The Sports Physical Therapy Podcast
The Sports Physical Therapy Podcast
Dynamic Knee Valgus and Pelvic Pronation with Steve Dischiavi - Episode 22
Full show notes: https://mikereinold.com/dynamic-knee-valgus-and-pelvic-pronation-with-steve-dischiavi
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On this episode of the sports physical therapy podcast, I'm joined by Steve Steve's a former P T a T C, working in the NHL with the Florida Panthers. He's now an assistant professor in the department of PT and director of rehab in the department of athletics at high point university. And this episode, we're talking about dynamic valgus control Steve's concept of pelvic pronation and how we can build better programs to reduce ACL injuries and rehab things like patellofemoral pain and hip femoral, acetabular impingement.
Mike:Hey Steve. Welcome to the podcast. Thanks so much for joining us.
Steve:Hey Mike. Great to see you. Thanks for having.
Mike:Yeah, no, my pleasure. Tell me a little bit, um, fill me in a little bit, so obviously you and I have known each other for years. We've, uh, we've, we've been colleagues through the inner Innerwebs, we'll say, uh, for years, but just, you know, had mutual respect for each other. Uh, I remember obviously back when you were working with the Florida Panthers and the NHL, which I'm sure was a really awesome experience, uh, tell me a little bit about what you've been up to since.
Steve:Yeah, so. I left the Panthers now, uh, about eight years ago and joined Highpoint university. We're about an hour and a half west of Raleigh, uh, small university private university. Um, I have a split appointment there. I teach in our PT curriculum as well as I'm the director of rehab and our department of athletics. So responsible for mostly. More complicated. Post-operative rehabs. I touch base on most of the, the operative cases and then help mentor, um, some of the athletic trainers, some of the ones that are still earlier in their career. Um, so it keeps my hands sharp clinically. I get over there a couple days a week, and then the other three days, I'm knee deep on our D P T curriculum trying to help the students. Eventually pass their boards first and foremost. And then I, I always try to steer'em in your direction because you're, uh, you're such a, and a, and a thank you for that for being such a great mentor to early learners and helping them get a foot in the right direction, especially those, uh, interested in sports PT.
Mike:Yeah. Awesome. So, uh, quite a transition, which I think was pretty neat, right. Coming from the pro sports model to now this dual. Teaching professor type position, as well as clinical director with a lot of athletics. This seems like, you know, a really cool transition for you. And it sure seems like to me, from following you online, that this has spurred quite a few research questions in your head, right? and you can, I, I, I like taking snapshots of researchers, right? If you go to PubMed and you type in somebody's name and you actually look at what they're doing, you start to see some themes. Right. It's not just like a random study here and there, but there's a theme, uh, appearing, but, uh, tell me a little bit about, uh, your research progression the last few years, what you've been doing to, to build that up.
Steve:Yeah, I like the way you framed that is, it is really interesting to see how people land in research and, and what kind of lens and bias they bring into that realm. Nom, no different, uh, leaving pro sports, as you know, from your time in pro sports and continuing to still work in that arena, the problems often come in, uh, really complex. But when you turn to the research as a clinician, you're help, you're helping, or you're hoping for all this help, that you're going to be able to find some answers to all these really complex questions. And I think that's where the ball started rolling for me in pro sports. And I had been adjuncting. PT program at the time. So, um, had always kind of really wanted to pursue my PhD and try to become more of a clinical scientist. I felt like I was, I was a, I could hold my own as a clinician, especially in sports PT, but I really wanted to try to pursue, um, Idea of putting some of my questions to the ultimate test, do some of the ways we really, really like to practice and do some of my biases hold up to the scientific method. So I think that's what I was really going for when I was transitioning from pro sports into academia.
Mike:Which is neat. And I think if you've listened to this podcast, now you see that I try to incorporate a lot of what I consider clinical researchers, right. That people that have clinical questions and then seek to answer them with, with the research studies. And I, I think that to me brings more impactful research a little bit. So again, that's why I'm drawn to a little bit of what you've been doing. Um, it looks like a lot lately you've been focusing on is on the topic of pelvic control. Right. So, you know, I guess you, you come from the hockey world, so that may explain some of it, but what, what got you into this specifically looking at some of your research on the Pels.
