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Jan 25, 2024

All Things Return to Sport with Dr. Tim Stone COO and Sports PT

Read the conversation below

Dr. Yoni Rosenblatt: Welcome to the True Sports Physical Therapy Podcast. One of my very favorite people and physical therapists, Dr. Tim Stone is with us today to talk about all things return to sport. Tim, welcome back to the pod man.

Dr. Tim Stone: Thank you. I am appearing on here far too often, I think in the last couple of months, but hopefully.

Dr. Yoni Rosenblatt: There's high demand. There's high demand for Dr. Tim Stone. My inbox is full with requests for can we get the Australian back on? So thanks for being here.

Dr. Tim Stone: Thanks for having me.

Dr. Yoni Rosenblatt: Yeah, no, no problem. Quick shout out to our sponsors, Spartan Flooring. They are hosting us today and we're thrilled to be a part of their facility out in Bel Air. And of course our ACL masterclass from Table to Turf, which Dr. Tim Stone is the star of is excited to sponsor today's pod. You're gonna learn a lot about taking that athlete all the way back to field today. So let's dive in right there. Let's say we're post-op knee, any type of knee injury, post-op surgery. When do you, Tim, start thinking about return to field work with this athlete?

Dr. Tim Stone: Yes, I mean that comes in day one, right? Like what do we need to do? What boxes do we need to check off to get them to actually step on a field and start working with them on the field? But I'm sure the question more relates to when does this become like a predominant like process or when is this the overarching theme of return to sport or part of their rehab process? And that's really to me when they've completed that return to run protocol that shows me they have the proficiency to tolerate a volume of running. And so now when I bring in field work, I can kind of dominate the sessions with higher intensity cutting work on a field and not focus so much on like having to worry about like energy systems or fatigue or things like that. And I know that we've already checked off some of those pieces that show me they'll be able to like accelerate or decelerate, for example, based on them having to get to that return to run program in the first place. So that's when it really dominates like the the rehab landscape.

Dr. Yoni Rosenblatt: Yeah, I loved your first answer. So already this is why my inbox is full with requests for bringing back Tim Stone because the lens you look through from the very beginning is how do I get my athlete all the way back to what it is they love doing? Usually predominantly it is running and cutting and things like that. And so that's really your goal, your long-term goal from day one. How do I get this knee or this leg and therefore the athlete ready to get all the way back on the field. That starts with how you're coaching quad sets. That starts with how you're coaching terminal knee extension because if they never get their terminal knee extension, they're never getting back on the field. It's important that you take that bit of knowledge from Tim Stone and apply to the athlete in front of you and say, Hey, these quad sets suck.

Dr. Yoni Rosenblatt: They're boring as hell. They will directly translate to what it is you want to do sometimes what you wanna do for a living, but at least getting back on that field. So I think that's an awesome answer. When you start thinking about getting the athlete to do the sprinting and the change of direction and things that we usually kind of. That coalesce into this field work, you're saying I wanna see them do a return to run test or program prior. What does that look like in your world? What is the return to run program?

Dr. Tim Stone: So the return to run program, there's a million out there. The one that we utilize most commonly is the Delaware Return to Run that I feel like is so well known amongst the PT community. And as well as the physician community and also strength and conditioning world that we're able to communicate really effectively where someone sits in this return to run process by utilizing that program. That's why we utilize it here. It's not to say that there's not a better one necessarily geared to like a soccer player or a lacrosse player or a football athlete. I'm sure there are very much more specific specific protocols. However, this one just is very simple and to me it's less about the content of what's in the return to run program and more just the way in which it progresses an athlete through each level or each stage. And it just gives a concrete guide that people are following rather than guessing each time they go out and try to run.

Dr. Yoni Rosenblatt: Yeah, and I love specifically about the Delaware return to run is they have these soreness rules, right? So if they were sore immediately following it stipulates, okay, how do you respond the following session if they're sore at the beginning of the session and it ebbs, how do you respond accordingly? So that's one of the reasons I push the Delaware so hard. Sometimes I'll start a Delaware return to run, depending upon how the athlete looks at different stages. I'll say, you know what? You're doing awesome. You're not gonna have a problem with stage one. Let's start with stage three, something like that. So it gives you a little bit of flexibility. What other tests do you need your athletes to pass before you take them out on the field?

Dr. Tim Stone: Yeah, so before they do return to run, which is probably the biggest jump in terms of like testing that we're doing. Where there's like a landmark that has a guide for return to run and then return to field based work. So that is 75% QI as a minimum. So we test that using a Tindeq which is relatively a cheap way to get a symmetric kick test.

Dr. Yoni Rosenblatt: Yeah Hold on Tim, let me cut you off. I want you to define QI.

