Running Injuries with Scott Greenberg - Episode 40

In this podcast episode, I’m joined by Scott Greenberg to discuss running injuries and how to get started working with running athletes. 

Plus, we'll discuss some of the newer techniques Scott has been using, including the use of blood flow restriction training in this population.

Full show notes: https://mikereinold.com/running-injuries-with-scott-greenberg

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Transcript

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On this episode of the sports physical therapy podcast. I am joined by Scott Greenberg. Scott is a physical therapist, the manager of operations and the residency director for the university of Florida Gators. He's an expert at running and foot and ankle injuries. And in this episode, we're going to talk about how Scott developed this niche, how he works with these athletes and some of the new techniques he's been working on with runners, including using blood flow restriction training. Hey Scott. Thanks so much for coming on the podcast today and joining me. Uh, how's everything going? Everything's great. Thanks for having me, Mike. Appreciate it a lot. Yeah, I've been looking forward to this one because you're, you know, one of the, the leaders of the academy, um, the sports academy that, um, I think over the years it, it's been fun to see you present on some of these topics about runners and running injuries and stuff like that. So I've been really excited to try to get you on for this topic because I, I feel like I haven't, I haven't really talked much about running injuries over the last few years in the podcast, and I think it's long overdue to have you on to share your knowledge with us. Right. Uh, awesome. I lo, I l I can talk running all day, so let's do it. Which, which is a great answer. I know that. So, uh, let, let's jump in. I, I know you've worked with a lot of runners and so when you work with runners, you deal with a lot of running injuries. You, you know, the specifics of running, running injuries, you have to be really good at foot and ankle, right? Like, these are some of the things that go hand in hand with running. Um, why don't we start, before we dip into some of those things, like, I want to hear specifically like, Like, how'd you get started in this? Like are you a big runner? Did you specialize in this like yourself as an athlete? And then how did you pivot to say like, oh, I'm gonna focus on this for my professional career? No, I think those are great questions and you know, I've been going on being a PT now going on something like 24 years, so it's been a long time. So as I think back to how I got my start, um, Always loved sports, always involved sports, played sports my entire life and knew I wanted to have a career professionally involved in, in sports in some way, shape or form. And physical therapy just, just spoke to me. It just was what I wanted to do Once I realized that being a professional athlete wasn't in the cards, right. So, um, Went to PT school and came out and again, knew I wanted to do sports medicine, but didn't know exactly what. So I think one of the things that all clinicians should do when they come out is really be a generalist more than anything else. Get yourself into a good situation, surrounded by a bunch of smart people, um, and, and then see where it goes from there. And then kind of just take it all in and see what speaks to you. And, um, for me, in my first two years, within the first two years of practice, um, I've had the opportunity to see both non-operative and operative care. Um, got to dabble a little bit in foot and angle, and it really did interest me. And when I took my second job, uh, which was, you know, a year three post, post-grad, um, working with the team doctors for the University of Florida, not as a physical therapist for the Gators yet, but just working in their clinic. I wanted to figure out a way to fast track myself to be considered the guy in something, right? So I looked around and at the time we literally had a, a true sports medicine clinic. It was, uh, four physical therapists, two athletic trainers, two team surgeon, team surgeons, and one the non-op guy that were all sports medicine all day every day. And, you know, I was fortunate again to be surrounded by some really bright people, people that have spent time working with the Dodgers and people that really knew a lot about the shoulder and the knee. And I said, man, this is great, but you know, how can I stand out and how can I kind of break in to, to gator athletics, let's say myself. And, and then I, you know, strategically thought about it and said, you know what? The foot and ankle's always been something that's really interested me. The beauty about the foot and ankle is that, um, you know, every sport. In some way, shape, or form, you can even throw swimming in there. Cause a lot of our swimmers do a lot of. You know, on land running conditioning type stuff, um, they, we, we, they all run and, you know, understanding how people run and, um, and how the foot and ankle, um, you know, uh, articulates with the ground and the implications it has. You know, one of the first courses I took was when the foot hits the ground, everything changes. Right? So classic, you know, the foot and, yeah, absolutely. So the foot and ankle and running mechanics kind of went hand in hand for me in terms of, you know, kind of. Getting my roots into something that I can really stick my teeth into and really, you know, say this is mine. Like I own this, uh, for this organization, for this, for this group of doctors. Let me be the guy. And again, you know, it doesn't just get handed to you. You have to actually show not only the want, but you actually have to be successful in what you're doing. And you gotta go above and beyond. You gotta put the time in, you gotta go to the classes, you gotta learn extra. Um, and then at the end of the day, you gotta do a good job, right? You gotta do a good job. And, um, I've been fortunate to, you know, uh, I think do a good enough job where people give me opportunities. And then when those opportunities come, you know, you keep the door wide open and you don't mess up, you do a good job and you, um, you know, you take advantage of those opportunities and they lead to bigger opportunities. My first opportunity came, um, as a result of me. Um, fabricating foot associates, to be honest with you, that's how my break into the University of Florida Athletic Association kind of took hold, is that they needed somebody to do foot orthotics. And obviously I took some advanced training in that. Um, along with my foot and ankle knowledge. It just made sense. Right. Um, back then, 20 years ago, Somebody had foot pain, orthotics were automatically prescribed. Right? So I wanted to understand, yeah, I wanted to understand how they're made. Why are they so expensive? You know, what can I do to, what can I do to facilitate