I vehemetly hate prone-hangs for regaining knee extension. I mean VEHEMETLY. I know that regaining knee extension(your knees ability to straighten out) post-operatively is important and that a lot of people find success using them but I will never use them. I just think there are methods that are just as effective and much less uncomfortable. The point of prone hangs is to encourage regaining knee extension through what’s called tissue creep. Tissue creep is a concept where we increase the length of a tissue by introducing stretching for long periods of time. So the idea here is that if we do a prone hang for long enough, we’ll stretch out the posterior joint capsule of the knee and the range of motion will come back.

Have you ever done a prone hang yourself, though? They’re awful. You lay on your stomach with your knees hanging off a table for an extended amount of time (5-10 sometimes even 15 minutes) letting gravity pull your leg to the ground while your thighs dig into the edge of said table. Now you might be thinking “I do that a lot already. What’s the big deal?” and I’ll tell you what’s the big deal: you haven’t just had surgery. Post-operatively, someone is already in pain and getting their range of motion back can be an uncomfortable but necessary experience. So now you have someone in pain, doing something that is incredibly uncomfortable and you’re subjecting them to that for prolonged amounts of time with the added discomfort of their thighs digging into a table? Sounds kind of cruel if you ask me.

Now the term cruel might seem dramatic but it’s correct. Cruel is defined as willfully causing pain or suffering to others. If you’re an athlete trying to come back while you’re in season, the pressure to regain range of motion can increase even more which might lead to even more cruel methods of regaining range of motion. We’ve probably all seen the video of Neymar’s medical team cranking on his knee right after he got surgery to regain his range of motion. He’s damn near in tears just getting his range back. It was absolutely unnecessary and the definition of cruelty. Most clinicians will agree with that assessment. Rehab shouldn’t look or sound that way. But there are a lot of clinicians out there that, once regaining range of motion starts to not get smooth, or is taking a little longer than they would like it to, immediately jump into these kinds of methods.

I once had a supervisor tell me something along those lines whenever I was working with a patient coming back from a knee injury. Range of motion wasn’t progressing as fast as we had liked but was still getting there. We were in a time crunch as this patient really wanted to return back to activity quickly. So when things weren’t going well my supervisor suggested that I lay my patient on his stomach and force this patient’s knee into flexion and then into flexion. My supervisor specifically said “He’s not going to like it very much but it’s what we have to do”. I remember thinking “Excuse me?? We don’t HAVE to do anything.” and immediately ignoring the suggestion. (There’s a reason we put people under anesthesia for joint manipulations you know.) I wasn’t going to do it. I refuse to cause that kind of pain and suffering to another human being just so we can be “on track” with the rehab timeline. So we didn’t. Instead, I put the patient in positions where they could control their range of motion and level of discomfort. I encouraged them to work on their range of motion multiple times a day and we worked really hard to make sure that we were making progress. Taking measurements frequently and finding small goals to use as signs that we were making progress like getting a full revolution of the pedals on a bike. It still took a little while to get where we wanted it to be but we got back to full range, and still were able to return to activity on time. We never needed to crank on that joint.

I think that’s the problem with our medical system today. The medical system is ultimately more focused on disciplining bodies — making the body do what we want it to do regardless of what is current capabilities are — than meeting people where they’re at. The body heals on it’s own timeline. Not ours. Are there general guidelines for how long that healing should take? Absolutely. But there is no reason for us to try to force something just because they aren’t on our timeline. It degrades your patient’s trust in you, it creates a negative association with musculoskeletal rehab, and sets the expectation that the rest of this process is going to be impossibly painful. Even though it doesn’t have to be.

What I’m not saying here is that if you do this to your patients you’re a bad person. Most of us get into these professions because we want to help people. Be a positive force for good in others’ lives. Our job as clinicians is to be that force for good by acting as a guide through the process. We need to train into and occasionally through a little bit of pain. In a lot of cases it’s necessary. But directly causing that pain to our patients because of timeline pressure or a lack of ideas is something that I can’t stand for. So go on, be a guide, and be that force for good that we all want to be.

See you for our next cup.

When I work with Athlete that needs rehab, I tend to be really quiet whenever they’re doing their exercises. I think that in a lot of cases that sounds counter to what a lot of people think about whenever we talk about coaching exercise -- rehab especially. It seems to me that when people think of rehab or an exercise there’s this “perfect” way to do something. For instance there are all of these ideas of what a perfect deadlift is. Knees over toes, flat back, full lockout hip extension at the top of the exercise. Which is awesome. That’s great technique and we should all strive for our patients to move like that. However, not all of our patients move like that. As a matter of fact I would argue that very few of our patients move like that at first.