Dr. Tim Stone: Yeah, so that's a quad index score. So we're trying to see the between the affected and non-affected limbs. And so if we're looking at quads, it's just a simple like knee extension kick test and we typically test them at 60 degrees or 90 degrees. Usually both. We're finding a little bit better data on the 90% right now. So we'll do that. The other one is the other direction and just getting the same score but for hamstrings. So the same thing. We're looking at 75% there as a minimum before they do the return to run protocol. And so for return to field stuff, I like to bump that up at least 5%. So we're looking at that 80% proficiency piece as a minimum guide to letting somebody start that. So those are probably like the two biggest things. If you have access to nothing else except for the ability to like test your well one just quadriceps, that's gonna be your biggest indicator of the thing that's gonna tell you whether or not they're able to progress into field-based work.

Dr. Yoni Rosenblatt: Yeah. And do you have a metric that you compare side to side or sorry, quad to hamstring on ipsilateral side with, are you looking for anything there?

Dr. Tim Stone: I think some of our clinicians do that. I'm not super as familiar with that process. I think, yeah, I don't know. I would just say some of our clinicians have data that they would use to support that. To me, if we're trying to simplify this process a bit, the easiest and the most common one to find is that like QI of 80% in this scenario.

Dr. Yoni Rosenblatt: Okay. And let's say this is a post-op ACL 'cause we see more of that than anything else around what month mark is this transpiring, do you hope? All things considered and going well?

Dr. Tim Stone: Yeah, so really, the earliest that I'm like putting on cleats and getting on the field would be like that four and a half month mark. I think in there are just so many buckets to fill up until that point. You don't. Once you start that cutting process or that field-based work process, your athlete's gonna want to dominate their life with those drills, with those exercises. And if you start it much earlier than that, you're gonna lose sight of those foundational pieces that you need to really, really recoup before it's safe. So four and a half months is the earliest, but it's really not uncommon that we're not starting that process until six months with someone who's doing very well. And if I'm at all honest, I've started this process with people at eight months and had them ready to play at nine months if those other foundational strength power buckets are filled. So I think I've said this before, people don't forget how to accelerate decelerate and change direction. They just have limbs that don't have the like qualities that allow them to do those things. And so I just. I think you can't coach somebody out of a weak quad that can't accelerate or decelerate or out of a weak hamstring that can't hit top speed. So I think it's just far more important.

Dr. Yoni Rosenblatt: Yeah, I think that's a great point. So let's start there. What are some of the drills you make sure that they can do and are doing as they prove their proficiency to you to prepare them to put those cleats on?

Dr. Tim Stone: Yeah, so the first thing would be to be able to tolerate the running program. One, that's a check, right? No increase in knee pain, no increased swelling. They've made it through at least that level five, which is two miles straight. That shows me that they're gonna be able to tolerate just like some of the forces that go through running. So that's like the first box I'll check. And then we're looking at different plyometric qualities. So we break those buckets down into two different categories of your plyometrics. So you have like your shorter jumpy, like bouncier type things, and then you have your deeper depth, more explosive type plyometrics. So first I wanna make sure that they can go through those short, shorter, fast twitch sharper pieces and then beyond that to now really start to change direction quickly. They need to be able to get into those like deeper plyometrics.

Dr. Yoni Rosenblatt: Okay. So that looks so that first bucket you talked about that rapid explosion, the smaller knee joint angles, that would be things like bounding, that would be things like quick skips, A-skips, B-skips, C-skips, lateral shuffles, things like that. Right. Did I leave anything out there?

Dr. Tim Stone: That hits probably most of them, yes.

Dr. Yoni Rosenblatt: Okay. And then talk to me about the deeper ranges when you would start seeing those and testing those and progressing those.

Dr. Tim Stone: As soon as they're able to tolerate the smaller types stuff. So as soon as they can get through that, then I'll just try to progressively increase those forces and loads within each jump by like adding bigger joint forces and bigger joint angles.

Dr. Yoni Rosenblatt: Yeah. And don't forget the angle of these forces. So I think too often we get very pigeonholed into really thinking sagittal plane. You're thinking about up to a box, you're thinking about down from a box, you're thinking up and over a hurdle. Don't forget that this athlete is going to need to change direction eventually ways to prepare those would be what Tim?

Dr. Tim Stone: Say that again for me, please. You wanna repeat that.

Dr. Yoni Rosenblatt: Yeah, no, yeah, no problem. So I think we pigeonhole ourselves into sagittal plane motions and that's good for acceleration deceleration until we start changing direction. So I would say you gotta start hitting things in the frontal plane, transverse plane, like snap downs at an angle. Like I spent all day today working on, it was a hip hamstring dominant day from what tissues I'm gonna be loading, but it was rapid angled snap downs. It was rapid lateral lunge and catch right? So now I'm playing with planes of motion. Don't forget that when you're taking your athlete back to the field, I guess is all I'm pointing out that we don't just live in the sagittal plane. Like when you take them out to the field, it is multi-directional and you have to prepare your athlete to handle those forces. You have to prepare the tendon in a lot of cases and the joint to handle those multi-angle forces. So let that show up in your exercise prescription prior to taking them to the field. Outside of those examples that I gave of an angled snap down or a lateral bound drill, anything that pops up in your mind like oh, I like to do this drill before I take them towards putting those cleats on.