this? And, and, um, you know, I started, you know, I took, um, uh, a certification as a, a board certified P DOYs, which is somebody that can modify footwear and modify shoewear. And I started making orthotics, you know, from. From much different than I do today. Um, I used to start with, you know, pieces of material and, and actually heat'em up and, and gloom materials together and grind them and post them and yeah. And do the whole kit and caboodle. You know, pair of orthotics used to take me two hours to make, and if you're making a bunch of'em, you know, that's on your time. And, and I put that time in on the weekends coming in a, coming into the clinic at five o'clock in the morning to get this stuff done, uh, because it was something that I was, a passion of. Mine turned into a passion and something that I really wanted to. To take advantage of. And again, once you're kind of known for the guy to do the foot and ankle stuff with orthotics, other opportunities kind of come your way. And, and over the years now, I only, I don't just see foot and ankle stuff. I see, you know, lower extremity stuff. I do, I do my, my fair share of ACL reconstructions and such. You know, I see my, my fair share of hip pathologies. Um, I try to keep it lower half. That doesn't mean I've never seen a shoulder in my day. Um, but, but I'm, I'm, I'm happiest when I'm treating below the belt. That's awesome. I like, I like that. I, I guess I'm the opposite, but like, you know, like you, I think you get pigeonholed in things, right? Mm-hmm. And then we, you know, we only have X hours a day now, right? So like I can fill my schedule up with baseball pitchers all day and then, you know, it gets a little boring. And to be honest with you on my part, if like, that's all you do, but, um, yeah, you know, I really like a lot of the things you said there, and I thought that was a great, you know, You know, start this episode. Um, we talk a lot about, um, you know, trying to have a strong niche in this profession. If you're trying to stand out and you're trying to be the best at something, it is really hard to be the best general orthopedic physical therapist in the world. Mm-hmm. You have to understand that, but it's hard to be the best general ortho. So I love how you said, let's get a great orthopedic base, but then pick something. And I always tell people that, is it a sport? Is it a joint, is it a technique? But like pick something like that and I really love how you did that. Um, were you a runner? Did you do track, I mean, I know you were an athlete, but like what did you do specifically that said like, I wanted to work with runners. I. Huh. My common joke, I, you know, I teach a lot of running continuing education courses and that question always comes up. And my joke is always, my joke is I always, I only run when chased. Right. It's my common statement I say all the time. Yeah. So I laugh. My history of works. Yeah. My, my history of, that's a good joke. Courses I was, I was a, I was a soccer player, baseball player, and then I wrestled in the, in the interim. Right? So obviously soccer, lot of running baseball, not, not as much. But, um, the wrestling was a way for me to keep myself kind of in shape. Obviously at five foot, you know, seven, just like yourself, Mike basketball's probably not in our cards, right? So, right. I said that in about sixth grade, but yes, I like for, for, for sticking with that longer. So, so I realized that wrestling might, might work for me and. And one of the things, you know, I've, I, I'm sure I take, I took about 10 years off my life with all the wonderful ways of cutting weight and running in a sauna and wearing a wetsuit and all that good stuff. But, but you know, running was something I had to do a lot of to, you know, lose 10 pounds in a day and a half, right? So, running is, I have a love-hate relationship with it. Um, I love. The mechanical side of it. I love the biomechanical approach to understanding what something looks like when it's happening at an efficient level and what something looks like when it's not. But in terms of myself running like the Lar, the longest, the furthest I've ever run, I've done a a 15 K, and that's about all I ever care to do. Um, I think marathon training. I love people that do it because it kept me in, you know, working for a very long time. Um, but I think it's a long race. I really do. 26 plus miles is, is long. I think a half marathon distance is, is a great, is a great distance to kind of, to kind of have as a. As a, as a goal for, for many. But you know, the three, the five Ks and, and such, the 10 Ks are great distances. And, and I think people can dabble in, myself included, dabble in those for exercise purposes, to lose a couple of pounds here and there. Um, but, but that, that's my running, that's my running history more for sports and as of necessity to lose weight. And then as time has, has gone on more of a, just a basic exercise thing, I'm, I'm not competitive with running at all. I'll mute this up. I don't know if you can hear, but my neighbors landscapers are like going crazy right outside my window right now. Very little. I can hear it. I'm like, what is the chances? You can't hear it that bad right there. I was gonna say, not terrible. The, the noise cancellation is probably pretty good. I was gonna say like the, the dude is like literally right there. I was like, I'll get a spike the audio. I'll find, I'll find that now and we'll get there. So, alright, we'll keep going. So, um, All right. Scott, can I, can I share a secret with you? Can you not tell anybody, although I guess the, all the people listening to this are there, but, um, I've, your secret is safe from me, Mike, all of you listeners too. Um, I've ran a mile like. Twice in my life. Like that's the mm-hmm. That's the furthest I've ever run. And that's, and it was because the bear got tired. Right? The bear got tired. And, and I, I do not like running. And I, and I gotta ask you this almost now, just because I feel this is true for me, but like, like can everybody run? Are some of us just built, like our body's not built to efficiently run? So then therefore, like, We don't like it, we don't like the way it feels. Is, is that a thing? Or, or, or can anybody be a runner? Cause I know you just brought up like, running for fitness and exercise and even mental health. I mean, running's awesome. I wish I could do it, but I, I truly hate it. I is is there something to that, that not everybody is built to run or did I just make that up? No, I think, I think that's true to a degree. I think there are certain people that are built not to run far. Um, I think, you know, I will ne I was not built, you were not built to dunk basketball. So it's just not part of our dna. It's not what we're capable of doing. Um, I've seen some very overweight, unfit, uncoordinated people run marathons, right? We've all seen it. Um, how long can they keep that up for? That's the really