So if our patients don’t move like that, then what do we do? In most instances, a coach or rehab practitioner would feel the desire to step in and say “make sure you keep your core tight” or “flatten your back” or do some drills to reinforce hip hinging and then make their patients do the exercise again with the focus on moving exactly like the drill. But for me and my patients? I don’t say a whole lot. Unless their technique is utterly atrocious or down-right dangerous, I tend to let them finish the set. Not because I don’t want to coach or I don’t know how. Instead, I reflect on the fact that patients are complex adaptive biological systems. The key word there being “adaptive”.

People generally like to be coached in some way. Especially people in pain because they don’t want to be in pain anymore. So whenever you give feedback like “flatten your back” or “show me your shirt” or “knees over toes” people will generally do their best to listen to that feedback. However, there is a such thing as too much coaching and I would argue that a lot of people coach too much. Human beings being adaptive means that the way that people do things adapts and changes on a regular basis. The more that you try to coach and give feedback, the more your patient or client is trying to focus on. Whether you like it or not too much coaching, especially in rehab situations where someone is trying to get out of pain and back to activities that they enjoy, (which is probably not weight lifting in a large number of circumstances.)may be convincing your patient that there is only one way to move that will keep them out of pain. Do you really mean to suggest that your patient with chronic back pain can only ever deadlift their kids off the floor? I’d venture to say that’s not what you think. So that means that a little variability is okay. As a matter of fact I would go so far to say that we NEED variability in the way we do exercises.

Don’t get it twisted now, I am in NO WAY saying that we should allow our patients/clients to do exercises with awful technique. I’m asking that we allow some space for variability and allow movement patterns to emerge in a way that we can intervene on. Lets talk about knee surgery for instance. If a patient that is post-op knee surgery is beginning to squat and we start to notice that the patient is favoring the involved knee and leaning towards the uninjured knee, what do we do? What we don’t do is just keep saying “focus on using that knee” because it doesn’t get us anywhere. Do you think your patient is trying to do that? No. Your patient knows what a squat looks like. Their knee is lacking the ability to do that particular task so they find a way to do it that allows them to complete the task within the current constraints of their body. So when I’m working this this patient that means we finish the set, maybe cut the exercise a little early, and work on isolated quad strength in ranges of motion that are tolerable. That means we may move on to TKEs(closed chain quad work) or maybe leg extensions (isolated quad work) and revisit the squat in a couple of days. Once that strength improves I bet you’ll like what you see.

Here's the thing: despite what you might believe, most human beings are incredibly good problem solvers. I don't think that "motor morons" exist. (That's also an incredibly demeaning term to describe a human being.) As a matter of fact, I think that most of our patients are "motor geniuses" especially when it comes to solving movement problems that we ask of them. They just might not solve the problem or answer the question the way that you want them to. So instead we need to ask more questions (movement questions and literal questions), shut up a little more, and be more intentional with what we're looking at and what our interventions should actually look like. If we should even intervene at all.

See you for our next cup.

At one point in my life I thought for sure that I was going to quit athletic training. I was a young student who had spent his entire life wanting to be an AT and when I first started in my program I thought that I was living the dream. I got to hang out at a Division I football facility and wear all of the university issued gear from shirts and shoes to backpacks and coats. From a gear and aesthetics perspective, I had it all. But as a clinician what I didn’t have was the confidence to put myself out there and actually speak to the athletes that I was training to work with. What I didn’t have as a student as the confidence in myself to actually believe in my abilities and let other second-guessing my thought processes or ideas impact how I went into the clinical placement as a student every day. It got so bad that I had finally convinced myself that I had no other choice but to drop out of the Athletic Training Program at the University of Utah because I just didn’t have what it takes to be an Athletic Trainer.

I finally reached out to a professor that I trusted as asked to meet with them. The first words I got in response were not what you would expect. They weren’t “Sure.” or “We can talk after class tomorrow”. Instead, they were “Are you okay? Are you safe?”. I responded with yes and that I would like to talk about something important about my future in the program. Jess, a former professor of mine who I now consider a trusted friend and mentor, sat with me in her office while I told her about how I didn’t have it in me to make it through the program and become an athletic trainer. Jess listened for a while and eventually told me about how I worked so hard to get into the program and that she saw all of this potential in me. She talked about how she saw my energy when I walked into the classroom and interacted with my classmates. She told me that she knew I could go on to be a great Athletic Trainer, that I could accomplish every single goal I had and that if I just made it through this semester I would get there. I believed her. I didn’t drop out. As a matter of fact I went on to graduate and receive an award for my current and future contributions to the profession. Jess taught me to have the confidence in myself to keep going. To keep pushing through the hard things even when it seems like the end is nowhere in sight. She believed in me when I didn’t even believe in me.