Dr. Tim Stone: Specific drills? No, because I think I would rather classify these into sort of different principles or different buckets like we spoke about before. So we already just talked about and apologies before, I didn't really give a clear guide on what the terms were for those deeper angles and shorter jumpy things. So your extensive plyos would be the category for those shorter, sharper type jump work and then plyometrics, and then your deeper would be your intensive plyometrics. So I'm thinking about it more in terms of one plane and then two intensity. And so when I'm returning to sport, I think I used to do this all based on plane of motion first. Like linear is more safe and then frontal is more risky. And I think that's ingrained to us. Like in school we think about what's challenging or how does an ACL like tear in the first place? It's usually like predominantly like in that frontal plane. So we're okay assuming that frontal plane is gonna be the hardest thing to get back to.

Dr. Yoni Rosenblatt: Yep.

Dr. Tim Stone: I think less of it like that now and more of it in terms of the intensity of the plane of motion. So I want to start frontal and sagittal transverse and rotational planes all at the start, but I want to apply a lower intensity to all of them to begin with and then just increase the intensity over those planes of direction rather than separate it. So clearly and concise into like the intensity of a direction, if that makes sense.

Dr. Yoni Rosenblatt: Yeah, I think that makes a lot of sense. I mean, we're talking now in a roundabout way of the many levers that we can pull to challenge this athlete. And so we have to think, one lever we can pull is intensity. Another lever we can pull is direction of force, right? Or your planes of motion. A third is probably volume, right? How does their 10th rep look compared to their second rep? And building that out and just making sure that the athlete has checked all of those so that the tissue is now robust enough to what it is that we're gonna test them or train them in when we put those cleats on. Does that make sense? Does that sum that up?

Dr. Tim Stone: Yeah, for sure. The one thing I would also add to this whole entire piece is when you're watching and you're looking at an athlete subjectively when you're doing different planes of motion, the most challenging thing that a patient that's had an ACL reconstruction will have is that they're going to be quad deficient predominantly. And so where does that show up in every plane of motion that you're testing? So it's gonna be more accentuated in your linear type acceleration and deceleration work. So it's quite easy to identify it when you're doing those types of drills. This would also be like a shout out to saying like do frontal plane stuff early because it's less stressful on the joint because there's other hip musculature basically that's gonna help them to do that. And it's not going to be as quad dominant.

Dr. Tim Stone: However, when you're doing frontal plane, transverse plane, whatever direction it is, I always like to think, well there's some sort of sagittal plane component to every drill. How are they managing the sagittal plane component of this predominantly frontal plane exercise? So that's a lot of mumbo jumbo to make that really simple. If you are having somebody do a cicada hop, so if jumping from one leg off their right leg and landing on the left leg, coming back to the right, so predominantly frontal plane, but when they land, they still have to get into that triple flexion position, which is a sagittal movement on the spot.

Dr. Yoni Rosenblatt: In the sagittal plane.

Dr. Tim Stone: Yeah. And so you can see that if someone's struggling with decelerating the knee in a frontal plane jump, they're still gonna show a sagittal plane deficiency. Their knee is not going to travel far enough forward over that toe when they land. And then same thing for accelerating, when they go to jump off that leg in a frontal plane position, they're still gonna show a deficit in that sagittal plane like translation of that knee going through or past that toe before they jump. So.

Dr. Yoni Rosenblatt: Yeah, I also think that that opens the door to beginning to sprinkle some of these concepts into your programming for the athlete and giving them a taste of either what they're dying to do, like put on cleats or prepare them for their desired goal. So it could be they're not ready to handle max effort deceleration because of their deficiency in the sagittal plane, but maybe there's room to sprinkle in. Okay, put your cleats on. We're gonna work frontal plane, we're gonna work aggressively frontal plane and you can start to get. Really like their motor learning and motor control to be brought up to snuff, but also let the athletes sweat a little bit in the frontal plane 'cause they can control that better possibly than sagittal plane. So that's a really good point and I think worth considering, when you're with an athlete three days a week, four days a week, and you're on month four, you've seen them so many times, you wanna show them, Hey, we are progressing. That's one opportunity to do it. So, okay, so let's say they're good in the frontal plane, they're good in this sagittal plane. They've earned the right to walk out of our facility to one of our turf fields, let's say. And they're gonna be moving and doing some field work today.

Dr. Yoni Rosenblatt: Right. What's your warm-up? How do you get this athlete ready to roll?

Dr. Tim Stone: Yeah, so first things first, you have to get heart rate up, get blood flow to the area. Okay. They're most likely going to have some sort of stiffness in that joint before they get going. So if you just jump straight into it, or you even go straight into your Plyos for if you're a warm-up which is an excellent hit list. They're not going to tolerate those well until they have a really good, just basic general body warm-up. So whether that's a couple of times around the field, jogs slow whether they're just starting to get some reps in there, that's fine. Whether it's like, if you're limited on space, it's more of like an assault bike warm-up or a bike warm-up. Something that's gonna just start to like redirect blood flow, like into the legs into that quad specifically for this athlete.