the debatable question. I think everyone can run a certain amount. Um, Are there certain types of body morphologies that I feel are putting them at greater risk potentially for injury if they run greater distances or run for a prolonged period of time? I personally believe that. Um, but, um, I think everyone could run. Um, I think we just gotta think about this, and I talk about this all the time with my students and patients. You know, what we do as physical therapists is, is difficult, especially if we're trying to really come to the root of why something happened, right? But if we break it down to simple terms, like if your stress exceeds your capacity, Something's gonna break down and you're gonna hurt. Right? So if we break it down to those simplest terms, that's really what we're, we're thinking of and what my capacity is and what your capacity is, is very different. And what stresses we're putting on those bodies is very different depending on our terrain, our, our movement efficiency, our strength, our rest, our recovery, all of that plays into that. So at any given time, can somebody run? Yes. For how long? I think that's where we really start to open up Pandora's box of questions as to. The true answer to that question. And, and I, I love, I love the analogy or, or the concept of the workload and capacity thing. And then I've always thought of this at least like with, you know, like my athletes with baseball players and stuff. That is, there are some things that you can do mechanically that will, um, that will increase the stress that happens during the throw. So there are mechanical, uh, there are no, there's no such thing as, Good or bad mechanics, just the mechanics just alter the stress. And there are mechanical changes that you can do to apply more stress. So of course you would need more capacity, but at some point in time, I mean, efficiency of the movement is also important too. Do you, do you agree? Is that like one of the things you look for in your runners too? Is there, is there a biomechanical efficiency that helps optimize that ratio of workload capacity? I, I do, I do believe that, you know, I always tell people when we're changing form, cuz we do change form. I, I am a believer in changing form and we can go down that rabbit hole in a little bit. But, um, I always say no change without consequence. Right? We don't change something and have that, that that force kind of. Um, evaporate into, into thin air that stress evaporate. It goes somewhere else and hopefully it goes somewhere that our body can tolerate it. Right. And like you said, you know, there's no perfect pitching mechanics. We've seen, you know, the Dan Quien bees back in our era, guys throwing side arm, and it looks like, it looks like it's gotta hurt and it's not very efficient, but he's very successful at it, you know? Right. And then there are other people that are more over the top that also. You know, either succeed or don't succeed. And, and um, same with running. There are some things in running that we kind of hold true to ourselves, right? There are some running, I call it, um, non-negotiables. For me, you know, running and landing is close to your center of mass is something that I strive for every one of my runners to achieve. Um, that to me is non-negotiable. What part of the foot hits the ground first? That is something that we're gonna have a big debate on, right? And, and certain people feel strongly one way or the other, and we can get into the way I feel, but, but landing close to your center of mass, um, is the most efficient way to run. Are you gonna truly land underneath your center of mass? Probably not. But you, the, the closer you get the, the, uh, the, the lower the braking forces, the, the, uh, short of the ground, ground contact time, which then decreases the amount of work your body has to do. Most running injuries in the distance population occur when the foot in contact with the ground, right? In sprinting, that's a little bit different. They're in contact with ground, far less, the force is far greater. Um, but in distance running it's more contact with the ground that creates the problem. Um, so if we can limit that stance time, get him landing in a more efficient, under their center of mass position. I think we're, we're achieving a lot of good. Um, I do also believe personally that landing in a four foot mechanics is probably most optimal for most people. Um, you're not gonna see a sprinter sprint on their heels. It's just not, it's just not appropriate. It's, uh, you may see somebody sprint on their heels. They're not gonna be a good sprinter, but the successful sprinters Right. Maybe an athlete, but not a sprinter, right? Correct. Correct. Yeah. Correct. So, so if you, you know, the highest level, the fastest of the fastest are landing on the balls of their feet. Um, and for me, you know, in any sport, if you wanna make an athletic move, you're gonna have to push off your rear foot, roll to your forefoot and cut off your four foot. Having somebody cut off their rear foot is not, again, a, not an efficient. You know, um, functional, kind of powerful position to kind of move into. So for me, um, I just feel like our body's more elastic, more able to load and explode if it's in that four foot position at initial contact. But again, not all four foot contacts are made equally. Um, you can land on your four foot. And, and the reason why, one of the reasons why I believe four foot contact got such a bad name is that people are forcing it. And when you force a contact, just like anything else, it's not natural. You start to exhibit other non. Appropriate, uh, patterns and activate muscle activation to achieve that. So you oftentimes see excessive plant reflection of the ankle with a, with a force four foot contact. When I have, when I teach courses, and I, and I try to demonstrate this point, I always tell people to stand up and I have'em run in place. And when they run in place, every single one of'em lands on the ball, their foot. And then when I ask'em to run on their heels, it's just not natural. They don't do it. So I said, nobody told you to run on the balls of your foot when I asked you to run in place. It's just natural. It happens. That's what we want to have happen when we're running, and I think all too often people start to hear things, oh, I need to be a four foot runner. They start forcing it. They start reaching, they start extending their knee plan, flexing their ankle, having contact way out in front of their center of mass, which again, is not the goal of what we're trying to achieve. So how much time do you spend in the clinic looking at running mechanics? Is this something that you do all the time? You know, if so, like what are some of the things you look at? Like, I know this is an area like with our podcast, where we answer questions like we get this question every now and then because I think so many people are interested in like, how do you