Steve:Yeah, you're exactly right. I think that bias of, uh, trying to understand the hockey stride and spending over a decade in the NHL really was, um, the driver for some of my interest in the hip. Pelvis region, but interestingly, and, and you'll like this, when I first started out in corporate PT, my first assignment was working with a, uh, farm team for the blue Jays. And at the time you got put on a team and you were on a knee team or a hip team, or so I ended up on the shoulder team for a minor league baseball, uh, program. And I'd always been as an athletic trainer and a PT. I've always had some field coverage, some strange in that way, my entire career I've had. Time in the clinic and time on the field. And then it was time in the clinic and time on the ice. And now it's time in the clinic and time in the training room. So I've always been able to use my ATC kind of skill set, but transitioning from those baseball players and then transitioning to hockey. Was really fascinating starting to see the connections, not just structurally ball and socket and things like that, but the development of energy through the kinetic chain and how things actually go from propulsion to deceleration and shock absorption. And so on. I was fascinated by. I was really nervous, maybe going into the NHL thinking, you know, I was a recreational hockey player at best. And you know, you have to have a, a very intimate understanding of the biomechanics when you decide to go into a sport. And I had already been doing some hockey, uh, rehab before the Panthers in the clinical setting before I joined the team full time. So I was really able to take a deep dive into kind of hockey, biomechanics. That's kind of where my fascination started. And then initially that light bulb went off and I said, I probably know a lot more than I think I do because of all these relationships to the upper quarter, which really kind of fascinated me at first. So then jumped in full time with the team. And now you are on a daily basis and, and you know, this more than anybody you're, you can't hide from anybody practice, travel. Dinner, you're seeing the same players over and over and over, and really trying to sharpen that skillset to solve all these difficult problems, I think that, uh, hip pelvis connection is really where I started scratching my head saying, okay, how do we solve some of these problems? And if it is like the shoulder, how would we apply some. The same kind of clinical research, because I don't think the clinical research at the hip and pelvis is at the level in terms of volume. And it is now it's definitely more common in the last 10 years is we've seen that switch from shoulder scopes to hip scopes, right? The, uh, statistics are actually pretty similar, so we've all had to up our treatment IQs with regard to hip scopes and so on. But that's, uh, that's when I really started to have and develop these clinical questions specific to the hip and PVI.
Mike:And I think the questions that you've come up with are fantastic. Right? They're they're some of the questions. Many of us are probably asking ourselves one area that you've drawn attention to lately is dynamic, knee valgus. And you actually had a piece in J O S B T. And I'll put this in the show notes, but, um, you know, you, you called out the concept that I really like the way you said, you said this is that we should probably be focusing more on controlling valgus instead of preventing it or avoiding it completely. And, you know, I. I think you got a little heat over this, right? You could probably elaborate on that a little bit too. So, and I get it because, uh, it's, it's subtlety. I read the article and I know exactly what you were saying, but sure. There's some people that are gonna take that to either extreme and probably take it too far. Right. But the concept of controlling valgus versus avoiding it. Um, tell me a little bit about that and a little bit about, you know, the research that you've put into that.
Steve:Yeah. And that was a, uh, that. A as it's easy to look back on it now, cuz that was 19. And then in 2017 we published a paper in BJ SM that talked about rehabilitating overhead throwers. And we were looking at, and you were actually cited in that paper. And we actually were looking at how high of evidence do we have to support rehab for an overhead athlete? And what we found was there is this. Level one or the, the higher levels of evidence don't nearly come to match the complexity of the task. So we saw that single plane exercises, particularly for external rotation, conically below 90 degrees was, was one of the most highest exercises that are researched for an overhead athlete. And any clinician would say, well, Really doesn't look like the task and where all the great exercises were housed were in expert opinion level. And there's this huge disconnect. And as a clinician going into a D PT curriculum, and we need to give the students this evidence based approach and evidence based exercises. Well, to tell. A student at the highest level of exercise we have for an overhead athlete is 99 or, um, 90 degrees of external rotation arm at the side that doesn't really match the message that we're trying to send as a, uh, a contemporary clinician. So that led that, that simple concept led me to start to understand why is there a big disconnect between what we do in the clinic and, and how it's looked at at the highest levels, especially RCTs. And that's really when I wrote that paper and it's funny, uh, the, the reviewers and the journal editor were tweaking the title and were saying, Hey, were, would you be okay, tweaking the title a little bit. kept tweaking it and kept tweaking it and it kept getting more controversial and more
Mike:I was, I was just gonna say you were getting more in trouble.