Dr. Tim Stone: That's first on the ticket there. Then I'm gonna move into those extensive plyos. So we're gonna do some bunny hops. We're gonna do a little bit of that, like slalom, like mogul-style jump side to side forwards, single leg versus double leg with that, just so we're prepping the knee again for what's about to happen. And then we're gonna do some more deeper intensive plyos. So a little bit more like either like start with double legs, so some forward bounding there. Then moving into some single legs. So we're gonna go like side to side forward with that, but we're gonna get greater depth. And then after that, we're gonna just go through a few little like drills of like a 10-yard pace, depending on what it is we're gonna do from in the day, it's gonna be more specific to that day.

Dr. Tim Stone: So if it's a linear day, I'm gonna have them just run five yards breakdown, run five yards breakdown, run five yards breakdown, run five yards breakdown, just repeat that process. So they're getting the skill work of what we're doing for acceleration and deceleration at a very low intensity. And then after that, we'll start to work a little bit harder. We'll start that session. So that's flow. I don't know whether that last drill I would put into the warm-up or the start of a session probably your first session that is the session.

Dr. Yoni Rosenblatt: Yeah.

Dr. Tim Stone: Yeah. But once they get six, seven, eight months in, that's gonna be like part of the warm-up and then you can start throwing things at them there. So if it would be like a frontal plane base session, I would have them do some, like more side shuffle karaoke-type movements. And those would be kind of like your warmups for the on field stuff. So differences between that like linear and frontal plane type stuff in terms of what we're doing to prep the athlete to get started.

Dr. Yoni Rosenblatt: Yeah, that's really great. You throw around the term kind of sprint or jog and breakdown, sprint jog breakdown. What do you mean by breakdown? How do you teach that first time out?

Dr. Tim Stone: Yeah, so this is where I probably spend most of the time like coaching and queuing early on. And that's why I think it doesn't get out of my return to sport process ever. We do this every single time somebody gets out there. So there are different categories of this based on how fast you're running if you're looking at a decel. So if we're looking at shorter, sharper D cells, if we're looking at like a three-step stop. And then if we're looking at like longer sprints with a hard stop, we might look at a four or five, six step stopping pattern. And so there's different requirements that you need to possess to be able to kind of like show that. And then finally, beyond the step count through deceleration, we're also looking at what the foot placement is when you stop. Are you stopping in a split position? So one foot in front of the other or are you stopping with two feet even at the end of that drill? And so I'll play around with both of those two concepts left foot in front, right foot in front, or both feet kind of side by side in terms of the stopping patterns.

Dr. Yoni Rosenblatt: What's harder?

Dr. Tim Stone: If you're talking about the, if you're talking about like skill acquisition, definitely like that cicada stop where you're one foot in front of the other, when your front foot is the operative leg, that's the most challenging, right? Because you're gonna end up finishing on that leg with all of your body weight to stop and then pivot and come back. But both, even in the reverse, I would say like you can still see a deficit in what happens in steps one and two before that, even when it's the non-op leg being the final finish. So, are you doing enough work on steps one, two before the third one finishes, or one, two, and three before you have the fourth one finish in front. And so that's a piece of coaching it there.

Dr. Tim Stone: So we'll coach like stamp nice and hard before you get to that final pivot step or that final stopping step so that we're hearing, we're hearing left, right, left, or we're hearing right, left, right. Versus if you don't give those kind of cues, we're gonna hear like if we're finishing op leg, the first step should be a heavy op operative leg stop. It'll be super light, and then it'll be really heavy with that non-op leg, and then it'll kind of be like a short sturdy step with that op leg again versus someone who's proficient at it will be pretty, even with all three of those deceleration steps.

Dr. Yoni Rosenblatt: So those are great teaching moments and great cues, right? The sound of their step, the distance of their step. And then what I also like to do is film them a couple times and you can see what their trunk is doing. Are they allowing their trunk to kind of stay all the way back, trying not to put weight forward. Maybe they're avoiding that anterior shin angle and an excessive shin angle on the opposite leg, and just slowing that down and showing that to the athlete, it could be they don't even know they're doing it. Simply showing it to them is worthwhile visual feedback that can help. And then also allow this to color your next session, right? Because you're gonna see, hey, maybe they're having trouble with that anterior shin angle or that positive shin angle. Let's make sure when we do our Bulgarians, when we go back inside or the next day, that we're giving them a cue that keep that shin forward and so that they get more comfortable with loading that anteriorly.

Dr. Yoni Rosenblatt: These are all great things to think about. Another thing is center of mass, how high are you staying? I will routinely see athletes almost like tumble forward over their plank leg when they go to stop because they're not able to drop that knee angle low enough to truly put the brakes on. So sometimes it's as simple as holding a PVC pipe over their head, making sure they land lower than a given amount, or maybe it's, Hey, you don't have the strength yet, let's make sure that that shows up in your, in in the rest of your strengthening program. Does that make sense?

