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July 12, 2023

David Grey - Achilles and Foot Pain Explained

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Dr. Yoni Rosenblatt: What's up, guys? You are about to hear from David Grey, owner of the David Grey Rehab based out of Ireland, and even better known on Instagram, follow him @davidgreyrehab on IG. He is at the forefront of the lower limb rehabilitation. We really dive deep into the way he assesses the foot, the Achilles specifically, and then on up through the chain. He has some really unique cutting-edge techniques that are super doable and repeatable in your clinic today. The way he just assesses foot mobility and his thought process to getting athletes to overcome their pain by getting back on the field stronger is certainly unique, there are a lot of nuggets here, a lot of pearls of wisdom. I also really appreciated the way David approaches the profession, he has a truly open mind that you'll really learn and hear about throughout this pod. It was a great conversation. As always, make sure you share this conversation with anyone you think would really enjoy it. Make sure you leave us a review, a five-star review would be outstanding and appreciated, wherever it is that you're listening to this podcast. Without further ado, here is really a great conversation with David Grey.

Dr. Yoni Rosenblatt: Welcome back to the True Sports Physical Therapy Podcast. It never ceases to amaze me how willing some of the giants in our profession are to jump on a random podcast like this and just share some wisdom, David Grey at the forefront of what it is we do for a living in Sports Physical Therapy. And I know that I've got a lot of Achilles and foot patients that I could do a better job of helping, and I'm gonna learn how today with David Grey as he gives me a ton of free information to help my patients. So definitely excited to learn, David, thanks for joining us.

David Grey: Thanks for having me, Yoni. I don't know about giant of the industry or even if I'm gonna be able to help, but I'm looking forward to the chat at the very least, thanks for having me on.

Dr. Yoni Rosenblatt: Okay, fair. And listen, man, you already... You jumped over the highest hurdle by pronouncing my name properly, so I appreciate that dearly. Your acumen as it pertains to the lower half really in your approach to the lower extremity just drew me in, you've already answered a ton of questions with your social interactions and all of your coursework has been awesome for me and my current case load in my profession. So thank you for that. How would you sum up the way you look at the lower extremity and specifically at the lower leg?

David Grey: I don't know, I will sum up... I don't know. It's tricky, it's tricky. I will sum up how I look at the body in general, and that might... Just to start from there, I guess, and I just look at... When I'm looking at a client, I like to look at what's missing in their body, and not just... I know people's minds typically go straight away to like mobility or strength, and that can be a big part of it, but there's also this kind of coordinative aspect of what patterns are they, maybe avoiding due to previous injury. Obviously, injury leaves a big legacy and you can restore strength and mobility sometimes, but people just keep avoiding patterns for whatever reason. So I have a lot of faith in the body that when we just address, not small, not being picky about things or not trying to force everyone into a box, but when we just look at the big elephants that are in the room here, like this person just doesn't load their forehand in this way, they don't move their hip in this way, they're just not strong in this position, they're not reactive in this way. I have a lot of faith in the body that when we just start to train some obvious qualities that are relevant to them that people will usually start to feel pretty good along the way, obviously, where it's not like purely a strength's point of view, biomechanical point of view or anything like that, it's a full like biopsychosocial approach to that.

David Grey: And when I say what's missing, what's missing is often like building confidence, speaking to people as well, so it's not purely a biomechanical point of view, even though I really enjoy that side of things, it's a bit of everything and yeah, just what's missing. And then obviously when it comes to lower limb, a lot of the time, what might be missing is a little bit of mobility to the fold of the ankle, the knee, the hip, reactivity in terms of pretensioning what's happening before the foot hits floor, how well... Yeah, like what's happening at the swing leg, what's happening at the stance leg, how well people can be strong in deep positions as they decelerate or accelerate, all of these things, particularly associated more with speaking more with people who need to need to utilize the gait cycle of human locomotion, more so like outside of the gym. I'm not going to discuss about powerlifters or Olympic lifters or Crossfitters necessarily, even though they can benefit from a lot of this work as well. I'll usually talk... But ultimately, they don't really need to be able to leave the ground and come back to the ground again, so what they need is usually similar but also quite different.

Dr. Yoni Rosenblatt: So you really striving hard to simplify things is something that lands with me. I usually say physical therapy or physio in your world is so simple. If it's tight, we stretch it, and if it's too loose, we get it more stable and stronger, and that's it. And all we have to do as clinicians is figure out which one is it, and what is the norm? So my question to you is, how do you gauge whether it is that that foot can adapt to what it is we're asking it to do? How do you know?

David Grey: You don't know. You don't know. You can never know. Even when you do a drill and someone starts to feel better, you don't know exactly why they improved. So you can start to take some educated guesses and you're looking for usually predictable and repeatable responses. So when I see someone with this type of thing, with this injury history, with this lack of movement in this area, and then I do a drill that is designed to maybe help move this joint in this way, they, it usually starts moving in that way. So it's obviously a guess, but it starts to become a more and more educated guess as you go along. So how do you know? I dunno. I take a more of a joint centric view on things or bone centric view, which is I just look at the joints.

David Grey: There's a lot of joints in the foot, there's 33 joints in the foot, and we're looking for them to just be able to move. And if I see a foot that just can't move, and this, a lot of people will associate like a stiff foot with a very supinated foot and a kind of a floppy foot with a very pronated or more pronated foot. And actually I don't see that to be the case at all. It's like saying like a stiff spine is a more kyphotic spine or a more extended spine. It's, that's just a resting position. That's where it is. It doesn't describe the move or look, even look at the movement potential that's available... That's available there. So when I look at a foot, for example, you'll see I've got the chance to work with some like world class sprinters.