Steve:Exactly. So I'm like, well, that's not really what I'm trying to say. I mean, it is, but I'm not trying to stir the pot and now looking back on it, I'm like, that's okay. That's what makes great readership, right. It was all over Twitter. And so you're exactly right. You had to take a deep dive into the article and I'm not suggesting people didn't come away with the deepest meaning of what I was trying to come across.
Mike:Well, come on, Steve. I mean, had Twitter was all about knee jerk reactions based on journal titles. We know that we don't not everybody reads the whole article.
Steve:You know, and at, at my advanced age, Mike and, and I laughed because I, you know, I'm still learning social media and I didn't really maybe appreciate that initially. But, and then I started to read all the comments and people were contacting me and I, and they were basically making their comments off the title and the picture, which was really kind of funny. And I'm like, well, that's really not the point I was trying to make, but it's, uh, I'm really happy with that article actually. And the fact that it did create a conversation, um, there were a lot of people saying, uh, someone had said I was excited to read it. And then when I read it, I was like, well, yeah, I kinda already do that. I'm I already know that. So I don't think it was revolutionary in any, and you re and you kind of, kind of alluded to that as well. When you read it, you were like, yeah, I kind of, I, I kind of hear what you're saying. And I made a reference to a, a, a baseball player in the, in the piece, but, uh, some people. Maybe didn't fully want to have this conversation about system tension in, in, in three dimensional kinematics. And, um, you know, how, how this idea of stored elastic, energy and propulsion. And these are, these are really difficult concepts to try to tease out in a research method. And, and I fully appreciate that. And that's why it was only an editorial, but it really kind of kicked off the direction I wanted to go with. My research was. Is it possible to create these tension related three-dimensional exercises that maybe hit several different constructs? And could we study that in, in more of an, uh, an exploratory way with explanatory research, as opposed to this pragmatic design that says, let's just treat it like we would treat any patient walking in the clinic. Could, could we control for some variables and things like that. So I thought that piece really kicked off that conversation. I definitely wasn't surprised for some of the comments that I got back, but it definitely did. Definitely didn't make everyone very happy, but, um, but that's okay.
Mike:Well, you know, it's super hard to develop a research article to specifically look at that. And gosh, I wish more people realize that is that we cannot have finite answers to every question in the world. These research projects are impossible to develop, but you know, you brought up a great, great concept that concept of. Tension based dynamic valgus. Right. And I think that's sometimes what's missing, especially with some maybe early career professionals that are just hearing kind of conflicting sides of the story and maybe each end of the spectrum on social media, but it's not the position of valgus, but rather the amount of tension in that position, valgus without tension. Bad. Right. Just put'em in a that's when you, you tear something, right. You get a forceful position, you know, maybe from, uh, you know, a traumatic accident, skiing, football, something like that. It's because you're in Val without that tension. But if our goal is to control that movement and maintain intention, then all of a sudden, you know, maybe that's gonna have some more carryover to some of those sporting events. So I thought that was amazing. Right. Did, did I miss anything? Did I, did I say anything poorly?
Steve:No, that was exactly it. And I, and, and again, I think a lot of us as clinicians are already looking at it this way are already trying to adapt, uh, to, um, bringing tension into the rehab exercises. And I think what I was trying to say was. And I think the, the follow up articles to that, and eventually the research that, um, I was able to collect through my, um, research process, I think will shed some light onto that conversation. Cuz some people would read it and then say, okay, so if it is tension dependent or at least at least it's a construct that should be considered. Should we be doing anything differently then should we be rehabbing them differently? Should we be screening them differently? Should be, you know, and I, and I appreciated, you know, Amy Dale's podcast that I listened to not long ago, I appreciated her approach, uh, when she was talking about, um, mechanism of injury and. The Della Villa article that recently came out that talked about all the different ways, uh, the injury occurs and the mechanisms. And one of the highlighted sentences in that paper that really made me smile was if you don't fully understand the mechanism, how could you potentially create exercises to address it? I
Mike:Right.