Dr. Tim Stone: Yeah. I actually have relied so much more on what's happening in the upper half of your body when you're decelerating you know, in the past year or so or two years even than what's happening in the lower half. Because as I mentioned before, if you have adequate quad strength, like you're showing us adequate quad strength, what's happening in the lower half really does sort of just begin to happen again. Whereas what you're doing with your upper half in relationship to the cadence of your stepping pattern can really have a big impact. So there's two drills that I really like for this. One and both are stolen from wide receiver drills. So the first one is like what we call like throwing your hands. So that's when you see like a lot of videos out there on social where you see like wide receivers always will give you those like sharp, choppy hands, but they're really aggressive with their upper body.

Dr. Tim Stone: If you throw a right hand really aggressively, your left leg also has to respond as aggressively. And so it can help facilitate loading into that limb. So we're asking for like hard arm like heavy arm movements to yeah. To kind of accentuate that. The second one I really like that I've seen in the last year a lot used, I've been trying to integrate I don't think there's a name, but I kind of call it a knuckle drag decel. So as somebody approaches a cone or approaches a line where they're gonna decel just to get them to what you talked about, lower their center of mass with a PVC pipe. In this case I'm ask knuckles, the as that gets form or this really like low body form and really challenges the quads a lot when you're, when you're going to like decelerate quickly. So that's just trying to like drag your hands across the turf, you lose a little bit of that like reciprocal motion, but it really, really helps athletes to get their butt down, get their knees over their toes.

Dr. Yoni Rosenblatt: Yeah. I think that's worthwhile reminds me of my own storied athletic career that when I bumped up to varsity athlete and we're running suicides, as we called it back in the day, when you run to that line, I just distinctly remember the coach blowing the whistle and being like, Yoni, at this level we touch the line with our hands. And so a lot of times that gets lost on kind of the younger athlete, but if you're forcing the athlete to come down and touch that line that they're targeting, like exactly like you said, everything has to collapse appropriately and they should have the knee strength to kind of hold that, tell me about when, when you get this athlete out there for the first time, how do you manage volume and then how do you ramp it up or scale it back?

Dr. Tim Stone: Yeah, we used to play around with a certain amount of contacts on the ground. I think that is really, really difficult to track when someone's like sprinting. It's either in like plyometric session. I'm looking for indicators of the athlete, like either getting better through the session or getting worse through the session. So if I'm giving a cue and they're able to load that knee more, I'm still going, right? But as soon as they start to show me like it's dropping, like we've hit that peak in terms of like mechanics or technique and it starts to back up, it starts to get worse. I'm cutting session right there. If it's 20 minutes into the session, okay, I pivot. Like we'll go do some strength up for something that's not biometric-based that they can still get some benefit out of. But I'll say 45 minutes is in just fits really nicely into our, into our model, but 45 minutes with a 10 minute warm-up gives you that 35 minutes of like hard heavy work is really for most of these athletes enough enough of a session to get them kind of like going to the point up until they need to like return to practice. And you might maybe need to do it a little bit more there.

Dr. Yoni Rosenblatt: It's also, it's a lot, you can get a ton accomplished in 45 minutes, especially if you're timing the rest breaks you don't get caught on a tangent like I often do. Like if you're really mining the clock, I think you get a a lot done in the vast preparation we've had for this podcast and conversation. I was talking to an NFL linebacker that you worked with and he said one of his favorite sessions was one of his first field sessions with you in which he started to struggle and you would not let him try another repetition. It is not going to get better just by trying harder. You simply cut the session off and said, we're gonna go do something else. And he did all the pissing and moaning he wanted, you didn't even hear him. You just moved on to the next drill or, or maybe the next setting.

Dr. Yoni Rosenblatt: Because once you see that form start to go to hell, it's not coming back. And you're going to either learn at best bad habits or worse cause some damage. So I think that's, that's really astute of you. You got to be locked into your athlete. You cannot be on your phone, you can't be talking to other clinicians. You wanna be watching how this athlete is performing and as soon as you see that down tick and they've tried it a couple times, go on to the next one. So I think that's really worthwhile. Okay. So as this athlete is progressing, you're seeing good form, when do you start thinking I want to add a, another piece of their return to sport, whether it be I want them holding a stick, I want them chasing an object, I want them carrying a football when I want them dribbling if they're a soccer player with a ball on their foot. When do you start to make that determination? How important that is that to you?

Dr. Tim Stone: So we wanna get those things incorporated into their rehab as early as possible in ike a lower intensity. So you can add a soccer ball with like passing as soon as they start, they're return to run program. So same things with like wall ball. If you're a lacrosse athlete anything really, like you can get pretty low-level like skill-based work or repetition based work, like very early on in terms of like having them produce like a drill with the stick in hand or a ball at their feet that to me comes late a little bit later on when they've shown me the qualities of acceleration deceleration in all those planes. So again, I think I've changed my mind on that too. Like I used to say like this person just moves way better when you put a ball at their feet or put a stick in their hand and I just don't buy that anymore.