David Grey: They have usually a more pronated foot looking foot, shaped foot, and it's incredibly stiff as well, not very supinated. And so yeah, you see different people talking about stability and I think it's a funny word that maybe they associate with more supination sometimes rather than pronation and mobility then more pronated foot, not necessarily. I just look at the movement of the bones. So when you're looking at a foot, like can it change shape? Can it move from a pronated to a supinated position? It doesn't have to be like this huge change of shape, just the ability to move it in some way. Just you would, like, you would look at a shoulder just like you would look at a hand. Would you love to be able to have your hand flat at certain times if you were doing a pushup? And would you love to be able to kind of crunch your hand if you were gonna try and pick up a pen or grip something? I would love to be able to do both. I absolutely would. And that makes sense to people when it comes to a hand or a neck or a shoulder or any other joint in the body or area. In the body. But then when it comes to a foot, people just want it to be one shape and stuck in that position. And I would reject that notion.

Dr. Yoni Rosenblatt: Yeah, it's a great rejection. The way you simplified it for me was I am basically looking at whether the foot can change shape or not. That's all you care about. So my follow up question to that is how do you gauge whether it can change shape enough.

David Grey: Enough? I don't know. But whether it can change shape in the first place is just by looking at it. So you can also, like...

Dr. Yoni Rosenblatt: Look at them walk? Look at them walking?

David Grey: The best way to do it is, just you can look at them walking or even simpler, much simpler is just literally you have someone standing up. They pop their right foot in front, not in a big lunge position, just a small short split stance position. And you ask them to bring their knee forward and back a few times. And you will, if you just look at the foot, you can look at the medial arch, transverse arch, you look at the heel bone, you'll just see if they start to pronate and sup... They should pronate as they bend their knee in a little bit naturally you don't have to cue this, it should just kind of happen.

David Grey: 'Cause the weight of our body, our knee moving forward, the tibia shifting, are dropping forward like that. All those things should start to load the midfoot and open up the joints on the plantar surface, which puts a bit of length into the plantar fascia, not just like the medial arch dumping down into the floor. It's this lengthening from front to back and side to side. So that's a simple way to see when they, when they move in, are they pronating a little bit and when they move out, are they supinating a little bit? Obviously you can check people lying on the table where you just can have a little poke around at the foot and not... I think people place too much emphasis on like the tissue like the plantar fascia. How does that feel? Which is fine as well, but like actually grab the foot and move it around.

David Grey: Not just the ankle, but the joints is there, can you actually move the bones a little bit and get them to get some space in between them? So that can be a nice way of doing it. But ultimately I think the best way is just getting someone standing, bending their... Bending their knee and having a look and see if it can move. When a lot of people would say like, use words like overpronation and like your... Part of your question was how do you know if it moves enough? And a lot of people then would say, okay, like this completely dumps onto the inside of the foot and now that move that's moving too much. I would consider that someone who probably can't pronate their foot at all. So they're actually losing the outside, the lateral aspect of the foot and you're not actually not opening any of the joints on the bottom of the foot In that instance, there's actually already a word for overpronation.

David Grey: That's why I don't use the word overpronation. We have a word for it. It's called eversion. It's where the whole foot is just dumping in as one unit. So that's eversion. And you're not actually opening any joints in the foot when you do that. So enough, I don't know. But moving, just is it moving in some way? A little bit at least. Is there some movement there? That's a good question. And it's not hard. You just have to take someone's shoe off and ask them to bend their knee and straighten their knee and you'll see it.

Dr. Yoni Rosenblatt: Okay.

David Grey: Or not see it.

Dr. Yoni Rosenblatt: Okay. So early in my career I was obsessed with manual therapy and I did some manual therapy education and they tortured me with here's how you assess the movement of this joint and now this joint and here's what...

David Grey: Yeah.

Dr. Yoni Rosenblatt: It should be moving like, and can you feel that? And do you do any of that crap? Because before you answer that, I'll say, I don't do any of that crap because it was too goddamn confusing. And I'm not really sure about any evidence as to whether I can actually feel that type of motion. But people didn't log onto this podcast to hear from me. They did from you. So you shoot [laughter]

David Grey: Are you speaking specifically about the foot there or everywhere?

Dr. Yoni Rosenblatt: I'm speaking dead about the foot. Just, yeah, foot.

David Grey: So like it's easy to get a good gauge at the hip. So like internal and external rotation, and you're probably not measuring it perfectly, but you're not really worried about measuring it perfectly. You're just seeing like, is there some movement there? And then you can compare it with left versus right. So like, yeah, you have 40 degrees of internal rotation on your right hip and zero on your left hip. Well, you might want to be able to get some back, especially if that movement... Like personally if I walked into a shop and you asked me which hip would you like to buy, the one that has some movement or the one that has none, I'd probably buy the one that had some movement. So I think most of my clients would as well, and that goes for the foot. I'm not trying to on the table like feel exactly which joint is trying to move or can and can't move. You can't do it with the, like with the... Do it with the big toe for example.

David Grey: Like you can isolate that and be pretty clear, like, okay, you can get a good gauge in your hand, does this have any movement? If you ever have someone that has no big toe dorsiflexion or big toe extension, it's very, very clear, very quickly. Like they just run out of room very quickly. So with that you can, but there's three, probably three things that I teach people, if I'm looking at a foot on the table and it takes like 10 seconds and if I'm feeling a foot on the table, and it's not the be all and end all, but I'm just looking for a big elephants in the room. One I call calcaneus wiggle, which is just like, I grab the heel bone in my hand and I just kind of try and isolate the heel bone from the rest of the foot. And I'm not trying to be specific, can the heel evert and invert? And again, I'm not talking about the ankle, I'm talking about the calcaneus here for our people. 'Cause people will get confused 'cause they think a calcaneus can't move. It can. So like eversion, inversion, internal rotation, external rotation, plantar-flexion, dorsiflexion, that's all the movements available at the heel bone.

