. Hence again, it could be a strength and conditioning coach, somebody like us, like somebody that can test you above, hopefully test you above the capacity at which you're going to operate all the time so you don't run back into an issue. think that's a huge deal because we see people just get back out and they couldn't even do what they did before. Outside of that, if you do have a surgery or you know you're looking at a surgery,

I would say one of the most important things we talked about pre-hab would just be like, take a honest assessment of how healthy are you? So if you've got 20 plus LBs and you're crushing alcohol a few nights a week and your diet's not awesome, it would probably behoove you to just clean that up rather than do pre-hab with somebody or any of that stuff we just talked about or just be an organism that can adapt to something, like another trauma, like a scalpel through your labrum.

Beau Beard (25:33.976)

better than somebody that's gonna be inflamed and not have all those healing pathways kind of as optimized as it could be. But also that's gonna benefit you anyways. And that's when we come in or patients come in here, we're always trying to A, address the biggest thing. So if you came into us for prehab, I think if we saw somebody that like, you move pretty good, but you know, like the Twinkies and the, know, Cap'n Crunch and the Sweet Teas, like that's probably like chill for a while, if not forever, especially right now, cause that's not gonna be the best thing for you.

But that's what we're trying to do, even if you don't want to hear it, like what is the biggest thing you should work on, regardless of what you came to us for. And if we're not the person that should be given that advice, we'll try to refer you to that person. Any input on that? It's like you have a case right now where you're like, I think this is primarily functional medicine. I don't think that patient thinks that, which can always be a tough combo. know? Which one is that one? I got a lot. feel like that. We're in Alabama. So yeah, there is. And that's probably everybody's practice nowadays.

You were telling me about somebody the other day. I think it was shorter the frozen shoulder. Yeah. Yeah. Yeah. Yeah He's on like some cholesterol stuff. It's had it on both sides before yeah, there's some bits and pieces there for sure, especially on a guy frozen shoulders for for men are typically not like a Not common at all especially not bilateral one he had like just after like four weeks after having a

Labral surgery that was like 10 years ago. This one just popped up. He has a, he has a labral tear in his shoulder. He knows that. And then it was just like two months ago, woke up and couldn't move his shoulder, but he's been on a cholesterol medication for the past like 10 years as well. he doesn't really know what is like a one C, glucose and all that is for like diabetic reasons, but he says he's not diabetic. yeah. Yeah. We all are probably almost says, he hasn't checked. Yeah.

But also a lot of times they can be like, yeah, you're fine. they're like riding that fine line. Yeah. My mom. vitamin D is like, yeah, you're good if you're like five and you're like, they're at seven and you're like, I'd like to like 60. I've seen numerous people, know, the cutoff is like 30 and they'll be at 29. And someone's like, oh, you're pretty close to the normal levels. It's like you're on the lower end of the normal level and you're actually in the pathologic range. You don't need that stuff. That fluctuates. Hormone receptor sensitivity doesn't matter, especially if you're a middle-aged female.

Beau Beard (27:57.518)

so let's go back to these two specific cases. So like I said, both of them come in to post-op PT four weeks after not in great shape or the PT is like, dude, I'm starting over. And that means they're going to probably have to be more aggressive, which is more uncomfortable for the patient. The patients are both active and wanting to get back to us. And now they're frustrated and certain mass questions and it just takes a longer amount of time. So by the time, and then this is just.

you hate to this is way the medical system works. If you're in an insurance model, those PTs run out of visits, Where at least paid visits via insurance, right? So if you get, you know, I don't know, 25 visits with a PT and you needed more because your shoulder socks, I mean, you're either paying out of pocket, which can be a hefty amount for some people, or they're just like, Hey, this is all we can do for you, which we hear all the time. You know, like you get released. So in that scenario, you know,

Well, what do you do if you know something's not right or you're not able to do a sport or activity you want to do? Again, that's where it could be the same person. You just got to fork out money or it's like, I'm going to go to somebody that's like looking at all things instead of just the area that was injured because sometimes it's not you need to work on the tissue or we need to do more, you know, ice or heat. It's like how you're using those things and how you're protecting those things is actually what's limiting range of motion, creating pain. Welcome to both these guys.