Dr. Tim Stone: What I think that is is us as clinicians getting distracted by what's happening, like with their skill level with the extension o of the sport versus like what they're doing from a mechanics standpoint and they're probably still showing you crappy mechanics, but it looks good 'cause they're good at their sport and so like I would, I'm hesitant to like bring that stuff in until they're able to show me those basic skills of acceleration and deceleration in the frontal plane linearly as well. And then also from a rotational perspective too. Then you use that as a motivational factor for your athlete to get it or like earn the right to get a stick back in their hand in sessions with you or get the ball back on their feet in sessions with you.

Dr. Yoni Rosenblatt: Yeah. How much, as the former LAX doctor, how much does putting a stick in your athlete's hand change their mechanics that you're working on?

Dr. Tim Stone: It really shouldn't if you're doing everything right. I think that timing is important. What terms? What's sort of like happening with your upper body and lower body? So like with a stick you're I'll use it as a conduit to improving like acceleration or deceleration. We talked about like throwing hands heavy, like with a lacrosse stick, I'll use it as a way to help improve their ability to accelerate from like a jab step. So having a stick in your hand gives them some familiar, some familiarity.

Dr. Yoni Rosenblatt: I kept that word also. Yeah. It's terrible. It's an impossible word.

Dr. Tim Stone: An impossible word especially for an Australian like me.

Dr. Yoni Rosenblatt: And me.

Dr. Tim Stone: But you're able to then like talk to them in terms of movements and terminology that they understand. So if I tell you to do a right hand to left hand split dodge exiting to the left, the movements that need to happen to produce that come like this. If they have the proficiency in the drills before, it will also show up in that drill as a proficient movement movement. Right. If they, if they don't have the quad strength to do that, it's gonna sound funky. It's gonna look funky. They'll be, like what the heck just happened to my split dodge that was like my money maker?

Dr. Yoni Rosenblatt: Yep.

Dr. Tim Stone: So it's helpful to like reinforce movement patterns and progress a movement pattern, but it certainly won't like clear up, I think any deficits that may have going into those sessions.

Dr. Yoni Rosenblatt: Yeah and if anything, like you said, I think it'll distract you from the purpose of the session. So I think you want to be careful about that. Maybe there's room for it when you're doing balance activities to make it a little more spicy than just standing on a bow suit. But I think it gets, I get frustrated when I see an athlete doing drills with their stick before they have perfected it without I think too often we get too cute with it and it kind of leads us astray. How do you handle the ominous and the confusing? Well, I kind of, I feel it's in my knee a little bit, but it's fine. So I guess my question is how do you handle when an athlete has some symptoms on the field and when you're completing field work?

Dr. Tim Stone: So first, repetition of asking the athlete. The first time you ask them, they might respond with that. And then if you follow up with another question or describe like the pain or what does it feel like, when is that happening, you'll get more from them. So usually they'll start to go down this path and then let you know this is not okay anymore. Or sort of divulge more information. But again, I think you can, I guess objectively, quasi objectively, like see when things start to break down, if there's pain associated with that, like you're pulling the pin right there, there is no space and no room for like cutting activities to say like, I have some knee discomfort and, and expecting it to get better with more work. Yep. Right. With more drills. It just doesn't work like that. We need to get out of this, like this thing we do as PT is because we don't have another option for them to regress, keep doing it. So we don't have Yep. We don't have another option for them to like apply some therapeutic technique for them in that session. We just say keep going. It'll get better the more you run or it'll keep getting better the more that you cut. It's just not.

Dr. Tim Stone: That's not true. It's not what we see on a daily basis here. It's are you proficient? Can you tolerate the intensity? Can you tolerate the volume with no pain or zero symptoms? Any symptoms with this stuff is like not acceptable in my opinion.

Dr. Yoni Rosenblatt: So I agree. I think that's totally true on the field in the present, but also what's the next day look like? Right now I'm working with an NFL guy who they, being the organization is obsessed with Alter G running and getting him on the treadmill, coming back from an Achilles rupture, and it'll ruin the entire week of rehab. He'll do it on a Monday and he looks okay doing it, but Tuesday, Wednesday, Thursday, the guy's sore, he's limping around. Well, was that a good use of time? And if you're gonna do it, why do it on a Monday? If you know he's gonna end up sore, fill up all those other buckets, and then Thursday or Friday, you know you'll have the weekend to recover. Maybe that's a time you dip your toe in the waters of field or running, things like that, and then make sure you are grilling, you're so good at this, Tim, grilling your patient as to what was the weekend like? What was it like on Saturday? We ran on Friday. How'd you feel Saturday morning when you woke up? How'd it feel walking down the steps Saturday after you got up and moving a little bit?