David Grey: I'm not trying to like isolate each of those. I'm just seeing can it wiggle around in my hand a little bit? Can it move? I go for a big toe extension, I wanna see can that move and then I go for our first metatarsal dorsiflexion. So can the metatarsal actually push up? You put your thumb on the bottom of the metatarsal, you push that up into the sky without the whole ankle moving. So there are three things that I think you can get a decent gauge of, but you can... The only way to get a gauge of a midfoot, the middle part of the foot, which is if you look at a foot model, you'll see like all the complexity in the foot is really at the midfoot. All the joints are kind of in there. A lot of the joints are in there. And really, like if you are going to stand on one leg with your knee bent, your weight will be on your midfoot. Midfoot is where you have the most options in your movement. If you're too far on your toes, too far in your heels, you're kind of falling forward or backwards.

David Grey: The best athletes will push the hardest when their weight is on... Their center of masses over their midfoot. Just so many good things happen when we're on top of our midfoot. And the only way to open up the midfoot is my body weight being on top of it and gravity pushing into my body, my body pushing into my midfoot and my foot obviously then pushing down into the floor a little bit. So I would say that, yeah, I'm not so sure you can assess the foot that well on the table joint by joint. That's why I think you gotta look at it in a closed chain environment because ultimately that's how it's operating as well. You're walking around on your foot, you're not walking around and your foot is like in the sky beside you or something.

Dr. Yoni Rosenblatt: And that is why I wish I would've met you 15 years ago. So I didn't bother memorizing what it is the norms of navicular cuneiform joint movement were. But I'm glad to meet you now. So when you do that, right? You find your calcaneus, is your calcaneus moving as you say? Is it just moving on talus? Let's say it's not, right? So now you have a hypomobile, let's call it Hindfoot. You have a hypomobile calcaneus, what do you do? What's your interventions there?

David Grey: I just get to them. One like depends. So if you decide, if you decide that you want it to get moving, 'cause that might not be an issue at all. It might be completely like, doesn't matter. Doesn't matter, it's fine. But it also might be something that you want to work on. A lot of people have a Achilles issues and all they do is calf raises and that works for some people. But you said that we're talking about like you are having, you're having therapists listen to this conversation who are probably working with a lot of athletes and working with people who are strong already. And I know in my job I get some of the best... Consistently get like very, very high level athletes from all different sports.

David Grey: And guess what they've done for five years for their Achilles issues is calf raises. And they have the biggest calfs now in on their team and they still have Achilles issues and obviously there's load management issues, there's so many loads of these things. But that's when I think you have to start to look at like how well someone actually moves their foot. And obviously if you had a hip flexor issue, you would say, "Okay, the... " Actually let's make it even simpler. You have a bicep issue, you would check how well the elbow moved. Well, like you have an Achilles that's attaching down or actually really kind of like just becoming the calcaneus, it's just blending in there at some stage. We don't know exactly where. It's like tendon, just kinda all this stuff...

Dr. Yoni Rosenblatt: Melts.

David Grey: And then a heel bone. So like, yeah. So I would, if I had a bicep tendon issue, I'd probably check it while your elbow moved. Well, when we have an Achilles tendon issue, you do, people do check about the, check the ankle, but they don't look at the heel bone, they don't look at the midfoot, any other part. So they're only interested in looking at ankle dorsiflexion and plantar flexion. I just really think that's part of the equation, but like just really not enough. And this is not just a theoretical thing. It sounds theoretical, we've had thousands and thousands and thousands of people, go through our programs and work with me personally on some of our physios and completely change their Achilles issues, their plantar flexion issues, their sesamoid issues, their shin splint issues, their ankle impingement issues by focusing on improving the movement of the whole foot, not just the ankle. And these are people that have just completely failed rehab, physical therapy elsewhere.

David Grey: How you get the heel bone moving is you have to have your center of... You have to have weight on top of it. There's only the compression. You need compression, you need to... For example, you'll see people doing a knee to wall like assessment and they'll push their knee forward. And if you look closely, what you'll see is, you'll see space even though you're told a million times, keep your heel bone down. Keep your heel down. 'Cause we're checking dorsiflexion. Their heel is not down. It's a hundred percent not down. And, it's not heavy on the floor. And how you know it's not is 'cause they'll push your knee forward and you'll see their toes smash into the floor immediately. When the toes are smashing into the floor, I can guarantee you the heel bone isn't heavy on the floor.

David Grey: You need to actually start in those like knee coming forward and back drills, you need to start with your knee, in a negative shin or your shin in a negative shin angle. Your knee is behind your ankle and you need to be rocking your knee forward and back with the emphasis on keeping your heel pressure. And you should actually feel the pressure shift in your heel. I know this is hard for people to visualize 'cause it's a, we're talking about it, but it is visually very clear when you see it and I have posts where you can see it happening, but it's hard to just think about.

Dr. Yoni Rosenblatt: It is. It's hard to think about it. It's hard to talk about. That's why everyone is gonna go to David Grey Rehab and download the course and pay for the course. But, gimme some tricks to how do you teach the athlete to do that? It's gotta be more than, "Hey, just do the activity you're not good at." How are you educating them to create that mobility that needs to transpire at calcaneus?

David Grey: It's a very sensory thing. You need to slow down. You need to help them understand why we're doing it. And remember I spoke about the midfoot earlier, You really can't get your weight and load and unlocking in the midfoot if your heel isn't down. Because if you think about supination, when does that occur? What is supination really? It's this locking up of the foot, right? When toes start to kind of push into the floor, that's obviously we're pushing away then and we can't be pushing away on a floppy foot. We need to limit relative motion at that stage. It's a global example of this is... It's why powerlifters are very stiff and tight because they need to limit relative motion.