So they both were getting a lot of like myofascial work and mobilizations and it improved stuff. Like they got better, but then both of them are at these ranges. They're like, I can't get any further. I don't know why. So let's take the Highlands game guy. severe limitation. So if you're watching the video, you kind of see what I'm looking at or doing here. When he goes in extra rotation, he's like, this guy with like, you know, cannonballs for shoulders and, but here's the kicker. He's already out there throwing.

is going to compete here in a couple of weeks and he's set a PR like two weeks after I started seeing him. like he's able to do stuff, but he can't, has zero internal rotation actively. Maybe 40 degrees external inflection is like here. So I think, and I've told him you doing that stuff is creating the problem. Your shoulders having to put a parking brake on every time you just, you know, have this like high velocity, you know, fast activity. He's not going to stop. then I have to kind of be okay with that because it's his shoulder.

Beau Beard (30:14.968)

say, okay, that's just more treatment, right? It takes more time. But what I said earlier was part of that like gigantic muscular overlay of his like deltoid and tricep is the thing that's also like hindering him because we have to deal with like all these giant muscles that can just lock down. And like I've went in and needles hit his nifraspinatus and also he's like, but then like he comes back in the next time it's exact same. So we know that it's like this neurologic holding pattern. Well, if that persists for too long, you will get into legitimate like frozen shoulder.

The capsule needs to move, otherwise that capsule will have trophic change and that's not going to be fun. I've told him that, he's aware and then he leaves smiling and smirking and I'm going go do my thing, which is fine. We've addressed it. But what do you do in those scenarios? mean, that's a surgery, sometimes manipulation under anesthesia or heavy-handed internal soft tissue stuff. But that's what he's doing. Now the other guy, same thing.

His lat was locking him down. He was having pain in the front of his shoulder. We started working around that and he's, I'd say, I think you saw him with me last time, 99 % their own range of motion just has a little bit of pain at end ranges and like doesn't feel completely comfortable hanging. So where he was at six weeks ago, right? Barely any external rotation, not full range of flexion. It's like when it's not tissue, it's a different approach.

So if you went through PT and you're still locked down, the chance of it being like, oh, they didn't stretch my capsule enough is probably rare. So just realize, like, if you go back to somebody, they're like, we need to do more like mobilizations and stretches. I'm not saying that's the case, but the likelihood is probably a little bit low if you just did 12 weeks of that and you're still stuck. Okay. So on a patient base, I hope that you take something away from that. Now, one thing that gets used a lot in post-op PT and even in here is like passive modalities, which we've mentioned a couple of times.

Ice, heat, game readies, ultrasound, depending on what decade you're stuck in. I don't know, what's your guys take on passive stuff for like post-op? Like all that stuff that we mentioned, eStim, any of that. When you see game readies, I'm not opposed to like icing something. know icing's got this like bad rap or whatever. If you're four weeks into...

Beau Beard (32:33.378)

like PT and your shoulder hurts after a PT session, like I don't care what you do to make it feel better. To say that's gonna blunt the healing process, like, okay, whatever. Because what are they gonna do, move more? Like you just worked me for an hour and now you want me to move more because it's movement medicine and I can't like lay here with like a passive modality, like I think that's kind of crappy. Now 12 weeks out, if you're still using that stuff for your main pain relieving, I think that's where the problem lies, thinking you need those things at that point. If you count dry kneeling as a passive modality.

Yeah, I mean that's a I would say that's a big neurologic input too though if I'm doing that on our Highlands game guy I don't think I'm making a huge dent and like the muscle from a trophic tissue change I'm like Let's break that holding pattern use that temporary blip and then like rehab around her to work with it. I was gonna ask you about him when After you needle his shoulder and he has a lot more shoulder and turn and the time we did that I just staccatoed it which was like killing him. Yeah, so then

In addition to that, were you able to find anything that he did at home after? Because I'm sure you've sent him something home as far as soft tissue to do, but then like an actual exercise that he was able to do that. Yeah, so we, and I kind of stole this from Austin Einhorn, so shout out to him, but he's big on, especially like when he's working with like his high level collegiate MLB pitchers of this idea. If you're not familiar with Austin, go look up his Instagram. He's a great guy, evolved coaching, but talking about how, you know,

The great apes of evolution were like the only basically mammal that had a rotator cuff. So what that rotator cuff does for us, we all kind of know that like helps depress your humoral head and the glenoid fossa. But to like make that work, you kind of have to be able to hang off stuff. Like that's the biggest component to that. And he goes, a lot of people just in general can't do that anymore, right? Just strength, whatever it is. So he goes like, if I'm a baseball player or a thrower, so we got this Highlands game guy.

