Fixing Rehab: Smarter Healing, Pain Relief & Strength Training with Dr. Tom Walters

26:41And so for a long time, we called it impingement syndrome. It turns out it actually doesn't fully explain. Some people, that is a major driving factor, the biomechanics, but almost a large percentage of humans have some impingement on that tendon and a lot of people don't develop pain. So it just turns out like a lot of things in the body, it's more complex. And now it's just called subacromial pain syndrome, but it relates to supraspinatus tendinopathy, rotator cuff tendinopathy. And it follows a very similar kind of treatment plan to the elbow tendinopathy and the patellar tendinopathy where you're gradually putting load, you're gradually strengthening supraspinatus and its tendon.

27:18And there's specific therapeutic exercise for that. Just like we were talking This is like you start to realize with each of these tendons, if you incorporate these specific therapeutic exercises that strengthen those tendons, you're going to be much less likely to have these issues when you get into an exercise program that is working on the big prime movers and not as focused on the little muscle groups. Yes, 100%. So do you see if we're looking at, okay, somebody's doing, they're either prehabbing or potentially they're rehabbing. What do you think, I guess this wouldn't work on the prehab side, but for the rehab side, what do you think of PRP injections?

27:58Are they helpful? Is it kind of maybe, maybe not? Yeah, I think it used to be for a while, a couple of years ago, I would have said I would have been more likely to say they're kind of up in the air and we don't really have a lot of great research to know for sure. But I think PRP especially is coming around more where I see more evidence supporting it for pain relief with different joint and connective tissue issues. So I often recommend to people if they have a stubborn tendinopathy and they want to try something else to try something like PRP, or if they don't want to do something invasive yet, there's something called shockwave therapy.

28:36Shockwave therapy is sort of like a really powerful ultrasound. And there is some research supporting it for like plantar fasciitis, resistant tennis elbow, some of the tendons that are a little more exposed that you can kind of hit with the shockwave. So that's another intervention that some people can try. Always in the beginning, the main thing is trying to modify their behaviors, work on that load management, and then strengthen. And then if that's just really a frustrating case and it's lasting a long time and really interfering with life, then yeah, things like PRP and shockwave are worth looking at.

29:10What about BP-157? I still just don't see. It's funny. Somebody just DMed me yesterday about their peptide company and I just, I'm still not. 100%. I'm not 100%. Yeah. Even stem cell, I see a lot of pushback even from surgeons on stem cells. So I just don't think there's enough. I think a lot of that stuff is probably highly placebo driven. And maybe peptides, I think there's probably a lot of potential peptides. And, and I also don't sit around and read that research a ton. So there could be somebody might say, no, there's a great study on BP 157. I just when I wrote the book, we covered it in there.

29:45My co author Glenn was super into peptides. And they're just at that time, wasn't really compelling evidence for peptides yet. Yeah. So if we look at the different phases, So you have three phases in your book. Can you talk about those and what we would do in each phase, what that would look like? Yeah, I think it's a, there's different, there's kind of three different phases you can look at, whether you're looking at healing, or you're looking at treatment, and they kind of go together. But, you know, when you first have, when you first have an injury, people are going to go through an inflammatory phase right away.

30:24So, and this is where you need that inflammation. Like we sometimes think of inflammation as bad. And like systemic inflammation that's there all the time isn't great. But when you first have an injury, you need inflammation because your immune system is coming in and sending macrophages and different cells into cleanup injured tissue and kind of remodel the area. So that usually lasts a few days. In that window, what would be kind of like the acute pain stage with people, we're doing a lot of things that are like soft tissue mobilizations, kind of like you might think of like self massage. So like if you had plantar fasciitis, it might be where you take a massage ball and kind of massage the plantar fascia on the bottom of the foot.

30:58Some people have seen that. Some people will take like a water bottle, like a plastic water bottle that's got frozen water in it, like kind of do an ice massage on the bottom of your foot. Ice is even kind of changing where there's been some questioning of should we use ice in the inflammatory phase because there's been some research showing that it can slow the inflammatory process, which might slow the healing process. The same with ibuprofen. And like ibuprofen, Aleve, these non-steroidal anti-inflammatory drugs, they slow the healing process. So we even now try to encourage people like if you can, the pain's not killing you, try to not take anti-inflammatory medication.