Steve:I, I really, you know, and I think we all look for our bias, right? So I was reading the article and I saw that and I was like, oh yeah, that
Mike:Like ha yeah,
Steve:Ah, speaks to me. Uh, I like that.
Mike:well, I I'd say, you know, that, that tension based dynamic valgus, that that was a really good thing that, you know, I thought you brought some attention to the other one was, and I thought this was pretty cool is the concept of this new term pelvic. Pronation, uh, why don't, why don't you explain that to us? What, how do you define pelvic pronation? Um, so that way, you know, if you're unfamiliar to that term, which I was when I first read it, um, it really, I, I thought it was a great use of the phrase, but tell us more about pelvic pronation.
Steve:Yeah, it's. It's also funny when I tried to get that paper published, one of the editors, uh, or one of the reviewers rather said this term, I've never heard it before. Does this really need to be in the paper? And it was one of the last edits I was making before publication and, and it was a hill I was willing to die on. And I
Mike:Yes. Thank you for that. Yes. Yeah.
Steve:they didn't wanna put it in. And in some casual conversations with some, some bigger name researchers that have been mentors of mine, when I originally described. Piece that I wanted to create all of'em had a very similar reaction. Like that makes no sense. Like why would you introduce a new term and cloud the arena with new terms? That's that's like the number one thing we shouldn't be doing. And I said, no, I, I appreciate that. But from a clinical standpoint, I've always felt like when we talk about foot pronation, We all conjure this immediate image of this three dimensional kind of shock absorbing method that your foot has to go through before propulsion and. You remember back in the day when we were rehabbing, even knees and things like that. When we were looking at foot pronation foot pronation was the devil. If you over pronated like, that was the, you had to let's go see an orthotist and we had all kinds of issues. Right? So we've developed and evolved that thought process. It's not as bad as it used to be, of course, but I think using that word pronation in that sense with the foot really. Clinicians specifically will start to apply an exercise strategy. That seems to be more three-dimensional. And if you look at the foot and how the foot works in terms of absorption to propulsion and creating this rigid lever in such a short period of time, when I was in hockey, I was starting to fully understand that this idea that the pelvis collapse, it collapses three dimensionally, very similar to the foot in its. Really is to absorb ground reaction force, get into a position after absorbing force to lock itself in a more kind of rigid position. So it can do propulsion and create this lever. And I was seeing this unique relationship between the trunk and the pelvis, particularly in hockey players and the skating stride. And then started to understand that we do that in most all of our activities as this three dimensional wrapping and the talk and Lang how to Netherlands talked about this with soccer players and how tension arcs gets gets developed. And the elasticity is what, where some of the power comes from. Which is really more maybe of a strength in conditioning and performance, kind of understanding than it translates to rehab a lot of times. But the, the essence of pelvic pronation is by definition. Really. We used to use it jokingly when we worked with our players as a verb, uh, And we would say you're going into flex abduction, internal rotation, and you're, you're basically fiering at your pelvis. And we, we dealt with a lot of, of course, internal hip impingements UHI and those kinds of things in the hockey population. And if you can't control your pelvis on a stable femur, you. Once it drops into this three dimensional collapse and goes into flex abduction, internal rotation. You get this impaction at the femur in, in the pubic and the, as tabular rim. Now, if you couple that with what we're really familiar with, which is ne valgus, which is also abduction and internal rotation, you get this nice kissing lesion type response between the pelvis and the lower extremity. So we used to use it as a verb and we used to say, you're Fier. Pelvic pronation are, are really similar concepts and that's, uh, by definition, I think the way I describe it is this, um, closed chain fiering response.
Mike:I like that. That's I think that's, that's a great way of phrasing it. And I think that term is gonna be helpful for, for people, uh, before we get too far on this, cuz I like this concept on this 3d, uh, motion. Right. Which makes sense. We have to control attention in multiple planes of motion. Um, I've heard you talk about. This reductionist lens approach that we've had in the past, we break down a complex task, like skating, throwing, jumping, running, whatever it may be. And we, we put it into to its individual pieces. And then oftentimes we just focus on those individual pieces and hope that when they all get put back together, things go great. Right. Um, I like that, but again, I see there's always these discussions and then people are too extremes and say, you always have to do it one way or you always have to do it. The other, I always think it's in the middle, but do you think this reductionist approach is always bad? Is there a time where maybe you have isolated weakness of one muscle that you wanna work on that isolated approach and then, you know, how do you then integrate that back up to more complex tasks?