David Grey: They don't have much access to movement at their... At least any good ones don't have much ankle dorsiflexion much. Maybe knee flexion, hip flexion, internal external rotation, much spinal movement. It's because they've trained their body to be incredibly stiff because they're pushing their, putting a lot of weight on top of their body and pushing as hard as they can. Their body is responding to that with a ton of concentric muscle activity. And not just when they're under a barbell, when they leave the gym, they walk like that, they sit like that. They are just very tight people and it's what they need. If we want to open up a foot, we can't be pushing down into the floor very hard because that's where we're gonna lock up a foot. We need to be able to do that as well.

David Grey: It's very sensory in the beginning. Doing choosing exercises where we move from a negative shin angle, which is... If you think about the early phases of gait, when you strike your, heel on the floor and your full foot comes down, then your knee is gonna be bending. It's this kind of, heel rocker, ankle rocker type of movement. And you can choose movements like that, split squats like that. For a practical example, If you think about a Bulgarian split squat, you are kind of... As soon as you put one leg back up behind you and the other leg in front, you're kind of on top of that front leg already you're there. You're on top of your foot already and you're gonna have a bit more like midfoot and fore foot pressure there. Even though your heel will be down.

David Grey: If you think about something like a front foot elevated split squat, you're kind of on... Your body is behind your front leg and you're... As you bend your knee, you're moving into that leg. Exercises like that where you're moving from a negative to a positive shin angle, that's what's gonna really start to unlock the heel bone and the midfoot. And, it's not hard. You just have to choose your exercises and coach them pretty well and actually ask people to sense the foot a little bit as well, which is... What a lot of these people need, especially people with foot issues. 'Cause if you ask them to, tell you to describe the sensations in their foot, they'll tell you it's painful. That's the only sensation I can describe is pain. And there's a world of sensation that we can find aside from pain and that we might wanna help them find that as well and tune into that.

Dr. Yoni Rosenblatt: In that example with a Bulgarian split squat, when you're trying to force that positive shin angle or you're trying to force that energy or weight shift through the foot starting at hind, then moving all the way through, you be a proponent of doing the front foot elevated split squat where we're now starting from behind and forcing that shin or need to drive forward while keeping compression down through calcaneus. Is that right? 

Dr. Yoni Rosenblatt: I wouldn't say the word force, but because that might get people to think about forcing something to happen, but by the exercises is constraining it in that way. When you put your foot up on something, your body isn't on top of that foot as well and then you bend your knee, you're almost traveling into your foot, which means your weight is traveling through your rear foot and into your midfoot. Whereas if you think about a Bulgarian split squat, you're on top of your foot. That's why Bulgarian split squats are disgusting. They're one of the most disgusting exercises because you're on top of your foot and all your body weight and the external load is on top of that and it just smokes you. Whereas a front foot elevated one obviously can be disgusting as well, but there's this kind of moving in and out of the foot more than just being on top of it throughout.

Dr. Yoni Rosenblatt: That totally makes sense. Is there any room for manual interventions or passive interventions to get that calcaneus to move the way you want it. No, I'm gonna go with no, based upon that response.

David Grey: A little bit like... [chuckle] No, there's room for everything. Look, there's room for everything I just wouldn't be... Again I'll go back to what I said about predictable and repeatable. And I know like getting people to move their own bodies is predictable and repeatable. And if you do it right it's gonna start to open up. We're not all going to be contortionists, we're not all going to have tons of range of motion. But like most people will be able to start to access a little bit more. And that means it's repeatable in terms of it will happen again and again with different people and they can do it again and again themselves. Every time they do the drill, they can open it up. But that doesn't mean manual therapy may not be helpful, but with the heel bone in particular, you're just not going to be able to get enough movement there probably through with your hands.

David Grey: Like their body weight being on top of a foot is gonna be much more beneficial I would say. But it depends. Because you gotta think about why these joints aren't opening up. So if someone can't flex their knee very well or like get that shin to drop forward, they're never gonna pronate their foot or open up their foot and dorsiflex. So you might be, you might think, okay, I can actually do some manual therapy to help them flex their knee or desensitize their knee so they can flex it better. And now they... For example, someone with patellar tendinopathy, they just won't want to flex their knee or someone with knee pain they won't want to flex their knee. And then a lot of these people... Some of these people can end up with ankle and the Achilles issues and stuff because they just never go into this positive shin angle and dorsiflexion.

David Grey: So other people, they're just very stiff through the forefoot and that's just does them give them space to maybe move through the rear foot and the midfoot. 'Cause the forefoot is so... Like the toes are... Like if you ever see hammer toes. There's no chance that rear foot is opening up because there's no space. The foot is gripping all the time. So potentially manual therapy there could open up some space into forefoot and now they can access more of the foot. So I would say the heel bone specifically, you're gonna struggle. But like a kind of a heel bone or a midfoot that's a bit stuck. Doesn't mean that's the cause of that in the first place either.

Dr. Yoni Rosenblatt: Yeah, Okay. That makes sense. Now if we progress forward towards that midfoot, you're finding hypo-mobility through that midfoot they're staying, they're not letting themselves get all the way towards pronation properly. Are you ever prescribing midfoot mobility drills? Do you send them home with a lacrosse ball? 

David Grey: No I don't. But again, that could be helpful. But if you put a lacrosse ball under the midfoot, what's that doing? What's that doing to the joints at the bottom of the foot or what's that doing? It's basically like you can do it with your hand. Everyone can do it with their hand at home. If you put your fist, make one hand like a long hand, push your fist into the middle of your hand, what... And that hand pushes up the flat hand starts to push up to the sky. Does that hand know that you just, you put the fist in the middle of it. Does that hand look more supinated or more pronated?