Dr. Yoni Rosenblatt: What was Sunday like? Okay, that will determine your Monday session, not, well, the plan stipulates we gotta go back on the treadmill. That just might not be the right answer there. So I think that's totally worthwhile. Another thing I would highlight, me being a lacrosse novice, is I will grill the athlete, probably not in that session, but during the first part of the rehab leading up to the field of what is it you do for a living? What is your moneymaker? Is it a roll dodge? Is it a split dodge? What are you doing with a stick so that I can then mimic my drills when we get position specific or we get sports specific? I mean, I've had extensive whiteboard education of what a linebacker needs to do in various sets. So I can then take that information and become an expert on, okay, this is what our drills are gonna look like. By the way, here's how it directly correlates to what you do for a living. Even though I'm not a football player, I'm not a lacrosse player, I gotta know their sport and their position so that I can use the drills to mimic what it is that they do the same way I'm very confidently able to say your ability to get terminal knee extension and quadriceps will translate into a run.

Dr. Yoni Rosenblatt: Here's how, let me show you on a skeleton, same thing when you go to a field. So keep that in mind as you're developing rapport, you're really building this library of things to get to when you get on the field. Does that make sense?

Dr. Tim Stone: Yeah, that makes total sense. And a piece I would add to that is the best way to learn this stuff is to like one, get on YouTube and just like watch the position. The first place I would like, whether or not you think a combine is a good way to see what someone's like ability will be in the NFL or not. Like these are typically like drills they're going to do, possibly like when they go to pre-season or back into practice. So you can see like what types of movements people need to do. One is a great way to do that is to watch film, watch draft drills. And then the third place, which I really love to look at this stuff is get a good network of skill-based coaches that work with this type of athlete. And they've spent a lot of time like breaking down what skills are important for these athletes to do. So I just pinch drills from them and apply it to different drills that I could do that will get them to show me something that I'm trying to work on with them. So in the lacrosse world, like I look a ton at Deemer Class. He's got tons of like simple skill drills I look and then Nick Tintle as well down in Texas as well.

Dr. Tim Stone: So I'll look at all of those drills and a lot of my return to sport drills, accelerating and decelerating, I'm just pulling something from what that skill coach does and relating it to, is this a heavy decel drill? Like what's the quad doing in this drill? And would it be appropriate for my athlete now or would this be something I would apply to them later in their rehab based on like the movements that they're doing?

Dr. Yoni Rosenblatt: Yeah, and Nick, those drills that you get from Tintle and from Deemer, that you can take those patterns that they're stressing and do a weight room session on them, right? And force the joint in those angles to make sure that they are ready to do that. I just had a great conversation with a linebacker this morning about what is transpiring at the Achilles tendon in the 40 yard dash takeoff. Those first few steps, how do you get all the posterior tissues taught so that when they take that first step, they're being shot out of a cannon as opposed to now I gotta recruit, now I gotta go forward, recruit first. That's why you see those sprinters lift their ass before they take off so that that Achilles tendon can get taught and propel them anteriorly or forward to maximize their efficiency and power.

Dr. Yoni Rosenblatt: That stuff is gold even early on when you're teaching these sessions so make sure you do that. I would encourage everyone listening to take a look back in our library of podcasts to Troy Jones. I mean, he's made a living in preparing athletes for the combine, enhancing their 40 yard dash. He gets into how he teaches speed, how he teaches set up all those things. Go back and look at that but also find him on Instagram. There's so much information out there. You just gotta make sure that you're spending the time to mine it and to look at it.

Dr. Tim Stone: Yeah, one thing he talked about, I remember listening to that pod too, was the projection angle of the athlete when they're performing a toss. So if you can take a snapshot of the projection angle for any motion, you can apply some sort of external resistance in a slower fashion and turn that into a strength drill. So if it's somebody trying to cross somebody up like on a basketball court or dodge or get around a DB on the football field, you can look at what that lateral movement looks like, you know, throw a slant board in there, get a cable column and have them do like a lateral type lunge exercise that just mimics the joint angles there in a slow controlled overloaded manner. And then you're just removing resistance, adding speed, adding complexity to the drill. And that's like your whole breakdown for a lateral movement right there, right? Slow heavy resistance to build proficiency and then force or explosive and then, yep, and then you're good to go.

Dr. Yoni Rosenblatt: Yeah, and I think the, you know, a population that you've become an expert on is pitchers. And the same thing would be rotational athletes, right? But it shows up in lacrosse too, right? Like how do we load appropriately rotationally? How do we get heavy rotationally speaking? What should the body be doing? What is the lower half of a pitcher doing as his upper half is rotating around a stable base? All of those things show up. And by the way, they show up in every sport. There are very few sports where we live in these just single planes of motion. So I think there's a lot of gold there. Anything, Tim, that we kind of missed before we jumped to lightning round that you really think is important to highlight on return to sport?

Dr. Tim Stone: I don't think people caught that joke for starters about me and pitchers. And I also don't think people caught the joke about you being a varsity athlete. 'cause I think last week you told me you've never made varsity before.

Dr. Yoni Rosenblatt: Okay, I never said that 'cause I made varsity in so many sports. Lacrosse was not one of them. But that was not a joke. So they didn't miss anything. But Tim, you have become amazing with the shoulder. I mean, certainly better than when you joined True Sports.

Dr. Tim Stone: Well, it wasn't a massive jump from when I started. So yeah, we'll go with that.