Steve:That's a. Question and Mike, and I think that that haunts us all as clinicians. Right? You've got this orchestra playing in front of you, but you've got one instrument out of tune or can't keep up or whatever else. Can you pull that one instrument out, go give it to a coach, work them up, practice them up and then put them back in the orchestra. Absolutely. I think we can do that. And eventually that person has to be able to keep up with the orchestra or it continually will be a, a problem. So this idea of reducing things down to one idea to work on, especially at the impairment based level is. Incredibly important. And in the foundation of, I think what we do as clinicians, um, I think it's our job to be able to identify who's that one wrong player in the orchestra and work on that very thing. So it has its place and I'm not suggesting throw the baby out with the bath water, but I do get pigeonholed. I think sometimes as you know, let's make everything more complex. Let's make everything three dimensional and I've Stu I've stumbled upon this idea of recursion and, uh, they use recursion. And different types of unrelated fields like mathematics and linguistics and all these other things. And recursion basically says it's something of a, it's a process of repeating items in a self-similar way. And that has really resonated with me meaning, can I still apply a strategy that will reflect that movement once it's back in the hole? And I. That's where I kinda like to live. And I think you kind of said it as well, somewhere in the middle. Right? But it's the difference between finding, let's say your perforance is not doing a good job of stabilizing your pelvis and decelerating your femur internal rotation during landing. Can we work on that in a reductionist manner? Isolate it. Maybe even do it in side. And still maybe capture some of the motor control elements that are needed once you're back up on your feet. And I, and I, and I'm a little biased, obviously the way the, the lens that I look through, but taking these concepts from people like T and lying health that have showed us that. Trunk rotation, ultimately alters hip position and hip range of motion. So we know that there's this three dimensional connection. We've got evidence now supporting that. And I think clinically, anecdotally, we've always thought that, but we've got some evidence to move in that direction to create our exercises. So if you are doing a reduction as type exercise, can we use this a form of recursion to make this reduction exercise look like what it might kind of. A task specific approach to whatever the final method might look like and always trying to hang onto this recursion. So if you are gonna reduce something down to its basic element, try to keep the motor control and the interplay of the rest of the orchestra, moving in the same direction instead of making this isolated technique, that looks nothing like how it would look once it's back in the. In the full task specific way. And can we, can we, and some of my research, I was really trying to answer that. Can we build capacity while gaining motor control at the same?
Mike:Yeah. And when you put that together, that's when the magic tends to happen. Right? I, I think sometimes. People get in trouble when they're either too much of a reductionist or too much of a complicator right. and they, it's a, the answer always laughs in the middle. And that's one of the big, you, you know, principles that we use a champion here is that, you know, if you, if you have a weak muscle, it's gonna have a really. Hard time stabilizing just to completely dumb down that, that phrase, right? Weak muscles can't stabilize. So you have to have a reduction approach to get that back to its baseline, but then you also then have to take that up to that next level of complexity and how it integrates with their task. People are, are all the time on Instagram and social media. They're getting stuck in one of those two buckets and not seeing that you need them both and they both have to grow right.
Steve:Yeah, it's a great point. And I think it was, uh, I listened to one of your other podcasts not long ago. And I think it was, uh, Dan Lorenz, who said, some, someone had mentioned to him, why are you not on Instagram? And he said, I would have the most boring Instagram account ever because I'm not doing the crazy. And that just resonated with me. I'm like, I, I love that comment because you know, you gotta do the basics well and nothing beat. Foundational strength and power and all these foundational elements of, of, of performance. Um, all the fancy stuff can come later. I always wonder is can we mix some of those, you know, more, more basic exercises in our rehab with a more complex approach.