Dr. Yoni Rosenblatt: More supinated.

David Grey: So flatter would be probably more pronated and then this kind of crunched hand would be more supinated. So putting a lacrosse ball under the middle of the foot is pushing the joints on the plantar surface of the foot. It's actually closing them more. So this is why I don't focus on. This is why this stuff doesn't work that well for plantar fascia, plantar fasciitis or plantar fasciopathy or whatever the term these days is, is because like the best plantar fascia "release" would be taking 10,000 steps a day and your plantar fascia being able to lengthen and shorten. But if you just start poking at it with balls and stuff, it will give some, potentially give some, make it feel like this tissue is getting some kind of stimulation. But then you just go and walk and like the foot is still not actually opening up and pronating and supinating.

David Grey: So again you could use a ball, but my focus would be on not moving tissue, would be on moving bones. 'Cause when you move bones, the bones are then going to keep moving and that's gonna keep mobilizing the tissue. So that could be an option, but like clinically reasoning it, I wouldn't be so sure. But then again, anything can work 'cause pain is complex. I think more like if they're not accessing pronation and supination, like looking at tibial rotation is a really good option and thinking, Like even doing exercises like foot clocks and stuff like that, you can use the pelvis as a driver where they bend their knee and they... Or they use the opposite leg. So let's say I'm on top of my right leg, I bend my right knee and as I bend my right knee, I reach my left foot forward to 12 o'clock.

David Grey: Next time I and then I straighten my knee as I bend my right knee, I reach my left foot out to 9 o'clock, I reach my left foot out to 6 o'clock behind me and then each time I'll go around the clock. Next time I do it, I reach my left foot out to 9 o'clock. But I actually turn my pelvis in that direction as well. So that's maybe given the potential for the femur and the tibia to start to internally rotate and you're just gonna get, start to get a lot of rotation through the tibia, which is hopefully gonna rotate the rear foot. And yes get people to the medial arch. I would just start to think about like how it can drive tibial rotation a little bit more if they're really not pronating or supinating at all.

Dr. Yoni Rosenblatt: And it sounds like you are the construct through which you assess this movement and mobility and the way you use terms like opening and closing is the reversed to so many, which is far more open chain, which is far more compressive in nature especially when using the example of the lacrosse ball, when in actuality that's not creating this elongation which you're forcing to transpire in the closed kinetic chain environment, which has a multitude of benefits 'cause that's the way we live and that's gonna be "more functional". It's just totally radical to the way I think so many people are teaching mobility training and I think that there's value just in that.

David Grey: Yeah, especially with the foot, especially more than anything else with the foot, because you can do open chain drills and you can mobilize a lot of joints. You'll see for example, like FRC and I think they do a lot of great stuff, but you can open chain your way to mobilizing a lot of joints and feel great and get really good results with it. But show me how you do an open chain joint rotation or controlled articular rotation on one of the midfoot joints. It's impossible. You just can't do that. You need to have your foot on the floor. It's impossible. I'd love to see someone that can isolate one of their midfoot, the joints in their midfoot and be able to move that. You can do toe yoga, you can lift up your toes and drop your toes.

David Grey: You can do ankle dorsiflexion and plantar reflection. Especially in the open chain. You can line your back and dorsiflex and plantar flex and evert and invert. You're not moving your midfoot, not a chance in hell. So like really the foot needs closed chain. It needs your weight coming in on top of it. And it's not just about ankle. The ankle joint. You can think about that as an isolated joint. And then you can think about there's 33 joints in the foot you need where you see joints. You should hopefully see movement. And again, if that goes back to the hand or the spine or the neck, we would love to be able to move them. And the only way of moving these guys and the foot is to do it in the close chain.

Dr. Yoni Rosenblatt: And I think you're also, I would say the same thing transpires around the tibia and you put such an emphasis on tibial internal rotation, external rotation. You see that in the FRC world. You see it very heavily in the open kinetic chain in the FRC world. And I think I've struggled, at least my patients have struggled with just creating enough torque other than the muscular contraction in the open chain. I think going closed chain allows you to create torque off the ground to then manipulate the joints in the closed chain environment. And I think you get more bang for your buck, I think.

David Grey: Yeah, you can and you can use both. It's lovely for a knee client to do who can't... Who feels like they can't lower their knee. When they bend their knee, they get very sore. What are we gonna do? Potentially, I can try that. But they keep telling me this is get... This is making me more painful. I can do open chain tibial rotations. At least it's giving them some movement, a little bit of blood flow. You're training the muscles there. You can do probably loads of really nice drills there. Open chain, knee flexion and extension where there's not much load going through the knee. But yeah hopefully everyone would acknowledge that eventually. Want to get them standing weight bearing, building strength and all these things. So like it's not one or the other. It's just about clinical reasoning and choosing the right tool and being able to progress in the right way. These are all great options, but it's just important for people to understand that when you choose an exercise or when you have an intention behind, you need to have an intention behind it. And if you think that doing open chain drills are mobilizing a foot, I would be very skeptical of that claim.

Dr. Yoni Rosenblatt: Yeah, a healthy skeptic. I can appreciate that. So, let's kind of reverse course. Let's go to hyper mobility. You got a floppy foot that cannot come back to a rigid lever to propel you forward. You're gonna try to teach this athlete some form of stability or maybe midfoot strengthening. Can you walk me through the way you look at that, but then also give me some type of progression there, how you progress a patient through stability drills?

David Grey: Stability is a kind of a funny word where a lot of people... A lot of like things get labeled with unstable and it's...

Dr. Yoni Rosenblatt: How about control? Let's use control.