31:33Just let it go through its normal process. Implement things like gentle soft tissue mobilizations, gentle mobility exercises. Like if you had an ankle sprain, we'd have people kind of just do like the ankle alphabet exercises and kind of move their ankle back and forth like that. Just keep it moving because blood flow is what you need. You need blood flow to come in there to bring oxygen and nutrients. So that's kind of the first few days, maybe up to a week, depending on the severity of the injury. And then you move into more of like a fibroblastic type phase where the body's starting that rebuilding process.

32:05And so like that might be where like if you had a really severe injury, you start forming scar tissue and things like that. And or you had a muscle strain and the muscle fibers are healing, things like that. or in that phase in treatment, we're starting to look at impairments. So does somebody have a range of motion restriction? Do they have a strength impairment? Do they have like a balance or kind of, we call it motor control, like a motor, like an inability to coordinate and control their body. And so in the rehab world, and that's what in my book, the three phases of the program, phase one is focused on pain alleviation.

32:39Phase two is addressing impairments. So you're looking at range of motion impairments, mobility impairments. So those would be stretches and mobility exercises. You might be using a tool like if it was your shoulder and it hurts for you to lift your arm to go through full range on its own, you might use a golf club or like a broomstick. So your other arm can kind of help guide that. Or sometimes people have seen wall crawls, like where you can kind of crawl up the wall and you're using an external object to sort of take some stress off of the painful tissues and it allows you to go. So you're just because like with the shoulder.

33:09Okay. So here's a great example of females. Females are much more likely to develop frozen shoulder. Yeah. And a lot of cases that starts from a rotator cuff tendinopathy. So, but what happens is people get rotator cuff tendinopathy and then their initial reaction to the pain is to hold their arm like it's in a sling and not move it. Yeah. And then they develop frozen shoulder. So you have to keep the mobility going. And this is true with so almost every condition in the musculoskeletal system. You want to respect the pain, but you have to keep the area moving. And so something like a rotator cuff tendinopathy will give people range of motion exercises that don't cause a ton of pain, but just keep them moving through as much range of motion as they can tolerate.

33:50So they're less likely to develop something like frozen shoulder. Yeah. And then the last stage of healing, the timeframes can vary depending on the tissue that was injured, just because of blood flow, different tissues have different supplies of blood flow. but in that phase kind of the last remodeling phase it's focused mostly on strength training you know you're trying to just build the musculoskeletal system even though it's not simple like a card is very mechanical and strength training has the best evidence for so many things because it makes all of your tissue stronger your bones get denser you build muscle mass your tendons get stronger even your ligaments and the discs in your spine become more resilient with strength training.

34:28So it's really the best thing that you're doing at the end of rehab, and you hope the person will continue with because it's going to protect them over time. Yeah. So if we look at pain specifically, and I know that you've been on a lot of podcasts, you've talked about pain, you have a chapter in your book about pain, this is hard because we know that there's a pain threshold that's different for everyone. I mean, even without an injury, I will have some women in there that I'll be training and they'll be on the leg press and they're talking to me the whole time. And then all of a sudden they're like, I can't do another one, Haley.

35:08You didn't even slow down and you were talking to me unwinded the whole time. But in their head, they were tapped out. Like, no, the pain's there. Like the second they feel anything. So let's talk about pain and what that looks like from a mental, like psychological component, and then actually how pain is. Yeah. Pain is so fascinating. It's probably the thing I geek out on the most, but it's such a personal subjective thing, which is why the treatment of pain, which is all I do, is very fun and kind of tricky because it has so many influences from what's the messages that you're actually getting from your body.

35:49Like we have these little, they're called danger receptors. The technical term is a nociceptor, but you have these little nerve endings all throughout your body that detect danger. And if they're triggered to a certain level, they'll send a message to your spinal cord and up to your brain just saying, hey, there's danger down here, pay attention. So you have that side, you have all the messages coming from your actual physical body. And then you have all these psychological and emotional factors that go in. And pain is so interesting because we used to think pain came from your body. You know, that was the old model.

36:23Like you're sitting doing leg press and all of a sudden your quads start burning and then you have knee pain or it hurts in your quad. We used to think that was a pain receptor in that area, sending a message to your brain saying, hey, there's pain here. and that there's been a huge development probably over the last I mean 30 to 50 years looking at oh pain is actually you have those receptors those danger receptors but pain actually is sent from your brain your brain has to look at all these different things your emotional state your psychological state what you believe about what's going on you're kind of like so like social support, like how threatened you might feel in the environment you're in?