Mike:Right. And, and that's what the expert clinician tends to do. And that's, you know, you'll get there if you're, if you're young and you're listening to this and you're there. It's okay. You'll get there. You'll start to see when they start blending more. I promise it's gonna come. But, um, Steve, you've alluded a couple times now to some of these, uh, articles you've published, you looked at some common exercise selection with, uh, pathology. So ACL injuries, Patel, morphine, FAI, and what you're looking for. Are the common exercises that we see and we talk about and are published all the time. Do they accurately reflect what's really happening with the path of mechanics of these injuries? Why, why don't you talk a little bit about that? I think we've already kind of covered a bit of this 3d complexity of the hip, and I'm sure that's where you're gonna go with that. But tell us a little bit about those findings for ACL Patel tomorrow, AI and, and, and, and essentially what you found in those article.
Steve:Yeah. You're exactly right. There is a, there is a common theme. Be. These different pathologies. And we look at the relationship between the pelvis and the lower extremity and this isn't to diminish the impact of the foot and how ground reaction forces are mediated. As it moves up to kinetic chain, I have just found my interest and my research area seems to be a little more proximal. But of course moving even more approximately to the trunk and then even more distally to the foot's important, but we all know that there's a big injury burden with these pathologies, but they all have a very similar underlying component and they all talk about these single leg ground impacts and. The interesting thing about the title in J O S P T's article about ne valgus. When we said controlling ne valgus, what do we really mean? We, we really mean, do you have the ability to eccentrically decelerate levers that are spinning under high speeds, high loads, very short periods of time. Do we have the ability to create interventions that can actually decelerate these levers? And that's what I really wanted to know. And we, you look back at that transition. Remember when we used to. Tape the patella. And I mean, we probably still do on some level, but you know, probably not as much, but when we looked at the VMO insufficiency and then things moved a little more approximately, and that SU zone powers paper in 2010, looked at that MRI result of, uh, the femur kind of spinning internally under the patella. And maybe it's the track underneath the train. That's the problem. And that kinda launched us in the direction of proximal control and how the hip controls knee position. And when you look at. Original article and they show that MRI, uh, the person stepping up into the MRI platform and their females with Patel, Emeral pain have two times the internal rotation. And I just look at that and I say, and I saw this all the time in the hockey stride, and we are constantly trying to figure out how to decelerate this internal rotation coming from the pelvis and the, and the femur. So we looked at all the exercises that are prescribed for these pathologies, maybe housing, this kind of common. Patho mechanical, um, mechanism that's occurring. So we started to pull all the exercises out, literally looking at every exercise under our inclusion criteria, across these three injury, um, mechanisms and overwhelmingly we came back and I think the, the ACL one's the one I probably kept the most questions on, but we looked at, uh, we looked at really four basic mechanisms that are reported in the literature, single link, single limb landings. Trunk, pelvic dissociation. Uh, we looked at, um, whether or not they can stabilize on, on a is, are they landing on a flight phase on a single limb? And we wanted to see if these exercises reflected that decelerator nature of the internal rotation of the, in the abduction of the lower extremity. And what we found were was less than 1% of the art of the, uh, exercises and the ACL. Paper specifically, it was over a thousand exercises from I'll review as early as 1996. And the other interesting thing you'll really enjoy with that is the, when you looked at the exercises, each program, some of them had four exercises and some had 104. That was the highest one. can you imagine doing a injury prevention program with 104 exercises, but, and you're pretty much just throwing everything at it and, and something's gonna work. And I think it's that, you know, Mike, I think we have to be honest that we're doing a great job. You know, I think the researchers that have created these injury prevention programs, I'm not suggesting on any level that they're ineffective. They're very effective. I think we all also agree is we don't know exactly why they're effective. So I'm looking at a really small portion of those injury prevention programs. Again, I'm not. Throw the baby out with the bathwater. What, what is happening and where the literature has gone over the last 25 years is pretty amazing. But one of the things I wanted to enter, enter into the conversation is do our exercises in a single, like landing replicate the decelerator forces and speed that's occurring to maybe slow down this injury event. And I think those reviews clearly show that those exercises don't do.