get started looking at running mechanics? I'd love to hear your experience with this and some of the things you look for. So, A couple things. I definitely do look at running mechanics. I'll give you a little story. So, you know, I've gone at the University of Florida, we have a very elite track program. Um, cross country is not as good as our, as our sprint team and jump team, but we have a very elite program. We win in na, we win national championships very often. And um, we've gone through a couple of distance coaches and as everyone comes in, I always ask them, You know what, when they're recruiting a, a given athlete to come to Florida, what are they looking for? And one of the common things that never comes up is form. Um, it's always, you know, do they enjoy running? What do their times look like? Have they missed a lot of time due to injury? Nobody ever speaks a form, and I have found that form is super important and coached at a high level in the sprints and in the jumps. But in terms of distance, it's not really coached. They, you know, and that's n that's nothing negative about any one of our coaches. It's just not something that they worry that much about. They're more worried and concentrating on building programs, building training routines, building workouts for their plethora of athletes that all are at different levels. Right. So, um, when I asked initially, is that something that I'd be able to, to really work with our athletes from the Florida, you know, collegiate standpoint. They were like, absolutely. Um, So in the clinic, obvi, obviously I would do that, but that was always something I'd, I'd hang my hat on. And the fact that even at the elite levels, form and, and, and mechanics is not something that's really coached that much in the distance population. Baseball, obviously pitchers, that happens all the time, they're coaching mechanics all the time. Why are we not doing this in running golf? They're coaching it all the time. Why are we not doing this with the distance population? So I think part of it is because there is. No right or wrong. There are, well, let's say this, there's a lot of wrongs and a l and, and fewer rights. Um, but, but you know, for me, I always felt that it was really, really appropriate to try to, to try to nip certain things in the bud. And, you know, the timing of when you make changes is oftentimes a big. A big problem. You know, the, the track cross country outdoor indoor season is very long in the collegiate, you know, the collegiate world, and, you know, having the right time to make those changes is, is tough because you know, when you make a change. Is the body able to compensate and, and, and deal with those, those, those moving stresses. Now, those stresses that have now applied to a different area, um, and, you know, having somebody run 80 miles a week and then all of a sudden changing their form and having'em continue at that 80 miles a week is, is not something that's probably the brightest. So if I were to tell my coaches, Hey, by the way, we're gonna back this runner down from. 80 miles a week to, to 10 because I changed their form, it's not gonna go over very well. Right. So I think the c the changes I make in season are very, very slight and very, very, um, small in terms of the overall, um, you know, scope of what changes could be made. But, um, when run, when runners are injured and not running, that is the best time to actually incorporate a new change into the, into the equation so, you know, obviously when, when mileage is high, it's not the optimum time to, to make a change, but really the best time to make a form change is with a, with a runner that's injured and not running because you're gonna ramp'em back slow and gradual anyway. So why not to try to introduce something that is, is going to maybe make them. I'm not gonna say less likely to get injured in the future, but if you see a glaring problem, then why not address it then? And, and getting buy-in at that time is also the best time too, because, you know, you know, runners are I when not even my collegiate runners, my, my runners that have been running 50 years and I try to introduce a form chain. They say, I've been running this way my whole life. You know, why am why all of a sudden now is it a problem? I say, well, you're not as strong as you once were. You're not as young as you once were. You need more recovery. And guess what? You know, it's not, it's not. If you break down, it's when you break down and you broke down. So your way obviously isn't working. Let's try a different way. You know, so, um, that, that's, that's, you know, getting buy-in is in anything is tough, but that is probably, for me, the best way to make that buy-in case is when they're injured and trying to get back. I, I think that's brilliant and that's a great way of, of thinking of it too. So, um, all, so you have in front of you, you're looking at them, you, what do you use a, you use a treadmill? What, what do you have Technology. Like, what do you like to do in your, in your clinic? So I think, you know, I've had a, a bunch of different things over the years. I think the tried and true way that I tend to do it in terms of trying to address the things I need to see is a treadmill with a high speed camera, whether it be an iPhone, an iPad. Um, I find great results with 2D analysis. I think 3D analysis is great if you have the ability to do so. Um, but 2D analysis is, is in my eyes more than sufficient. I tend to look a lot at the sagittal plane metrics such as stride length, um, uh, foot inclination, angle, tibial, inclination angle, knee flexion and initial contact, something I call hip separation, angle trunk, lean stance time. So those are all things that I feel like I can make a big difference in and get a good, um, 2d. Um, uh, picture for lack of a better, better way to describe it, of what I think they're doing right and wrong and make those changes That was awesome, Scott. I really like your approach to that and in trying to help people with their form when they're injured. Makes perfect sense to me. I, I really like the way you outlined that. I think that's the, the most logical thing to do, to make sure that we're not overdoing it with them. So if you have somebody in front of you, they're in the rehab process, like what do you use? Do they, do they just run on a treadmill? Do you have technology? What are some of the things that you use to look at their mechanics? So over the years, I've, I've used a lot of different things. I've used everything from 2D analysis to just my eyes, to 3D analysis at times. And, and honestly, the best way to do it, um, at least in, in a quick clinical setting for me, has been always 2d ana, um, 2D analysis with, um, a high speed camera of some kind, whether it be an iPad, an iPhone. I think you need video. Think you need to be able to slow it down. You know, whether you're looking at at least 60 frames per second, probably a little bit