37:04Does it feel like a dangerous environment? Do you feel safe there? Past trauma, nutrition, sleep? Do you have inflammation, systemic inflammation? Maybe you have a metabolic disorder. Do you have hormonal changes that are feeding into your immune system and your nervous system and how you perceive things? There's so many elements that go into pain perception and a person's pain threshold. Hi, Uncle Lazer here. America's built on fast cars, fast food, and even faster women. Moto Casino's built in America. You know what they're fast at? Fast cash, rise, redemption. You see, only Moto is U.S. owned and operated.

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38:04it's, it is such an interesting, I have so many cases where, you know, because I'm just talking to people and asking them about their, they're reporting their pain to me. And it's so interesting. Sometimes what people will tell you, you ask them on a zero to 10, how much pain are they experiencing? Like 10 out of 10. And they're just sitting there. If you were 10 out of 10, you'd be like usually sweating. Like it's like somebody stabbed you. Like this is a life or death. Like, so it's interesting what people will perceive from a pain standpoint. We've actually, in some ways in physical therapy, tried to move away from just asking a zero to 10 scale.

38:37Um, sometimes it's just like, I would just use mild, moderate, severe. It just, because it's so subjective and personal, it can be challenging trying to figure out if you're only using pain to navigate things, it can be kind of a tricky, um, you know, it just, it makes it tricky. You almost need other objective kind of things you look at in the person to determine how you move forward. But somebody who's exercising and saying that and is displaying no symptoms prior to that and all of a sudden they can't do anything more, I think sometimes the psychological and emotional side of how something feels is a major driver.

39:17I think a lot of people stop because of mental factors and not because it's actually their physical body. It's amazing how far people can actually push themselves if they can get beyond the mental. Some of the best studies in the world on people who have the highest pain tolerance are endurance athletes. Endurance athletes, like people who run marathons and Ironman races and these 100-mile races, they have the ability to push past those messages they're getting and their brain telling them to try and stop. And I think not that you have to go be like that, that we all need to be like that. But I think it's something we probably need to keep in the back of our head when we're training.

39:58Like, is my body actually injured and I'm in like really severe danger? Am I experiencing a dangerous level of pain? Or is this just like, I'm really fatigued and my brain's trying to get me to quit? That's interesting too, because you also see

40:18people identify with, you know, if they've had back pain, I mean, I had back surgery when I was 17. I was a gymnast too. And I had back surgery at 17 and I could very well now, you know, just be like, well, I have a bad back. I have a bad back. I've always had a bad back. Do you see that too? That you, like somebody really identifies and they're just like, no, this is what I have. and this is who I am. And so then it all, it plays into that, feeds into that loop of, oh, maybe I have pain, but talk about, so there's been multiple MRIs that you pull any, a bunch of people off the street and half of them, you look and think, well, you probably shouldn't even, you should be in significant pain, but they're, you know, they don't know any different and they don't even, they aren't mentioning it.

41:06But what does that look like? I I mean, that's a whole psychological component too, or what do you think of those studies? Yeah. I mean, the first part you said is so true. The psychological piece is something I spend a lot of time trying to talk with patients about because some people have such limiting beliefs about pain. And that one you mentioned is a huge one. I've had an accident when I was earlier, so now I'm going to have a bad back, or I got in a car accident, I hurt my neck, and it's just always going to be this way. or my parent had a bad, had back pain. So I'm just doomed to have it because they had it.

41:42People have these very limiting beliefs around pain. So I spend a lot of time trying to push back on those gently with people and just kind of plant seeds on just helping them understand pain. I think helping people understand what pain is and how the pain system works can help them sort of reframe. It's a big part of like the treatment of pain is helping people reframe how they think about pain. And so, you know, that component is so huge. And the MRI studies, there's tons of these, tons of MRI studies. I highlight these all the time. They basically take asymptomatic people. So these are people without pain, bring them in, do an MRI.

42:18They've done these on the shoulder, the knee, the spine. So, and it's almost like half of the population have things like meniscus tears, disc herniations and disc bulges, labral tears in their hip and shoulder. And these are people without pain. So it ranges from 30 to like 45 % of the population have these things. And so when people, you know, we actually are very apprehensive to have people get MRIs now in rehab because there's been studies showing that when people have an MRI and they see something on it, they will kind of instantly worry about it. And that worry will negatively impact their outcomes in rehab.