Later in the year, a clinical preceptor of mine, Katie, continued to build on that foundation that Jess laid for me. Katie was my first clinical preceptor outside of football. She had a reputation for being a manual therapy wizard and worked with one of the most sought after clinical rotation on campus. Katie also had STORIES. She had traveled the world, worked with some fantastic athletes, had a strong group of friends that supported her and it was clear that every athlete she worked with trusted her without question. On top of working in the chaotic college sports schedule, Katie played in a volleyball league, found time to travel even during the times of the year that were busy, and had dinner with her friends on the regular. Something that really struck me when I was working with Katie was that she was willing to tell me anything. If I had a question, she would answer it completely honestly. Even when things were hard for her. She showed me that things can still be stressful. But that doesn’t mean that it has to take over your life. She taught me that work life balance in this profession is possible but I think most importantly she taught me how to not take the job so damn seriously all the time. Katie still made time for fun in her life and in her job and I still find myself needing to listen to her advice more often.

Finally I need to tell you about Bri. Bri is also an Athletic Trainer, she was my boss for a while and she also happens to be my significant other. We worked at the same university for a while with me being hired through the university’s partnership with a hospital system and she was hired through the university directly. She’s intelligent, kind, and absolutely unfuckwithable. (I’m not kidding she’s not afraid to tell it like it is.) She has seen me at my highest points, pushing me to interview for and accepting a job in professional sports even if it meant we had to do the long distance thing for a while. She has also seen me at some of my lowest points. She has seen me frustrated with my job search immediately after grad school when it felt like everyone was getting job offers left and right and I couldn’t land one. As a matter of fact, she talked me out of accepting an internship position after being a graduate assistant for two years because “you’re worth so much more than that”. Throughout the 5 years we’ve been together, Bri has always pushed me to pursue what I want, has always supported me swinging for the fences and has called me out on my bullshit when I don’t swing hard enough or dream big enough.

Now here I am. All of these women have played such a vital role in my development as a person and as a professional. You want to know the crazy part? I’ve only told you about the things that they’ve done for me. I haven’t even scratched the surface of what they’ve done in their career. They’ve worked with professional athletes, Olympians, and are head athletic trainers at the age of 28. They’re some of the most sought after professionals in our field. And they’ve taught me how to bet on myself. I’m not in my current position without them.

I’m currently in the middle of starting my own company. I can’t lie to you, I’m fucking terrified. I have no idea what I’m doing or where to start. But I lean on these women and so many more every single day. They are the people that keep me going because they’ve bet on me. They believed in me and propped me up so that I can continue to chase my own definition of success. One that isn’t focused on titles or fame or whatever else society would tell you is an indicator that you’ve made it. And I can’t thank them enough. So go out and thank the women in your life. Because if you’re anything like me, you wouldn’t be anywhere without them. And to Jess, Katie, Bri, Cassie, Caitie, Carleigh, Calle, Caroline, Laura, Ashley, Ally, and so many more: thank you. You have no idea how large of an impact you’ve had on me.

See you for our next cup.

Recently I’ve been thinking a lot about how Toph Beifong might just have some qualities that we as clinicians might want our patients to exhibit throughout their rehab process. For the uninitiated, or those who don’t like cartoons like I do, Toph Beifong, or quite simply Toph as Avatar: The Last Airbender fans know her, is the strongest Earthbender of all time. At only 12 years old, she is able to out-bend and defeat multiple opponents that are twice her size at one time (She used to fight in a WWE style bending tournament and was the undisputed champion), hold massive libraries up by earth bending using only her fists, and take down entire fleets of metal airships by earth bending the metal they’re made of. Oh yeah, and I forgot to mention that she’s blind.

I can already sense you asking how this has anything to do with sports medicine. I will tell you how it relates and it has everything to do with Toph being blind. But I can already hear you saying “Toph being blind makes it hard for her to fight doesn’t it? How on earth does that mean that she’s able to take down anyone let alone multiple people?” To that I say, yes, if she was actually unable to see at all. Toph’s blindness lead to her developing the “Seismic Sense” technique, a form of what is essentially echolocation, where she feels vibrations in the ground allowing her to “see” her opponents as long as she is making direct contact with the ground (If you watch the show you’ll notice she’s always barefoot). Toph’s seismic sense is also what leads to her creation of metal bending. She was able to sense the unrefined earth in metal and bend it to make metal move just like rocks on the ground.