faster, probably 120 frames per second is probably better. Uh, it's definitely better. It's probably what you need. Um, I think 2D analysis can get the job done 99.9% of the time now, if you're looking for Yeah. You know, research level, um, quality type of analysis and, and, um, sometimes I, I think sometimes people get too, um, caught up in. Trying to make everything perfect and symmetrical by numbers. And I think if you catch the low hanging fruit, I think you fix the majority of problems. That's just my opinion over my years of experience. Now again, 3D gives you great information. There's no question, but the question is, um, how much is that is truly really required? When I'm looking at a runner with a, with a high speed camera that's two-dimensional, and I'm looking from the sagittal plane and I'm looking at things like, uh, contact from center of mass. Foot inclination, angle, tibial, inclination angle, knee flexion at initial contact, knee flexion at mid-stance, uh, hip separation angle. Something I kind of talk a lot about, uh, what trunk lean is, uh, how long are they in contact with the ground, if I can make changes to any or all of those different variables oftentimes. So those are all sagittal plane metrics. Oftentimes I find that the frontal plane metrics such as like. Knee valgus or rear foot inversion, e. E-version oftentimes take care of themselves because I think oftentimes those are related to. Prolonged loading or prolonged stance time and the body having to deal with stress for a longer period of time. So we know that pronation is a way in which we deal with stress and pronation oftentimes gets pigeonholed to the foot and ankle problem, but it's not, it's a, it's a lower, it's a lower body really problem. When you think about what happens, the femur internally rotates. The, the knee goes into this dynamic valgus, the tibia internally rotates the calcan evert. So all of this stuff happens. Oftentimes, we just concentrate on the foot and ankle and say, oh, the foot and ankle is pronating too much. Let's stick an orthotic in there and let's stick a motion control shoe in there. When in fact the foot's just doing what the body's asking it to do. And by putting an orthotic in, or, or, or by. Putting more of a stability shoe, you're really just shifting the problem somewhere else. The problem may be that they're in contact with the ground for too long and they're asking their body to absorb stress and shock, and now you've taken one of the body's abilities away to deal with that and creating other problems. So I oftentimes say like, patients come back to you over the years, and I'm sure you've dealt with this in the, in the upper extremity mic, where a patient. You see and you treat, and they do well for a, a certain problem, let's say plantar fas or plantar fasciitis, and you treat'em successfully, you think, and then they come back the next year and you're like, Hey Scott, I wanna see you. You fixed my plantar fasciitis. Now I've got this hip issue. Can you fix that? Probably the, the problem with the same all along, it's just kind of presenting itself in a different way. So, um, I think we, we, we gotta stop chasing that a little bit and, and really start looking at the root of problems if we can. I, I, I, I think that's an amazing, uh, thing that a young clinician I think would really benefit from too. And it's not about nitpicking, it's about finding those low hanging fruit and then seeing what happens, right? Seeing how many other things clean up. I think some people take that for granted that a lot of things will just clean up themselves. So, um, I thought that, I, I think that's amazing. I think that's, that's a really good approach. You know, Bri, Brian Heder and Cadence, not to interrupt you, not to interrupt, but Brian Heder and Cadence. You know, made such a, made such a big, um, uh, uh, IM impact on the, on the running medicine world by his, his research involving cadence manipulation. And, you know, it's just one of those things that is so easy to, to do for a right, for anybody. An entry level clinician, an experienced clinician. It's something that is very, very tangible and has great impact on movement efficiency and movement mechanics and load, uh, manipulation. So, um, again, to, to reiterate what you were just saying, low hanging fruit, why not Go for it. Yeah. Yeah, I, I love it. And just because you brought this up earlier, I gotta ask cuz I know there's a couple other things we wanted to talk about, but I gotta ask, how, how has your use of orthotics evolved over the last 20 years? Cause I know you said you were huge on it before you were grinding away on the weekends. Um, what, what do you do nowadays and how often do you use orthotics? So I am probably. I've been doing orthotics for a long time and I feel strongly that there's a place in our world as physical therapist for it. Um, you know, when I talk about, um, injuries, oftentimes I go down my spiel of, you know, so much of what we do is trying to increase capacity, decrease stress, and shift loads, right? And one way in which we can effectively shift loads. It's been shown time and time again. Is via taping and orthotics. Bracing. It helps. It shifts. Loads. Now, is there a perfect position to put the foot? We can debate that. Um, but we know that by changing how somebody's foot contacts the ground or how it moves, once it contacts the ground is going to affect the entire chain and the whole mechanics of that. And if I haven't injured, uh, you know, when working with athletes, you're working with baseball players at high levels. I'm working with runners and other collegiate athletes at high levels. Our job is twofold. Our job is to get our, our athletes on the field after an injury as quick as we can. And our job is to keep them injury free as long as we can. And if I can get both of those achieved by, um, putting an orthotic in and deloading a tissue that is under greater du duress, why would I not do that? You know, if I can put an orthotic into one of my runners and they can go from six outta 10 pain to three outta 10 pain, and they can run. Why would I not do that? Now, that doesn't say I'm not gonna strengthen that. Doesn't say, I'm not going to do those other things. Work on mobilization, make sure they're moving right, work on their form. But if I can get them from A to B quicker. By just sticking a stupid piece of, of, um, polypropylene into their foot, into their shoe. Why would I not do it? You know, people always talk about, you know, oh, it's gonna weaken the foot. No, it's not. If you spend some time outside of, of their activity strengthening, you know how often, and I joke about this, like, you know, you go to the gym, you strength train, you lift for an hour. Let's say I'm gonna work on my chest for today. I'm gonna do six exercises of chest. I'm gonna do some flies, I'm gonna do some incline, I'm gonna do some flat bench. I don't do chest 24 hours a day. I do it for a little