Dr. Yoni Rosenblatt: Go with that. Go with that. Okay, lightning round. The Eric Cressey lightning round. Here we go. Short answers, Tim, quick. You've never seen these questions, but here we go. What country makes better PTs? The USA, Australia, or New Zealand?

Dr. Tim Stone: I mean, you gotta combine both, a little bit of Australia and USA together, and you get this. So both of those.

Dr. Yoni Rosenblatt: Both of those, okay. And New Zealand is not on that list?

Dr. Tim Stone: No, they're up there, but I can't give credit to the Kiwis just 'cause of the rivalry right there. So no, they're out.

Dr. Yoni Rosenblatt: And if New Zealand are the Kiwis, what's Australia?

Dr. Tim Stone: I don't know, you tell me.

Dr. Yoni Rosenblatt: I don't know. What do you guys call yourselves?

Dr. Tim Stone: I don't refer to.

Dr. Yoni Rosenblatt: The Roos.

Dr. Tim Stone: Yeah, fair enough.

Dr. Yoni Rosenblatt: Okay, and US are the Yanks. Okay, what is your pet peeve that you see PTs do with their athletes when they return their athletes to the field?

Dr. Tim Stone: I mean, I think we spoke about this. Get a stick or get a ball on their feet or in their hands far too early. Two is not listening to your athlete when they're performing the drills. And three is having a set session where you're not able to manipulate, change, lateralize or swerve from what you're doing when you're seeing mechanics that you don't like.

Dr. Yoni Rosenblatt: Hell yeah. Dude, you gotta be able to lateralize. That's what I always say. That's really good. Okay. How do you determine when to take your shirt off when you're posting an Instagram video of you working out?

Dr. Tim Stone: Yeah, this is a real tough one here. Basically, like the morning I wake up and whether or not I'm feeling myself or I'm not, shirts on or shirts off. So Monday mornings, usually a little bit groggy, it's shirts on from then on, shirts off. The rest of the week.

Dr. Yoni Rosenblatt: Okay. Six out of seven, you're not wearing a shirt. Okay, what is your number one goal for 2024?

Dr. Tim Stone: I think there's a lot of little goals and things in there, but I think for the most part, what I would like to do is progress this profession in some way to move outside of like the fee for service type model for PT. So whether that's like consulting on fitness and injuries in general to corporate structures or teams or athletes, I would like to be a part of that process. And then also being able to expand upon who we can offer this awesome thing that we do as PTs, not just within the silos of our clinics, but across the country or across the world. So how do we get this to a point where we can get easy access to somebody in Iowa that could really use true sports or somebody in New York that doesn't have access to a PT that has specific lacrosse background. So those two are probably like my two biggest goals for this year.

Dr. Yoni Rosenblatt: Okay, awesome. I can't wait to see you achieve those goals. What do you wish you were better at PT wise?

Dr. Tim Stone: The shoulder of course.

Dr. Yoni Rosenblatt: How could you get better than you are currently with a shoulder? You're basically a shoulder expert. Okay, that was just my attempt to get you to say the word shoulder. Okay, where is Tim Stone in five years?

Dr. Tim Stone: That's an even better question. I have absolutely no idea what that looks like. I think if you know a little bit about my life, where I'm a day to day kind of guy right now, I got a lot of little kids that are, take up a lot of my time outside of the clinic. So if I'm still doing this, and we're still making an impact on the sports PT community in some way, I'm happy with that. I wouldn't say I have a specific goal for well domination at all.

Dr. Yoni Rosenblatt: Yeah, well, you're achieving that, whether it's your goal or not, you are achieving and I appreciate it. Tim Stone, as always, a wealth of knowledge, a wealth of expertise, a refreshing outlook. I love to hear the way you used to think and the way you think now. And you highlighted that a couple of times, it just seems like you're always growing. Where can this unbelievable family of sports physical therapists find you?

Dr. Tim Stone: Yeah, easiest place is probably through social media on my Instagram account, which is Dr.Stone.DPT. And then I guess I'm on LinkedIn as well. And my email is tim@truesportspt.com. That's pretty easy. Or you can just call our office and ask for me and.

Dr. Yoni Rosenblatt: Ask for Tim.

Dr. Tim Stone: Ask for me and I'll get back to you. Yep.

Dr. Yoni Rosenblatt: There you go. You can also find Tim on the ACL masterclass from Table to Turf, sharing some of this wisdom and so much more. So make sure you guys get all of your CEUs through that course. It's an awesome course that Tim worked really hard on. There's even more knowledge there of how to load your athletes, how to get them ready for returning to sport. But then what does that athlete look like at month nine, 10, 11, 12, ways to progress those drills, way to scale them, way to make them sport and position specific. There's so much great information there. So look us up there. That's available for download and I really appreciate your time, Tim. You were awesome as freaking always.

Dr. Tim Stone: Thanks for having me.

Dr. Yoni Rosenblatt: Yeah, man. Thanks everyone for listening. Appreciate you guys.

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