Toph developing these techniques is a classic example of what I would call emergence. You see, human beings are incredibly complex and adaptable systems. Humans adapt to their environment and their own limitations based on what they’re tying to accomplish. Those three things I just mentioned are what we would call constraints. The three official categories of constraints are organismic constraints, the limits of the human body (see Toph’s blindness), environmental constraints, what the environment allows (see Toph needing earth to feel vibrations in the ground) and task constraints, what the task requires of whoever completing it (see fighting). Toph’s creation of seismic sense and metal bending are just that. Toph’s adaptation to being blind is her body solving problem of blindness in real time. Her creation of metal bending took her seismic sense (organism) one step further to adapt to being placed in a metal cage (environment) and needing to escape (task).

In human beings that aren’t cartoons, the same thing occurs whether you realize it or not. Lets take walking for instance. Lets say that you’re walking in the park and you take a step off the sidewalk onto the grass. Without your ability to adapt to your environmental constraints, you would step onto the grass and need to learn how the grass moved and changed before you would be able to walk with confidence through the park or play sports on it. But that’s not the case at all is it? Instead, you just take a step onto the grass and without thinking about it adapt to the softness of the dirt beneath your feet, whether or not the grass is wet, or if it’s a beautifully manicured soccer pitch or a bumpy, unkept field. Either way you don’t even think about it but your body has adapted to it’s constraints and selected a strategy accordingly.

In rehab, the same thing occurs but our job as clinicians is to manage emergence and adaptation. Sticking to the walking analogy, if our patient has a limping problem our job is to understand what constraints are limiting the body’s ability to solve the problem leading to the movement pattern that we observe. This is where good coaching and clinical observation skills come into play. Does your patient lack the requisite knee extension range of motion resulting in them heel striking with a bend in their knee and causing a limp? Or maybe your patient has the appropriate range of motion but isn’t able to activate their quad as strongly as they need to absorb the force of walking so they walk with a shorter stride length on one side so they’re not on the leg for so long. Either way, understanding what could be affecting your patient and how they’re moving may determine what interventions you choose.

But constraints don’t just end at what you intervene on. Stick around and we’ll talk about how constraints can be used to encourage our patients to move in the way that we would like them to. How we can take this approach to explore how humans solve movement problems and encourage movement patterns that we want to see as clinicians.

See you for our next cup.

Sources

1. Davids K, Glazier P, Araujo D, Bartlett R. Movement Systems as Dynamical Systems.

2. Brown, Cary. (2006). The application of complex adaptive systems theory to clinical practice in rehabilitation. Disability and rehabilitation. 28. 587-93. 10.1080/00222930500219175.

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My name is Sawyer Williamson. I’m an Athletic Trainer, Strength and Conditioning Coach and wannabe philosopher. I started The Rehab Teahouse because I wanted an outlet to really talk about things that matter to me in the Sports Rehab and Performance space without feeling the need to over simplify and condense everything that I want to talk about into a 60 second clip that people will inevitably watch 4 seconds of before they mindlessly scroll away.

Let’s be honest, our industry does not chill out… like at all. Our industry broadly, but specifically in the sports realm, over medicalizes conditions, cares too much about being a “pioneer” in the field, and over-works clinicians while underpaying them and limiting our ability to practice at the top of our scopes. This combination of factors is what leads to a lot of clinicians to feel lost, get frustrated with the space, and either burnout or leave the field entirely. The worst part? The sports industry would like to have you believe that you should wear that burnout as a badge of honor. As a way of saying “Hey, I persevered the worst working conditions and let a whole industry undervalue what I bring to the table. Look at the cool logo on my shirt!” and while that’s fine and dandy, there is always a stressed out subtext to those that love our industry.

I believe that all rehab is training just in the presence of injury. That we can use training as a way to help the people that we work with to get out of pain, and get back to the activities that they love the most. I also believe that there is a real need for creativity, passion, and authenticity in our world. If you get onto instagram or tiktok, right now and search “sports physical therapy” or “athletic training", chances are you’ll find yourself in a space that has clinicians arguing about what the best exercises to “fix” a particular condition are, complaining about the state of the industry, or some misinformation about back pain or something. I could go on forever about what the instagram landscape looks like but my point is that there isn’t anywhere to get some guidance or learn something new to advance your practice that is just… warm and chill.

Enter my favorite cartoon of all time: Avatar: The Last Airbender. My favorite character, Uncle Iroh, famous for his warm and compassionate nature, seemingly endless wisdom, and of course his love for tea serve as the catalyst for our journey here. Iroh serves as a mentor to all he encounters, even going so far as to sharpen the fighting stance of his assailant while being mugged. Iroh is always challenging his mentees to grow, change, and embrace uncertainty. Hell, Iroh opened a tea shop in the city of his greatest military defeat and hoped to start a life there. Iroh’s chillness, his warmth, his values, and of course his tea shop are what inspired me to open a tea shop of my own. So again without further adieu, welcome to The Rehab Teahouse. Let’s learn some shit together.

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