bit and then I let my body recover, right? So why not let our bodies recover with an orthotics and then strength train, right? While we can, right. I mean, the logic is so sound right? You make it sound so simple. Mm-hmm. Right. But people say these things all the time, and I think, Scott, to be honest with you, that's what makes you a good sport physical therapist, because sure, you could just go sit in the cave and not do anything and just work on. Strengthening all day long, but you also have to get these people back on the field as fast as you can. So to me that's sports, physical therapy. That's how you put it together. And, and I mean, you, you, you made it sound so simple that I, I chuckled a couple of times because like, it's, it's that obvious in front of you. Yet people will argue that on the internet all day. Absolutely. And, and again, I am a huge proponent of strengthening and we could talk about, you know, foot and ankle strengthening and how I feel like blood flow restriction therapy, which I know is near and dear to you, is near and dear to me. I think it is the, yeah, the, the hidden gem of foot and ankle rehab. Whoa. You know, Whoa. That's, that is, that's, that's a bold statement. I, I'm telling you. Think that's where we're gonna pivot the podcast. All right. Here we go. Ready? So, love. So as, love it as you teach, as as you teach. And, and I teach, you know, with regards to blood flow, in order to get stronger, you have to challenge the muscles at, or the body at like 60%, 65% of your one rat max, right? You gotta put significant resistance through the tissue, and we know in order to get. You know, big or stronger hyper, hyper hypertrophic changes, you either have to put tension through the tissue or you have to create that metabolic stress or, or cell damage sometimes. So those are the three ways in which, and you know, if whether you're injured and can't put that mechanical tension through the tissue or don't want to. You know, creating that, that metabolic stress is, is ideal. And we know with the foot and ankle, you know, it's not like you can lift a whole lot of weight with, with your foot intrinsics. It's not like you can, you know, you know, TheraBand is not 60% of your one rep max. It's just not, uh, you just can't grab a dumbbell with your toes oftentimes to create that, that, that, that, that mode. So for me, it's almost like we're wasting an opportunity to. To get that response by not putting the BFR on while doing stuff like TheraBand training, while doing balance work, while doing, you know, foot doming. Why would you not take that opportunity to try to squeeze as much juice from that grape as you possibly can? Because I know people are not balancing with weight vests. I know they're not putting that load through the tissue. That creates that support structure that we need to kind of keep our foot and ankle strong. Wait, so I shouldn't be balancing with Weight vest now? Now I, I, I get. You can. You can, you can, but you can, you can balance with weight Vest and be a par. I love, I love that on a bosu ball at the same time. That's, that's right. That's right. I, I. I, I think, I think that's a no-brainer too, because like you said, it's, it's really challenging to, to get certain areas of the body to work out with high enough load. And I think you've just identified a very obvious, uh, way. So, so I assume you've been doing this, are you doing this non-op, you doing this post-op, you doing it on everybody? Like, like what, what's the population that you're doing this in Most? I typically do it with every single one of my patients. And again, my population is very heavily, you know, ne and below, especially like shin and below. And, um, there's, there's certain things I'll stress more with certain types of. Operative situations. I think it's wonderful for Achilles repairs. I think it's wonderful for, you know, brostrom, brostrom or lateral ankle reconstructions. But I do it with, um, medial tibial stress syndrome. I do it with plantar fas. I do it with. Poster TI tendinopathy. I do it with all of them. Every single one of my patients, I wish I had, you know, at one of my clinics that I treat, you know, we have a BFR at every single table, right at another one of them that, that I treat. Uh, we only have one, um, at, at, at that particular clinic. And literally part of the juggling act that I do that gives me the most stress is trying to determine what. When and how am I gonna get every one of those patients to utilize that b f R at some, at some point of the treatment? Because there's multiple people in there, sometimes at one times, you know, so I think there are certain, certain units that I think are, are, you know, that I use, that I really like. I, I like the Delphi as the gold standard, but I, I use Suji all the time. I'm, I'm a big believer in the company and the people there. I like how you can do it de tethered. You can do, you know, both lower extremities at the same time with the Delphi. You know, you need two units to do that. Now I know there are plenty of other brands out there, but, but again, I think it is, it is something that, um, we should be taking advantage with our injured population. I think it is something we should be taking care of or taking advantage of with our in-season training of athletes. What better way to give an athlete active recovery without allowing them to totally ne neglect their strength? Why, why not put'em on a B bfr and not tax the tissue nearly as much, but still get that metabolic response? Um, mm-hmm. I think it's great for our aging population of, of athletes because again, as we get older, our joints, our tissues, they're not able to tolerate the loads that we once were. And, and, and why not put the bfr on, challenge our body with less loads and create a similar type of strengthening environment. Uh, well, I'm sold. I mean, you got me. I think that's amazing. But, uh, te tell me a little bit about like, how you use it for, like, let's say I, I know it's, let's talk about an area that's hard to like load maximally. So say like you're working on like, uh, you know, intrinsics or, you know, even, even basic stuff like inversion, e-version type stuff. Like what, what do you do for like set rep dosage? Is it the classic protocols that they use, or do you do your own thing? Like what do you like to do? I do my own thing. So there's one, there's a couple of tools I like. There's something called the blackboard, which is in essence a wobble board split into two pieces for the foot and ankle where you can lock the heel up and allow the four foot to go into inversion and e-version. You can put it at a slightly angular plane. Um, and I'll have my, my patients do sets of 30. You know, cuz the goal of bfr this magical 30 15 15 15 isn't magic. It's just a number to try to create some fatigue, right? So, so whatever you do, If 30 15. 