43:00And it's been shown that now we know almost half the population has these. So there's no way to prove that that thing you see on an MRI is the cause of your symptoms. And it doesn't really change what you do in rehab. Now, if you had like these really severe symptoms where you're more of a surgical candidate, then an MRI is useful. But I kind of tell people now, like, don't go get an MRI if you're not planning to have surgery. Because what we do to treat that is going to revolve around your symptoms and how you move, your mobility, your strength, your symptoms. I'm not basing my treatment.

44:00Moto Casino app today. On that MRI, it's really on how you function. So people just have to, a big part of the education we work on people now is separating pain from injury because most people have this belief that pain means something's damaged in their body. And in a lot of cases, that's not true. You can have pain and absolutely no injury. There's a lot of people who go have MRIs who have severe back pain and have nothing, no findings. So that's equally as discouraging actually to a lot of people because they're expecting to be able to blame the symptoms on something. And then you can have people who have severe injuries who don't experience pain.

44:34You know, you have lots of these stories from like situations like with different athletes where they're like in the heat of the moment in a sport and break a bone or something and don't even tear a tendon. They don't experience any pain. You hear lots of stories of this from like soldiers and wartime situations where something really severe happens. They don't experience pain at the time. And you can think of less severe things too. Like all of us have probably like woken up and saw a bruise and we don't remember anything ever hurting or how we got it. So that's an injury. There's injury, the injury happened and your tissue is healing, but you don't recall having pain.

45:07So pain and injury are different things. And I think the main thing for people to know is that pain does not always mean that something's damaged in your body, especially when you're talking about something like tendinopathy, which so many of us are going to have. Like tendinopathy is not, you wouldn't really categorize that as an injury. It's more of a pain condition. It's more of like a sensitivity. It's not like you actually damage something. Okay. That's a super important part. If we move down, so one other area that I want to talk about, the feet. So the feet, there's a lot going on there, but also, you know, I'm going to lump like ankle in there as well.

45:47This is a commonly weak, a weak spot that I see in women as well, not only with maybe a tendinopathy or without, but it's the balance, the proprioception and the balance that starts to decline as we age as well. And, you know, do you recommend like when weightlifting, like a minimalist shoe barefoot? Do you prefer a padded shoe? What's your advice on that? Yeah, I think at the end of the day, you have to kind of figure out where your starting point is. if somebody's never worn a minimalist shoe or done a lot of training barefoot, I think you just also have to think of it like you're the rest of your training, you have to gradually get into it and give your tissues time to adapt to it.

46:31But I think, ultimately, I'd love to see people doing most of their training in a less supportive shoe, you know, something that's more of a minimalist style. I mean, I grew up only doing things barefoot. So like, I have all these weird muscles on my feet. I'm sure you do too from gymnastics, like I have weird hypertrophied muscles on my feet because I was always barefoot and holding my foot in funky position, especially like in martial arts, I'd be kicking and you have to hold your, I just did a lot of foot training. I didn't even realize I was doing a lot of foot training. Uh, but I think, you know, if you're someone who's been in a really supportive shoe, the problem with some really supportive shoes is that they feel great and they might be useful for like a really stressful competition.

47:12Like if you had to go run a marathon or something, maybe you use it, uh, in an event, But in the rest of your training, you want the problem with those types of shoes is that they support you so much. It's almost like having a brace on your foot. And we know we wouldn't brace other parts of our body because we know the body atrophies and deconditions. That's why you don't want to be in a sling for too long or have a knee brace on for too long. You're not having to use your neuromuscular system as much. And so people don't think of that with their shoes because we're just so conditioned to just, oh, you just wear shoes and that's what you do.

47:45And I think more people are becoming aware as more of these minimalist shoe companies are coming out and we're seeing more research showing that just even wearing a minimalist type shoe or being barefoot helps to strengthen your foot. And you think about females, like females are more prone to something called posterior tibialis tendon dysfunction where their tibialis posterior muscle, its tendon can basically sort of break down, which leads to progressive flattening of the arch. So you hear this sometimes in females around kind of menopause timeframe where that tendon related to hormonal changes, the tendon kind of starts to deteriorate and degenerate and their arch gradually flattens.