They should not be able to hang. They should be able to hang off one arm, maybe create like, you know, independent rotation. So we got this thrower doing like 90 degrees, not completely off weighted. he's on a box, heavy isometrics, then working in different angles, working towards a hang that would, I mean, he got off the bar the first day in here and literally went like full external rotation. Now that doesn't last very long, but that shows you right there. That's another diagnostic thing. What? That can't be tissue change. I mean, you literally blew through it.

Beau Beard (34:59.246)

But then he came back and he's like, dude, that is still really hard. My shoulder feels sore. Like internally can mean two things. Maybe you did have some like stiffening with the whole, know, how long PT took or how he's using his shoulder when he does the hanging is probably not awesome. It's like, Hey, let's just go down on the floor and like get a ring or a strap at 90 and start working out without that heavy load. And that's better for him right now. It's cause he's not me. He's huge. He's also waste 250. Yeah. So it's a lot of weight. Same thing with the Taekwondo guy.

He had much better range of motion. So I was like, you just need to start hanging, general hanging, right? Inside of a shoulder, doesn't like it. He is stiff. He's in this anterior shoulder position, stiff T-spine. was like, let's take you down on the floor. And he's like, oh my God, that feels so much better after doing that. And like went beyond, you know, perpendicular 90 degrees. He'll have to get to, you know, he was doing the offloaded weight or pull-up machine, right? Where can like put 80 pounds on it or whatever.

It's like just do some isometric stuff for the next week or two and then like use hanging as a litmus test after you do that. Like try to hang double hand just for 20 seconds to see if your shoulder still aches like that. Cause I think he can do it. I don't think he's getting hurt, but it goes back into the function thing of he sucked at that before. Like he had shoulder pain, bilateral flexion was limited due to his T-spine. It's like, okay, maybe his shoulders post-op and it's not perfect. And he's like running right back into a dysfunction or a compensation thing. So I just don't want to push him back into that too much.

What kind of work or rest are you having them deal with those isos? Just the kind of Keith Barr stuff. Not from, obviously it's not tendon, but just I think there's a lot of neurologic stuff to that. So I don't go 40 seconds rest. So I was doing 10 seconds on because we're doing 100 % isometrics. I mean, if I do any more, mean, there, I mean, our throwers literally like purple and shaking, like, you know, who's that ultimate warrior on the ropes for he going for WWF, but 10 seconds on 20 seconds off. Cause like neurologic recovery is fast.

Now, the further we get out and they get into hanging, I mean, I want to go into actual like duration things. So it's like, if we're doing an eccentric, we might be like, dude, can you do that for five to seven seconds and you get a 20 second break? And then if you're going to hang, can you hang for 30, 40 seconds? All right. Or can you switch from left hand to right hand, single arm for six reps? Yeah. I just, I think about that 90 degree, I mean, that's a lock off. Like when we were climbing a lot, that was still really hard to do. Yeah.

Beau Beard (37:25.09)

and we're not big people. So I wish having the alternative would be able to pull. And we'll do alternating grip on the pull-up bar. So they're like doing pull-ups or holds with the other hand. And that's what I had both of them doing slightly offloaded and they can both do it, but they're both like, yeah, it's kind of tough. And then we'll have them do like rotational pull-ups through there and just working their shoulders differently than they did because we don't want to just get them back to where they were. especially the Taekwondo guy, he never had an injury and he's not throwing rocks around.