1515 isn't taxing that tissue enough. Then you're not doing, you're not doing it justice, right? So, you know, I'll do sometimes with TheraBand I'll do sets of 60 with my TheraBand training, um, in my single leg stance balance work. I'll do time sometimes, like have a catch right standing on an AirX pad against a rebounder, and do sets of 30 seconds or do sets of 30 tosses, or hold it for a minute. Or, you know, I change it up all the time depending on what I'm trying to accomplish, how much load I'm able to in, you know, uh, in, in incur or, or, or push on the system. And again, if, if I'm doing balance with somebody and they continuing continue to have to put their other foot on the ground. Then, then maybe I need to go for a longer period of time because they're not stressing that tissue quite as, as long as I'd like'em to, versus somebody that's able to, to really balance for a long period of time is really gonna fatigue that tissue. So I think it's very unique, but I do not stay pigeonholed to that 30 15. 1515. I do use it on occasion, I think. You know, for open chain leg extension, I think it works great. I think for some of the straight leg raises and hip abduction, let's say, I think it works great. Um, but, but again, I'm not opposed to kind of changing it up depending on, on the, on the movement, on the exercise, and in the body part. Yeah, I think that makes sense too. There are certain groups who are 30 15, 15, 15 is not going to, that's they're not gonna be fatigued at the end. Correct. So I like that. I like the 30, 30 30. I think that's a good option. I, I like the time. I, I, you know, I, I, I couldn't agree more. I, I, I like the way you, you, you focus more on the outcome versus the process. I think some people, they go to a course or they learn it online and, and, and they say like, well, I have to do it this way. Right, right. Sometimes they don't use their brains a little bit. I like how you're focused on like, what's the goal? The goal is to get some fatigue. Right. So, um, so, so awesome. What, what about in, I know you said you use it in season, what about in healthy Runners? Have you done this at all for the performance enhancement? Like, like skew of this versus just like getting back with their recovery? Like, and I, I know you talked a little about how you could use it as like a deload for recovery, but anything specific with performance enhancement. I think so. Yeah. So we know runners typically don't run for, they run for exercise, they don't exercise to run. Right. So getting a runner right to, to really truly load their body is, is a tough sell. It really is. So I, I think there is a place for certain runners where they could, I. You know, put the BFR on their lower body and do some squats with some, you know, a 25 pound kettlebell and, and really fatigue it out that way as opposed to, you know, people don't have access to the gym all the time either. So, you know, right. Do we have the ability to throw a bar in our back with, you know, 2 45 pound plates on either side and really go to town? Probably not, not everyone has that, but you know, not everyone has bfr either, but they're becoming a lot more affordable for the home use. And I do think that. It's here to stay. I think it's something that really can, can benefit everybody. I really want to say everybody. I think it, it can help with performance. There is no substitute for true strengthening. I wanna make that point clear and known, right? If you can load the body with weight, load the body with weight. But if you need some time to recover or for whatever reason you feel like that body can't tolerate that load or wanna give it a break, BFR is a great option. Right, and we, we, that was one of the first things we talked about. I don't even know how many years ago now. It was probably eight years ago now. When we started looking at BFR Champion, we talked about it as a team. Like what are some of the things we need to be careful of? One of the things was like, well wait a minute. Like if we do this too much, let's say an Achilles, right? Like that sort of thing. You don't want to deload that. You don't, you don't, you don't want to just always just increase strength at a deload because. Then the tendon's not getting the correct. Right. And I think, again, sometimes people, like, they don't, they're not thinking outside the box. They're just like throwing it at that. So I, I, you know, I'm glad you brought that up. You have the load. I'll give you an example of how adjunct Yeah. I'll give you an example of something too. So I have a, an Achilles repair and a, and a pretty big football player right now. And one of the things that we struggled with is that, you know, if we loaded them significantly three times a week, Um, he would get a little sore. And so what we tried to do is maybe do a Monday, Friday regular load the tissue, and Wednesday maybe load the tendon and the calf, uh, with bfr doing less strenuous type of activities to get that calf to kind of still get engaged and try to benefit in other ways, but not put that same. We'll call it tissue stress through the tendon loading the tendon's important, getting the stress through the tendon. But at some point an injured tendon may not be able to tolerate it, and that's where the BFR can come in as well to allow that calf to then truly get stronger too. Cuz that's the thing you deal with all the time with achilles tendon, not tendon repairs is that calf just goes to crap, right? Yeah. Yeah. So load it because you need to load it, but instead of just saying, oh, you're getting so sore, let's just do it twice a week instead of three times a week. Add that third day, but do it with the bfr so that way it's less and you still Exactly. Uh, I nailed it. Uh, that was awesome. Uh, Scott, amazing episode. This was awesome. Uh, before I let you go, uh, high five at the end. Five Quick questions, five quick answers. Tells me a little bit about you. Not that I'm judging, but here's, here's, here's question number one. Okay. Um, I always, I always love to hear the responses, but, uh, what are you currently working on for like your own con ed, your own professional development? Like what are you doing right now to learn? Professional development. So I'm, first of all, I always go down the rabbit hole of YouTube. I watch videos on YouTube. I can spend hours upon hours learning something like I was watching the other day, like how to begin for, for a novice to 3D prints, like what it would take for me to buy a 3D printer and all these cool little plastic things I can make. Right? So, Um, that's one thing people, people that know me always, people will that know me, always know I have something cooking in the fire. And it's like one crazy idea is like what it is, right? So I actually read a book, um, called One Simple Idea by Stephen Key, and it's about, it's about, um, How to take your crazy ideas and instead of going through the manufacturing process yourself, like licensing people to get and take your ideas that are hopefully not crazy, that