Mike:And I, I think this ties it all together with what we just previously talked about a little bit. There essentially were a reductionist lens to an extent, right? Let's come up with injury prevention and rehab programs that are very reductionist in, in nature. Um, and to give'em credit, they worked a little or somewhat, or fair enough, right there, there is some efficacy of taking it that way. But the complex task in hand still missing is probably that missing link that we're having from having exceptional results. Right. And that, that, I think that's what I thought of when I, when, when I read your papers and I even reflect back at my own programs that I write for people and we work with people, we have to build that in a little bit more. So, uh, taking a reduction approach and working the component. Helps. And it's a step in the right direction. We have to do that, but we could probably do better. Right. So it sounds like what you're saying here is we need to get more complex. We need to get more 3d. We need to start putting that all together. Any suggestions on how clinicians can start thinking that way and maybe some exercise, uh, tips for them. How can we start improving our exercise selections for these things then.
Steve:Yeah, this is where we're, we're stepping from the evidence based realm into the evidence informed realm, which some people listening to this podcast are going to be immensely. That we're suggesting, we're suggesting that, you know, these things don't work with a 50% reduction with some of these programs. I mean, they're certainly working.
Mike:they work. Yes.
Steve:exactly. So you should be doing something and there's enough out there now to help us. But as a, as Amy alluded to in her podcast, she said, we, the best we've gotten down to our buckets, we know you should be doing some proximal control. We know you should be doing some biometrics. We know you should be doing some strengthening. underneath that. What goes into those and what they exactly look like has not really been teased out yet. So, and that's where I think I was trying to go was saying, okay, first and foremost, Is there a reason we should even be looking at this or have we figured it out? Do we know enough that these programs doesn't matter what exercises you put in'em as long as you house'em in these buckets, you'll be fine. And I, and I think there's probably an optimization process there still waiting. I still think that, um, but to be fully transparent, your question hints to. Someone listening that researches the ACL every day saying, why is this guy suggesting you should do exercises this way when there's no evidence clearly to support why you're saying develop an exercise that way. And one thing I've learned through the process of trying to develop a line of research is you really have to start by understanding the landscape of what's out there trying to determine if there is a small space for a new need, and then going down the road to try to go. Painful process of trying to tease it out, to see if it's effective. So I think it's clear and fair and transparent to offer that. Now that said where I went, trying to bridge some of these conversations from the J O S P T piece to some of my actual experiments. To answer your question specifically is I was trying to develop exercises that would perturb the trunk, which is what we see is a, a high level of injury mechanisms. Although a lot of these injuries are non-contact. When you look at like Del Villa's work, he mentions that perturbation to the trunk prior to injury is not unusual. So we know that the trunk plays. Portion, but it's not really well represented in prevention programs. So what I was trying to do is think about, um, taking a rope and spinning it around a top, pulling that rope and watching the top spin on the, on the table top that's essentially what I was trying to do. I was trying to develop this idea of potential energy, um, through the trunk and would. Rotation along the Z axis, this potential energy. Would it turn into kinetic energy upon single limb landing and force someone to go into dynamic ne valgus? And if I could do that, would I prompt a capacity building response to the resistance? And would I develop a motor control response in a very short period of time, that would make a connection between the brain and the limb to say, this needs to slow down this spinning of the femur and pelvis need to slow down immediately up upon impact. And that's what I was trying to do. And that's what I was trying to, uh, to measure when I conducted my experiments. And I used, uh, all Golder's work, um, to talk about this idea of training DS and using external. Feedback between teammates could, could I watch your knee mic while you were doing a single landing and give you some three dimensional and global feedback while I. Tethering you at the trunk to, to spin you off balance. And could I use that trunk perturbation to help you control your three dimensional position upon landing? Um, and that's really the training method, what I was going under. And there were several other exercises that, um, I was able to develop along this process to determine, okay, they house all the elements of injury mechanism. Now let's measure them in a very specific way as pragmatically as possible. And like you said, one of your first comments. I wish people better understood how hard that actually is to do.
Mike:Exactly. I, I, yeah, I would almost argue. It's impossible to do, but kudos to you for trying you know, and, and, and yeah, I, I, I mean, if people didn't have these evidence, Based or evidence informed questions, then we would never have evidence based practice going forward. Right. So we have to keep pushing that envelope. I think it's great that we have some evidence that these programs work, but we've all had pat teleph Maral pain patients that don't get better. We've all had FAIS that we can't fix non-operatively that they end up having surgery. We all have ACLS that do get injured, even though they went through an injury prevention program, but how can we make that better? And I, I think you're really pushing the en. With, with some of those things to improve.'em so, um, awesome stuff, Steve. I love it. Uh, great episode. I hope a lot of people can kind of dig into your research. Check out the show notes in this episode, uh, before I let you go, we gotta get, uh, we gotta get our high five in so five quick questions, five quick answers coming from you. So we can learn a little bit about you, how your mind thinks your growth mindset, stuff like that. But first question, what are you Steve currently working on yourself for your own professional development?