David Grey: I don't think it... Yeah, control might be a better word because I'll just go on that point just for a second. And it's not to be narky about it, but I have a post on my Instagram looking at, like, there's a guy who does a counter movement jump and he looks super unstable. And if I asked if you put up a poll or ask people all of their opinions, like why... Like as in unstable as in when he lands, he looks like he's just gonna buckle completely and it's a post ACL client. He's like five months post-op. He just came to me and he was still struggling quite a bit despite doing loads of rehab. And a lot of people would talk about stability there, but some people would say like, okay, he has a weak loop knee. Others would say he has a weak quad. Others would say that he's not coordinated. Or some people would have commented saying, you need to look at his vestibular system and his visual system in this instance. So like, stability doesn't maybe make it... It doesn't help me narrow down what the actual issue is.

David Grey: So I think maybe control is a... Is probably a better word in this instance. And you see a lot of people with maybe ankle issues who do struggle to control range. You'll see people... Yeah, ankle issues are usually the most common one. Like they just have maybe a lack of strength, a lack of control through range and sometimes an inability to actually stiffen up around the ankle and the foot, which is super important as well. So I do a lot of heels like kind of floating heel exercises in that instance. So people can even stand up and feel the difference between standing on one leg, so standing on two legs with your knees bent and then not changing anything except just elevating your heels a tiny bit off the floor and you'll feel the pressure in your forefoot and straight away you'll actually feel a lot more muscular contraction and muscular co-contraction starting to happen to help you stabilize.

David Grey: Then you can go onto a single leg, bend your knee stand, left foot is off the floor, right foot is on the floor, knee is bent. Stand there. You'll feel this kind of muscular contraction and co-contraction that's happening to help you stabilize there. I will use that word in that instance. And then when if you stay in the same position and take your heel off the floor a little bit, you'll feel way more tension, way more demand on this control to stop you from falling over. So this is a good point of view as well. To go back to what we're speaking about calcaneus mobility.

David Grey: If you take your heel off the floor or it's not heavy on the floor, you'll feel so much co-contraction around the ankle and the foot and the lower leg in general. And co-contractions are not good when we're trying to restore relative motion. We want less muscular activation so the joints can open, not more. So if I want to restore relative motion, keep my heel on the floor so I have a chance to open up the foot. If I want to teach people to freeze degrees of freedom and limit relative motion, which is what we're talking about here, is controlled potentially or locking up the foot I think you said. That's what we're looking at. Making sure that people can take their heel off the floor and then be able to do a lot of things there and ultimately, excuse me, ultimately the end of the progression are teaching people to do this, I think comes back to teaching people a lot of plyometrics, learning to leave the ground and land back on the ground again and continue to leave the ground.

David Grey: That's where I think control comes in because a lot of these, like the demands on control really come in there. And because really a lot of these, a lot of these things are driven through reflexes and standing maybe on a stability ball or things like that can be quite beneficial. Like you can't train some things early on in an ankle injury or a lack of control. You can build some strength there, but the contractions are still not nearly as quick as they would be through a plyometric exercise, a fast ground contact. So what we're trying to teach people there is because the stability ball work and stuff is too slow.

David Grey: 'Cause you're contracting when your foot is on the floor, but to be able to really control range and the best athletes in the world, and there's been studies on this show that they have higher levels of pretension and pre-activation before the foot hits the floor and they're not waiting for their foot to hit the floor to then say, okay, now I need my muscles around my lower leg to be active. They have much... There're very high levels of activation. The right amount, but high levels around the whole lower leg before the foot hits the floor. And obviously that's gonna help them manage the collision well.

David Grey: So I think for people who can't control through range, we need to train them through range. We need to train exercises where we have our heels off the floor, not just calf raises, but balance drills. Like there're those foot clock drills with our heels off the floor. You see in my foot program, it's hard to explain, but we have like squatting exercises with our heels off the floor, hinging exercises with our heels off the floor. Different funny things that people probably haven't seen before. And then we have tons of plyos that are just building strength, building reactivity, building control coordination and not in a conscious way. You can't really tell all these muscles to squeeze and co-contract together particularly well. It's a reflexive thing that only really happens when you jump and leave the ground and come back to the ground multiple times. Reps and reps and reps of that.

Dr. Yoni Rosenblatt: So how...

David Grey: So sorry, that was a bit of a...

Dr. Yoni Rosenblatt: No, that was great.

David Grey: Winding answer, but hopefully.

Dr. Yoni Rosenblatt: That was great because you answered one of the questions that I have when I try to consume a lot of your information and content, which is that pretension idea and you did a great job of breaking that down. What that looks like, that it is reflexive, that that body is ready to absorb and create force before that foot ever comes down. So how do we begin to train that? I love that idea. How do you take that athlete from, call it the single leg heel float position? How do you train them in that? Is it duration? Is it load? What's your first intervention there?

David Grey: So yeah, I'll go back to the foot program not 'cause I'm trying to sell it, although people... I'd love if people bought it, but not because I'm trying to sell it just 'cause it's like a four phase thing that... [laughter] It's a four phase thing that is written as step by step let's say. So there's a calf bridge exercise. Think of a single leg glute bridge where you're lying on your back, your foot is on the floor and you do a glute bridge. Except we are just lifting our hips a tiny bit and we're pushing through the foot and lifting our heel off the floor and holding in an isometric there, in that plantar flex position. That's quite disgusting for people. People will feel the worst calf and hamstring cramps just by taking their heel off the floor in like a glute bridge type of position.

David Grey: Very very disgusting for people. So that's training this synergistic contraction of the hamstring. The calf. And when the foot is pushing through the floor. We have drills where we do like wall drills where we're on our back, our foot is against the wall and we're doing a calf raise against the wall but our knee is bent. And that again sounds funny, but you're training this synergistic though, there's a lot of muscles starting to work together. We do wall pogo exercises where we're laying our back, our feet are against the wall or one foot is against the wall, hips are up off the floor and we're doing a little pogo against the wall, so we're hopping against the wall. All of those things are designed to build a lot of strength and some kind of coordinate inter-muscular coordination, but deload people.