48:21And so I think there's a place for all humans as we age, but especially females, to be incorporating movements and exercises where you are challenging your foot, whether it's barefoot or being in a less supportive shoe. but just think I just have to gradually work into it. It might not, you probably don't, you don't want to just, just jump straight into one of the, a shoe like that if you're not used to it, because it will end up causing probably a lot of arch and foot pain. So you just have to, you have to gradually give the tissue to, um, time to change. If you were going to switch over to like, say like, okay, I want to start using minimalistic shoes for most of my daily activities.

49:05Well, you might only be doing 15 minutes at start at the start, or maybe an hour in the day. And You're just trying to slowly build up that capacity. Yeah. And this is all, again, this is all in your book. So let's move on to your app. Can we announce that? Can we start talking about that? Yes. Thank you. Yes. I'm so excited about it. I think it's going to be, the book has been out two years and the book has helped a lot of people, you know, but the feedback I always get when it comes to exercise and movement, it's helpful to have video. And I think this is why like my YouTube channel and Instagram account are so popular is it's, it's okay to have pictures, but a lot of people just ask me like, could I get rehab and prehab programs in video format?

49:50A lot of times people just want like a exercise library. Like we were talking about these exercises, like imagine that'll be a part of the app where it's like, you can go in and just find exercises for your foot and ankle, like that you could just incorporate to work on mobility and strength. And so that'll be a big focus of it for me is to just create these video based prehab rehab programs so that people can start working on these things before they begin a program. Most of the people will probably come once they're already in pain and injured. But a lot of the education for me is like trying to get people to think about rehab exercises is not just rehab that you can keep doing them after to reduce the chances that it comes back.

50:29So yeah, I'm pumped about it. That's awesome. And when do you anticipate the app to launch? I think it's going to take about right around like 45 to 60 days. So I'm hoping that two months max. So maybe sometime in October. Okay. Well, good. Keep us posted. In the meantime, I'm super bummed that our time is almost up. But in the meantime, I mean, this, again, I'm going to show the book for anyone who's watching. This book is incredible, but as you said, the app is so nice because I'm not lugging this to the gym. No, that's the problem. But it just, I mean, it literally breaks down every single tendinopathy or issue.

51:11And I have used it so much for just flipping through and saying, okay, this breaks it down, tells me exactly what to do in phase one, phase two, phase three. So I love it. Where can people find you right now if they're not familiar with you? I did mention your Instagram, but at the first, but go ahead and, and just tell us where to find you before the app comes out. Yes, thank you. I'm at rehab science, mostly on Instagram and YouTube. So Instagram is kind of quicker, but people are on that platform. They know it's kind of quicker. I have a lot of posts that are just like exercises. Like you could find a plantar fasciitis post, kind of flip through carousel style and find exercises for that YouTube.

51:48I do a little bit more. I'm narrating, talking through the exercises. So it's just a little more detail, but they're both rehab science. The book is called rehab science. It's on Amazon and Barnes and Noble. My website is rehab science.com. So people can find me in those places. And if people want to like DM me on Instagram and tell me, say, Hey, I came from the podcast today. That really helps me have some context, but I try to answer DMs. So I'm happy to help people because sometimes like on that platform, it's hard to find a post that relates to what you're looking for. YouTube is a little bit easier because I have playlists.

52:19So you could go to the hip playlist or the ankle and foot playlist or the elbow playlist. All the conditions we've talked about today, I've covered these all in videos and there's exercises you can just start with. And like I said, the book is like a textbook, so it's a little bit, that's the annoying part is carrying it to the gym. But a lot of people use it as a home reference and they just flip open. And it's like you've got three phases. You have a program. You don't have to go do the PT. You save the money on going. It's like$38 on Amazon. It's like one copay and you have a resource that you can treat your whole body with.

52:47Oh, Tom, it's amazing. And so I'm guessing that the app is going to be called Rehab Science too. Yes. Yep. Same. Okay, awesome. Well, I look forward to having you as we had discussed before in something special for my audience. But thank you so much for what you're putting out in the world. Thank you for your expertise. And, and I have to say, you are such a nice guy. And that is so refreshing in this space. This is it's so refresh, refreshing in the in the fitness kind of arena for someone like me who's seeking out guests. So thank you for your time today and your expertise. And we look forward to having your app come out.

53:24Thank you so much. It was a pleasure to be on. I hope this helps everyone, your audience. And yeah, thanks again. Thanks for listening, everyone. If you enjoyed this episode, please consider giving us a five-star rating and sharing the BodyPod with your friends.

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