Yeah. And it's this non-dominant hand. It's how he throws punches, how he blocks, how he does lateral flies, how he does a red press. That's what slowly created a slap tear and a non-throwing arm. So in that scenario, I'm like, well, this isn't good. you know, let's work in both shoulders. Been painful in the past. So the likelihood of the same thing on the right is probably higher than the left. You just didn't have surgery on that one. So that's why I didn't think he needed surgery. Both have been a problem. Yeah. Yeah. Whereas the other guy had the SC joint. But I think the key like,

Again, talking about Austin Einhorn and kind of some of the stuff he does, like he's just saying, if you're going to throw, I don't know what the velocity of your arm is. We know what the velocity of a baseball is from this like false external rotation position, right? Cause you lead your body forward. get further than you can actively. There's just a ton of force going through the glenohumeral joint. And then to think like, we're going to do crossover symmetry and some stuff. And that's going to be like arm care. He's like, no, like go way above the capacity. And not only does that

protect the shoulder, but it also like improve your performance. And that gets back into that rehab purgatory. Like where did you get left in your post-op PT or rehab? You know, we could go all the way, you know, running and somebody had an Achilles repair and you're like, you got released. It's like, can you do stuff that's harder than you were doing before? So we don't run back into an issue where that's just pain or a rupture or something like that. Cause I think of local guy, all know around here that's a stud runner and cyclists that had haggling's deformity surgery. And then

A year later is on a mountain bike and almost goes ass over teakettle and sets the bike back down and feels a big snap and thinks he broke the crank on his bike and it wasn't his crank, it was Achilles. It's like, should your Achilles snap in that scenario? Probably not. But like, was there some stuff that could have been done to prevent that? think so. That sucks, but yeah. That makes me want to lose my lunch. I saw a guy go- Achilles rolling up.

Beau Beard (39:49.006)

I saw like a 65 year old guy. We've been watching a lot of American Ninja Warrior because Maddox is into it and he was going up the warp wall and you just see his foot stay flat and his leg goes out and he just goes, and he looks at his daughter or whatever and he's like, and he's like, can tell he's freaking out, but like the action of his, like it looked like his toes touched the front of his shin. That's gross. Yeah, I worry about that, but that's why.

Uh, lot of our people were like, you can't stop jumping. Like that's that old Russian saying when you stop jumping, you start dying. Like you stop losing those springs, then you want to go, um, sprint with your kid at soccer. I don't know. That's, that's, mean, most common injury or acute injury in men over 40 is like pick up basketball, Achilles ruptures. Yeah, I can do that. Get going. Yeah. I don't want that to keep springing, keep jumping, all that stuff.

Trying to think of anything else specifically on these guys. So both are back at doing everything that they were prior, just not perfectly. And again, should our Highlands game guy be doing what he's doing right now? In my opinion, no, but he's doing it anyways. So it just makes it tougher for me to be honest with you. Is he still working out or is he just doing implement stuff? Oh yeah, yeah. And again, he's overhead stuff. So here's another key with him. Yeah, it's a good point.

probably a week after I saw him, would have been about five weeks ago, if he was loaded, he would have full range of motion. So this is a guy like, if you're watching me, like he goes to lift his arm. If you give him a kettlebell. So why? Because his rotator cuff has to literally depress his humerus when he's not loaded, it kind of takes over. like, dude, I'm just going to lock your shoulder down. Welcome to the party with most of these like post-op shoulders that look like a frozen shoulder. It's like, no, you're reversing the function of your rotator cuff instead of it literally.

Allowing you on deflection is just gonna lock you in a position that limits flexion So like we couldn't so then he gets a false flag because what he can still throw he can still lift And they like I can't do this or if I sleep in this position like coming out of it in the middle of the night. It's torture Yeah, so he's working out and then he's like doing he can't get into front rack But I saw him front squatting on social media like 400 pounds or something guys P myth. So yeah, that's

Beau Beard (42:14.894)

You see those things and you're like, okay man. But that's where you gotta be honest with people. Like what's the risk of doing that? Tell them if you told them they're okay with it, that's not your body. But on that note, still talking about surgery, which I'll see this guy for fall today. I just saw him three days ago, two days ago. It's a patient I've seen for a long time. He came into me on his first visit years ago. This was three years ago. I told him you needed a hip replacement. He was like, I am not getting a hip replacement.

I was like, okay, I will work with you, but like we're talking zero range of motion on the hip, pain with everything. It's starting to mess his knee up. had a prior Achilles surgery. He didn't have extension of his knee. So I just start chipping away at stuff. Let's get your knee moving. Let's get your hip moving. He did pretty good. You know, it's like better than I thought he would do. We had him doing split squats and all sorts of stuff. I was like, and on his last visit, which would have been about two years ago, I said, if you feel like you are good again, get back into that.