David Grey: It's not their whole body weight coming down on top of them, which hopefully again might sound funny, but hopefully PTs understand if I did plyo or with this plantar fascia person in session one, they're definitely never coming back because they won't be able to walk for a week potentially. So these are ways to build them up and train them and get them stronger in a maybe safe and logical manner. So then you can, yeah, you can get them standing doing just floating heel exercises, balance drills, foot clocks with a floating heel, squatting with a floating heel, hinging with a floating heel. Wall acceleration drills where we're upright, we have our hands on the wall, we're kind of hinging back and then pushing up into a calf raise where we keep our heel floating all the time. Gentle plyometrics. Then, Bulgarian split squats. I do a lot of those where we go down to the bottom of the split squat with a lot of load. We take our heel off in the bottom and we drive as hard as we can through the foot then to come back up.

David Grey: Again, sounds simple, but like some very, very, or like everyone that does the program and these type of exercises, it becomes apparent very, very quickly how weak you are and we all are, in these positions. And then yeah, just simple simple, logical plyometric progressions, double leg, single leg, jumping off boxes just different types of directions. And you can actually pick up a lot of foot mobility there as well. Depending on, like, if you're looking for super quick ground contacts, you're gonna stiffen up a bit. You can have slightly slower ground contacts where the joints are gonna have a chance to open up a little bit more. You can do it in different directions to buy us more pronation or supination. And it's just like any good training program. I think it's about, some exercises will be like more about duration, like time. Some exercises will be more, less reps, higher intensity. Yeah, some exercises you might train every day, some you might do once or twice a week. I know it's mixed depending on the person in front of you and obviously the exercise as well.

Dr. Yoni Rosenblatt: Well, I think it's a great mix. Because I think too often, I would say our number one issue as a profession is not getting the athlete in rehab to this high level of plyometric progression intelligently, and understanding that, Hey, they gotta be out on the pitch. They need to be creating force over and over and over and over beautifully. They better be able to do that in a rehab controlled environment before they get out there. So I think that's I'd say the number one issue we have as a profession or mistake that PTs make is that they don't get their athletes all the way to that level. What would you say the number one mistake PTs make as it pertains to plyometric activity is?

David Grey: Not doing them? Yeah, just not doing them. So like, if you take an Achilles or a calf, soleus let's say like in slow, pretty slow running now, the numbers were vary, but you could see like...

Dr. Yoni Rosenblatt: David, let me cut you off. The whole reason I brought you onto this podcast was to say the word soleus. I'm glad we finally got there.


Dr. Yoni Rosenblatt: Because it sounds better when you say soleus...

David Grey: Do I say it in?

Dr. Yoni Rosenblatt: I'll use soleus.

David Grey: Okay.

Dr. Yoni Rosenblatt: You you use soleus. Go ahead. Yeah, but go ahead. You were saying.

David Grey: Depending on the day, I couldn't say it in a different way or name it a different thing. So where was I? Oh, I think we're after freezing now. Are we back?

Dr. Yoni Rosenblatt: You got me? Yeah. You're so far away.

David Grey: Oh, okay. Yeah, yeah. I lost you for a sec. So yeah, number one mistake, like with regards to that is just not doing plyo. So if you think about, if you look at some studies now, it will vary, but slow running, you might see six or seven times body weight going through the soleus in slow running. So people think that like a good rehab for a calf or an Achilles issue is doing 20 body weight calf raises three sets of 20 or three sets of 10 body weight calf raises and some squats. And then like, yeah, next week you're able to go for a run. I just think that's not going to... That's just not gonna cut the mustard. And you're going from one times body weight to six or seven times body weight. That's not my idea of a smart, logical, safe progression.

David Grey: So you gotta do them. You gotta do like these small pogos where your hands are on your hips and you're doing double leg and you're barely leaving the ground. Like that is not, if you're working with athletes who are playing basketball or football or these sprinting, there's so much load going through these areas. And the only way to replicate that and to bridge the gap up to things like sprinting and jumping and change of direction in high intensity is to do a ton of high intensity plyometrics. Obviously you don't start there, but you gotta build that up.

David Grey: Whereas if you look at something like a hamstring, like a hamstring tear or just a hamstring in general, like in slow running, yeah, you have a hamstring tear. There might only be like two times body weight going through a hamstring in slow running. So you have someone with a hamstring tear, you can probably get them jogging very, very quickly, like very soon after that's happened. But you have someone with an Achilles, a nasty, I won't even say, obviously not an Achilles tear, but like a nasty tendinopathy or a calf strain, a soleus strain, a soleus tear. There's no way you should be getting them running very quickly at all. They can't even walk, usually. They can't walk up the stairs.

David Grey: So you need to understand like if it's lower leg issues, you gotta get your plyos in. You gotta get a lot of them in, and you gotta get them in, in a lot of different directions with different amount of volume, intensity and complexity. And don't be surprised if you have plantar fascia, Achilles shin splint issues, ankle issues. Don't be surprised that they keep flaring up. They keep coming back if you keep rehabbing people and sending them back without getting them up to a high level of plyometrics, I would say.

Dr. Yoni Rosenblatt: Yeah. That makes a lot of sense. Can you describe what a good repetition of a plyometric a single leg plyometric exercise looks like? I think part of our issue is we don't know what good looks like to then coach people up to look good. Yeah. So what do you look for as the ideal?

