The 5 Most Stupid Things I Didn’t Do Early in My Career: Part 1
We all make mistakes. We’ve all done stupid things. But since we don’t always learn from these mistakes, part of the motivating factor behind this website is to share with you some of MY mistakes so YOU can learn from them, especially for the students and new graduates. Recently I had been talking with some of my friends about some of the stupid things we used to think we knew when we were just starting out in our professions. It really motivated my to share with you this 2-part series.
These are not things to be embarrassed about, but rather to grow from. The doctors that used to smoke in the patient rooms 30 years ago, well, that is sort of embarrassing. But who knows, maybe 100 years from now everyone will laugh at us saying, “wow, they used to think the earth was round, they were crazy!!!”
Part of growing is learning and adjusting from past mistakes. The whole “you need to fail before you can learn” concept is true. I hope I can help you cut some corners and you can learn from some of my mistakes!
The 5 most stupid things I didn’t do early in my career
Below is the first two of my 5 most stupid things I didn’t do early in my career. Part 2 will be posted later in the week. This post will be focuses on integrating soft tissue work and understanding movement.
Integrate Soft Tissue Work
This is a topic I frequently discuss on this site and have stated in the past was something I regret not doing more in my early career. I remember working with colleagues and sharing the thought process that “massage” was something for a “day spa” and more pampering than therapeutic. Sure, I performed soft tissue work on many people, but I did miss the boat on integrating many manual therapy techniques into my practice. If you are like I was, than this is something that if you change your attitude, you will see immediate improvement in your outcomes. This is because:
- Soft tissue restrictions can alter the kinematics of the body throughout the kinetic chain.
- Performing soft tissue techniques allows for greater results from other manual techniques you may be performing, such as stretching, joint mobilizations, and even strengthening.
- Hands on time creates a better bond between you and the person you are working with, which in turn leads to better compliance and better outcomes
What do I do now and what can you do to get started? I have personally progressed quite a bit over the last several years. I use a combination of many different techniques including standard deep tissue work, transverse friction, trigger point releases, myofascial release, instrumented-assisted soft tissue, pin and stretch, muscle energy, positional release, etc. They all have a use for different pathologies and all are popular based on my past poll of manual therapy techniques.
I am a believer of an integrated approach. Use as many techniques as you need – try not to have technique tunnel vision!
Here is where I would suggest starting if I were you, once you have a good grasp of these concepts than expand as needed. Click on the links below to see books from Sandy Fritz and Leon Chaitow. You should probably try to go to a live course, but these all have good DVDs demonstrating techniques. A good place to start:
When I first started as a new graduate, I had a very systematic and algorithm-type approach. If X = Y then Z, or basically if strength test shows weakness then strengthen, or if range of motion shows tightness then stretch, for example. This isn’t a bad approach and probably the most popular approach to rehabilitation. But in itself, does not allow for a true understanding of dysfunction.
Over time I really sought to educate myself in biomechanics, or more specifically for me the understanding of arthrokinematics and joint kinetic forces. You can see this in many of my presentations, writings, and throughout my book The Athlete’s Shoulder. To truly be able to treat a specific joint or injury, you need to understand how the joint(s) should work.
Here is a good example using the shoulder – the person you are assessing has limited elevation with a shoulder “shrug.” Taking the basic understanding I described above, you would likely want to stretch them into elevation, right? Well, yes, and no. You have to understand why the have a shrug, which could be:
- Decreased inferior capsule mobility, causing the humeral head to migrate superiorly away from the area of tightness.
- Insufficient rotator cuff function, losing the dynamic ability of the rotator cuff to central the humeral head during elevation, causing the humeral head to migrate superiorly due to the increased force of the deltoid and the lack of opposing force of the rotator cuff.
As you can see, stretching into elevation would not truly address either of the two proposed mechanisms of the “shrug.” You would need to work on inferior capsular mobility or rotator cuff strength. Eric Cressey and I spend quite a bit of time discussing some of this as it relates to the shoulder in our DVD set Optimal Shoulder Performance.
But this is just a local view of biomechanics, the other view is more global and equally as important, but also keep in mind how other areas in the body impact the joint you are evaluating. Taking this a step further, here are a couple of other reasons why someone may shrug, both further down the kinetic chain:
- Denervation of the long thoracic nerve causing scapular dyskinesis and the loss of the ability to upwardly rotate the scapula, resulting in the humeral head to impingement into the acromion because it can not get out of the way.
- Or maybe a more complicated example – tight hamstrings –> causing a posterior pelvic tilt –> causing a loss of lumbar lordosis –> causing excessive thoracic kyphosis –> causing the common forward head posture with an anterior tilted scapula –> causing a decrease in subacromial space and thus again impingement and shrug because the acromion can’t get out of the way.
As you can see, this global thought process is needed and often overlooked. You may be able to notice the thoracic kyphosis and attempt to treat, that’s great, but keep looking further away to find why the thoracic deviation has occurred. I don’t want to overcomplicate this, but obviously you can see that this approach is pretty neat and exciting when everything starts to click.
I’m not the biggest fan of the thought process that this is the end-all treatment approach, but it is definitely needed. You’ve probably at least heard someone trying to extrapolate the effect of an ingrown toenail on your left foot on right shoulder dysfunction. That may be a bit of a stretch in my mind. Yes, they work together, but don’t overly emphasize.
- The chain reaction is greater the closer to the stone –> the impact of the kinetic chain is greater with the closer joints, or the scapula impacts the shoulder far more than the toe, for example
- The chain reaction is greater when the magnitude of the force is greater (i.e. a bigger rock is thrown) –> An ingrown toenail is going to impact the kinetic chain a lot more than a joint fusion, for example.
As you can see in my photo to the right (that took me like an hour to create, by the way…), A ripple from the hip should have a greater magnitude at the knee and low back than the toe or shoulder. Just my thoughts and experience. I am sure there are always exceptions but this is how I have operated.
Where do you get started? There are a lot of places to learn movement concepts. I would suggest starting with Sahrmann’s book on Movement Impairment Syndromes and Phil Page’s book on Janda’s concepts of muscle imbalance:
What do you think? Have you had these experiences too? Any mistakes you want to share with everyone else to learn from? Keep reading part 2 of this series.