Do you want to the surgery? What's your quality of life? You make the call. If you feel like you're doing okay and you get six months out, you know, I'll consider that good. So I didn't realize this until he came in the other day. He had called in about six months ago or seven months ago, called in and said he was having a really bad flare up of his hip for the past two weeks. And I just told her from office, say, Hey, can you just tell him to get an ortho consult? Cause I told him if I ever had to see him again, like the surgery time. So they sent the referral and he never went, which is kind of funny because it was

significant other was with him and she didn't know that. I, I didn't know. And I look at, Hey, I put a referral in for you to a local hospital here. He goes, you did. I yeah, you're supposed to have surgery next time you saw me as something flared up. she goes, and it was like, you know, he was in trouble and he's just sitting there like giggling. so I looked at his hip this time.

It's worse. And now he's having back stuff and radiating pain. And I basically was just as truthful as I could be. go, I can treat your back, but it's going to lead right back to your hip. And then that relieves right back to surgery. So like my strong opinion is you need surgery. And he's still like, I don't want to do it. I go, then he got a negative image and we got an image of both hips and that hip is no bueno. We knew it wasn't. had a little styrofoam squeaky when I said, Hey, you hear that squeaking and your hippie goes, yeah, sounds like a chicken bone rubbing against. go, yeah.

Beau Beard (44:32.11)

Basically what it is. So that's one of those scenarios. He's at the point I won't work with him anymore. That makes sense? Like I won't, it is a disservice to that guy to keep working on his low back and not say, if you don't get this hip surgery, like you're going to wreck other stuff. And he knows that, but like it's not me being nice being like, yeah, I'll treat your back. Now it's like, that's my practice in my opinion. Like, hey, I'll keep treating your back when his hip is the driver. Now, if you don't have surgery and you must go someplace else.

That's up to him at this point, but when he comes in today, I'm gonna have to have that little bit of tough conversation, but the writing's on the wall now. mean, I can show him his hip looks like it's made out of Play-Doh. I'm just gonna be like, hey man, like that's what we thought. Like your back's gonna be tough to treat and yeah, I'm not gonna make your life easier. hopefully he does it. He's just scared. And then the little bit of me, and this is for patients out there listening, it's like, oh man, you're gonna push somebody to surgery. My worst fear is that he does have a complication. Then I'm the person that pushed him into surgery.

So yeah, I'm worried about that too, but like that is the best choice for him. There's always a complication. could have a lipoma removed and have a terrible infection or something with some of the minor, you know, most minor surgeries out there. So it's always a risk. Anything else on, cause I had in here like surgery prep, the rehab of it beyond surgery. I think we've kind of hit the clinical ends, the patient ends, everything in between. Yeah. I don't know. Anything else?

Yeah. So if you get told you need surgery, we always say, a second opinion. I wouldn't get a, I also wouldn't get a second opinion from the same type of physician. If you get an ortho that says need surgery, because we've had orthos that'll literally want to say no, want to say, or want to say yes, want to say no, and not only know, but you don't have the thing that I think they're operating on, which is kind of So I just say we'll go and we'd always say start conservative first anyways. So you should do some pre-op. should do some conservative care to rule it out. Cause that's.

something you can go backwards from, you can go backwards from surgery. But if you, let's say you do see a chiro or PT or an ATC and they're like, you don't need surgery and your quality of life sucks and they don't want you to get a console or something, like go get the console, it's your body. And then vice versa, if an ortho tells you you need it, go see somebody conservatively. If a conservative person agrees with them, better believe unless they're not confident. like, ooh, I got two different people and two different impressions tell me to go do the same thing. So that's probably time to make that move.

Beau Beard (46:57.774)

So if you're a patient or you're doc and you got questions about, something about surgery, please don't ask us questions about your surgery. Like we're going to refer you right back to somebody locally that can actually like see you as a patient, both legally and just ethically. But if you have questions, comments, let us know. And also let us know what you want to see for the next nine episodes of the Week in Review. Anything before we jump off here? I'm good. We'll be taking bets on what kind of facial hair Alex has on the next episode. Running out of options.

You grow a Fu Man Chu? Can you get it down the sides? you got a It minimally doesn't connect. Fu Man Gap? Take bets. Put it in the comments. See ya.