you can actually make something off of. So that was one thing that I, that I kind of, like I said, I have ideas all the time and, and I just, I just, not that I don't know how to get'em started, it's just that, you know, there's just so many of'em that, you know, sometimes you just need to, you need to step away and maybe just kind of come up with the ideas, be the idea guy, and let somebody else that knows kind of the actual process behind it make it happen. So, Um, there's that, and I'm taking a dry needling course actually this weekend. Actually, you caught me at a good time for that question. Yeah. Yeah. Uh, fir, like first one, is this your first one? First one, yeah. Florida. We're a little late to the, okay. A little late to the game. And, um, you know, still we're still battling at our, at our hospital with the, uh, insurance ramifications and reimbursement questions, but, um, but it's something I always wanted to do and I think there's a time and a place just like a lot of other things in our, in our, in our treatment, um, right. Uh, bag of tricks that, that I think we could utilize. And it's just another thing that, that I'd like to learn. Cool. Yeah, that's good timing. I love it. Awesome. Uh, next question. What's one thing that you've recently changed your mind about? Ooh, I think, I think we talked a little bit about, um, you know, orthotics over the years and how I deal with running injuries has definitely changed for, for sure. You know, back when I first started, you know, treating runners in the early two thousands, let's say, you know, somebody came in with faulty mechanics. We gave'em stability shoes, and we gave'em orthotics, right? Now I still believe in orthotics. I, I've fallen away from the stability shoes, um, a little bit in terms of the pronation control, elevated cushion healed shoes, the ones with a really, uh, large, uh, heel drop, you know, greater than like 12 millimeters or so. I stay away from those. Um, I do, I do feel, um, that, uh, orthotics still have a place, but I've also gotten a little bit soft on my forcing everyone to be a four foot runner. Um, kind of got away from that a little bit. I'd still believe it's the way to go, but I think there is a time and a place for somebody to maybe not run as much on the balls of their feet, especially if they're dealing with, you know, Four foot pain if they're dealing with, you know, plantar fascial pain, potentially. Um, if they're dealing with Achilles pain, potentially, those may be reasons why, for the time being, I may allow them to run a little bit more midfoot rear foot as opposed to four foot. Um, but I do believe that to make them a better runner, I do believe that they need to run on their forefoot. But to allow the injury to, to kind of calm down some, I have softened and, and allow that a little bit. So that's one thing. I love it. That's great. Um, you, you deal with a lot of students, right? What's your best piece of advice that you love to give your students? Uh, I think we talked a little bit about, uh, already, um, stand out. You gotta create, you gotta create a way for you to differentiate yourself from others. You know, I, I, I run a residency program here at uf. I direct that and I have a great staff that, that helps me with that. But, Um, I have calls every single day from prospective residents and they ask me, you know, what is your ideal resident candidate? And I tell'em, I don't know the answer to that. You know, when, when we're making decisions for, for our, for our who we're gonna interview cause we don't interview everybody. Um, we interview probably, you know, 10 out of an applicant pool of this year we had in the mid fifties. So we're interviewing 10 out of 50. Um, We take two, you know? How do you stand out on a piece of paper? What is it about you that makes you unique? You know, we have 50 qualified students that are all interested in being a sports resident. What is it about you that makes me read this and say, this is our guy, or this is our girl, or this is our student that we need to kind of interview and kind of take the next step with. So I can't, I can't say, I say we know it when we read it, but I can't tell you what it is, you know? Um, because I don't know what it is. I don't know what it is. But you've gotta stand out in, in a positive way. Don't stand out in a negative way. Stand out in a positive way. I, I, so I like, that's an amazing answer. That's the first, like, you know, sometimes there's recurring themes in these answers that I always ask everybody. I think that's a good one. And since you're an idea guy mm-hmm. I think that's a t-shirt, right? Stand out. And that's just like, boom on the t-shirt. Like, yeah, let's get that going on Etsy. Let's get, I I don't laugh. You're, you're gonna laugh when you hear this. I have a Shopify. Store where I have t-shirts and one of'em, uh, they're funny, some of'em are, um, are PT related. Most of'em P PTs, the original Fitness in Influencers. I got that one. I've got the, uh, um, uh, what is it? We know it hurts and that's why we poke on it. Something along those lines, you know, so I can, I can definitely add this to the list, so just let's do it. Dude, that is amazing. Hey. Yeah. What, so you gotta tell me what's your, can we buy this? Like, does this store exist? Like Abso It does exist. If you, if you go to, if you go to run safe run fast.com, there's a link. It'll take you right to my Shopify store. I mean, I'm in, I know, I know, I know. I'm going from here. I, those are amazing. So, um, what, what, what's coming up next for you? Oh, goodness gracious. We, I've always got something in the fire. I always do. Um, I stuff that I, I'm not gonna talk too much about until it actually happens. Um, I don't wanna jinx it or whatnot. There's some stuff, there's some stuff going on. Okay. All right. We'll revisit, we'll revisit this, uh, at a later time and we'll, we'll, uh, we'll, we'll circle back. On the next episode, but this is like the cliff hanger for the end of the season. I think that's awesome. So, yeah. Um, awesome. Well, Scott, you, I think you just mentioned a little bit, but like, where can people find out more about you? Is it, you know, obviously your website, maybe you can, you can say it again. Mm-hmm. Uh, social media, but where, where's a, a good way for people to follow you? Uh, probably either of those two sites, you know, Scott Greenberg, uh, dot DPT on Instagram is a good one. And then, uh, I have a website, uh, run safe run fast.com. Um, and then that's the same Twitter handle. Run safe, run fast. Um, those are the best ways to find me. Sometimes I'm active, sometimes I'm not. I should be more active at times. I'm not as active as Mike is, but, uh, but I'm trying to build up that Instagram following to, uh, to, to, uh, social influencer status. So we'll see. Nice, that's awesome. But Scott, that was amazing. Thank you so much for coming on. That was awesome. Happy to do it anytime, Mike.