Steve:Ooh, that's a pretty boring answer. I recently defended my, uh, PhD and. I was given a whole host of edits to address. So I will be busy over the next. Yeah, I would, I'll be busy over the next several months, just trying to make edits on my dissertation and, um, get that finally submitted and off my plate. So that's, that's my that's, that's the fire that's on in front of me right now.
Mike:Yeah, that's a huge fire too. So I like that one. Um, and you know, this episode, I think may partly answer some of this question, but what's one thing that you've recently changed your mind or evolved your thoughts on.
Steve:Oh, the, um, uh, one interesting conversation I had recently about, especially when we talk about evolving my thoughts, I was listening to a J O S P T podcast with Steve camper. Think he's in Australia. And he, he does that segment on evidence in practice and he breaks down these really complex ideas about research for really simple explanations. But he, he talks about, he goes on this tangent about, um, what is evidence based practice. And he. About that. And I think that he's convinced me to maybe change my mindset a little bit. You know, we have this through, uh, Three-legged stool example of clinical experience evidence in that's that's published and what your patient's expectations are. And then he goes, um, if you haven't listened to it yet, check'em out on the, the podcast. But he, but he talks about how evidence really is more than just published papers. Um, and he, and he gives his rationale as to why that is. And if we could just figure out a mechanism. Understand the bias and everything outside of published research and a model to create that we'd have much more information to draw from.
Mike:Yeah, that's gigantic. I love it. Well, you, you deal with this a lot, but what's your biggest piece of advice that you give students that you work with?
Steve:You don't the, one of the first things I learned this in our corporate positions, when we worked way back, when was, uh, someone had once told me no one cares how much, you know, until they know how much you care. So gaining these credentials and letters after your name is great and pursuing all these advanced clinical options is great, but be a clinician at heart, understand what it is to be a good clinician. Treat your patients right? Ask good clinical questions. And even though if you don't have the answers, your patients will give you a lot of respect. Everything and all the effort you do to try everything in your power to make them better. And then of course seek out people like yourself. I mean, people that are really out there, I, I give people like you so much credit, like you're out on the front lines, you've mastered kind of the social media and the, the learning based experiences online. It's fantastic. And students need to take advantage of all those things and find the right mentors to, to follow along as they build their clinical career.
Mike:Awesome. Thank you for that. What's coming up next for you, Steve.
Steve:Well, once I put this PhD to bed and get that off my plate, uh, I learned a lot through that process and just like anything, once you do it for the first time and becoming an early clinical scientist, I've refined some of my questions. I've refined. Some of my methods and I'd actually like to, um, start another data collection with everything I've learned up to this point. Maybe make some corrections to some of the things I didn't consider the first time around and like anything the next time you do it, you're probably a little better at it. So I'm looking actually forward to, uh, to, to developing some, some new, some new studies.
Mike:That's awesome. Sweet. And where can we learn more about you? Is there a place that you, uh, that you, you tend to call home? Do you have a website, social media? Where, where can people go to find out more about you and your research?
Steve:I do. There's not a lot out there. Um, I'm. Working on my website, my website's finished first PT, like finish first physical therapy, but it's finished first PT. My social media handles. Uh, I'm kind of like Dan, I don't have any post on my social media account on my Instagram. I haven't quite got there yet. I do have a Twitter account that I, uh, I try my best to stay up with, but it's, uh, first underscore PT, like physical therapy and that's where you can find me. And, uh, Please reach out if you have any, uh, questions or if you have anything disparaging to say about the, the J OSBT piece, throw it out there. and we can banter it around.
Mike:Exactly. That's awesome. Yeah. Well, awesome. Thanks again, Steve. I really appreciate it. I'll put those links in the show notes so people can head and, and find out more about you. Uh, thanks again for taking time out to do this podcast episode today.
Steve:thanks for having me, Mike.