David Grey: I won't say ideal, but I will say first I think it's important for people to understand what a plyometric actually is. Because when I say plyometric, or when you say plyometric, a lot of people listening might think of something like a box jump, and that's not a plyometric exercise. So plyometric there, there's a couple of key markers I would say that would make something a plyometric. And one is that there is a landing and a takeoff coupled together. So does a box jump have a landing? Yes. I land up on the box. Does it have a takeoff? Yes, I jump off from the floor, but they're not coupled together. The takeoff, I squat down and I jump up. The landing is up on the box. Whereas if you think about something like a pogo, the landing and the takeoff, the energy is being coupled together. They're happening together pretty much. And the second part that is a key characteristic of a true plyometric exercise would be short ground contacts. So it needs to be pretty short ground contacts.

David Grey: You'll hear varying reports of how short it needs to be and maybe you don't need to be too picky unless you're working with sprinters and stuff then you do. But they can't be sinking down a lot into the movements. It needs to be pretty quick on the floor. And my kind of marker what it is, if you don't have technology to measure the ground contact time. You shouldn't be able to point out a clear, like if you think of a squat jump, you can clearly see they land, they sink, there's this eccentric, there's this isometric movement, then there's this concentric. If you can really clearly see that and really... Yeah, it's just too slow and that's not a true plyometric and they're not using as much elastic energy, they're not using their tendons as much, it's more of a, like, even though I don't love the term, it's more of a muscular movement. That's the key components there, is short run contact times and the landing and takeoff are coupled together.

David Grey: And then you think of, I like people to be able to strike with somewhere around the middle of their foot so they're not striking too high up on the toes, they're not striking too much on the heel, like middle of the footish, middle to front of the foot. I like them to be quite relaxed and rhythmical, it shouldn't sound floppy but it should sound as a big thing in plyos. It should sound like there's a nice pop off the ground.

David Grey: And yeah, you can just build up, I will build up people's intensity of the landing and the complexity in terms of the directions that they're moving. But the big lens is, are they keeping short ground contacts and are they staying relaxed and rhythmical? It looks quite nice. Nice is a nice lens to put on plyos, 'cause it doesn't look like they're slapping the ground and doesn't look like they're just sinking a ton. Things like that. Yeah, just looks nice short ground contacts and quite relaxed and rhythmical I would say.

Dr. Yoni Rosenblatt: Yeah. We've invested in force plates in a number of our locations and that's given us a lot of real data to be able to see. I love the idea of just using your smartphone to just video it, watch it, make sure that they're rigid at ground contact, make sure that they're not sinking and sloppy. And I love that you highlighted the auditory cue because their ability to snap and pop off that ground is huge and it gives them great input, should they be doing it at home. They should be able to hear a great rep and hear a poor rep and then know how of fix that. I love that that's a piece of your world. Okay, I wanna just dive into a little bit more of a case study in our remaining time 'cause I think you'll be a huge benefit in this case. I got a 30 year old professional football player who has had... Dude, he is the definition of chronic Achilles tendinopathy, who has done more heel raises than anyone should ever do in their life, right? He comes in to see me.

David Grey: Yeah.

Dr. Yoni Rosenblatt: Or he comes in to see David Grey, massive calves, 270 pound dude when he is sticking to his diet. What does your first session look like?

David Grey: I'll just do a generic assessment with not too much thought on the Achilles, obviously it's in my mind, but I'll just look at how they move in general. Table tests, like how's your hip movement, knee movement, ankle, feet, a little bit there, toe touch and standing, show us your squat. No good or bad for any of this stuff. I just wanna get a feel for how you move, on the table I'm getting a feel for your movement potential and then in standing, I'm getting a feel for your moving strategy, how you actually coordinate things. Are you moving with speed or a lot of apprehension in certain movements? Do you have access to certain movements, blah, blah, blah, etcetera. I bet like lateral reflection of the spine, extension and rotation. And then I'll zoom in a little bit more on the feet.

David Grey: So that drill that we spoke about, just that small split stance, knee forward and back and then I'll do that calf bridge probably exercises a little test to see, can you actually hold this isometric position even on the ground for 30 or 45 seconds? And I would say the answer is probably no. You're even gonna probably struggle there, so that's our assessment. It's not fancier than anyone else does. It doesn't take longer than anyone else does. It's just being clear on what we're actually looking at from people do their movements. When you look at someone doing a standing rotation where they just twist their whole body left and right, you can see when I rotate my body left, you can see if the right foot is pronating and the left foot is supinating. When I rotate my body right, you can see if the left foot is pronating, the right foot is supinating. In all these drills you can zoom in yourself on whichever part of the body you wanna look at, but in general, you're just looking at all their movement strategies.

David Grey: Usually session one just gonna be, 'cause I know with this football player, 'cause he's probably gonna be limited through like his midfoot, his rear foot. No one has ever taught him. All the calf raises have made him more and more and more stiff through his foot. Even if it's more pronated foot or supinated foot, it'll be super stiff. The heel bone won't be able to move, the midfoot won't be able to move. I'll just coach some of that little mobility work, rocking that shin forward and back, maybe a bit of tibial rotation. Couple of those simple drills and then one isometric drill, like that calf bridge, which is, I think it just builds, I explain in the video in the program, it helps build a real deep connection to the soleus that, they won't have felt funnily enough with doing the calf raise exercises, their regular calf raise exercises. It gives us like, that we focus on squeezing really hard through the lowest part of the soleus.

David Grey: And if you look at a lot of these athletes doing their calf raise, the regular calf raise work, when they go to push up and plantar flex from if just like a straight knee or something, what you'll actually see is they just trust their whole body forward in space. They just extend their back and they're using all these weird propulsion strategies. A lot of these people will feel lateral shin and anterior shin work. And when they do calf raises, which is weird, they shouldn't. They're fine in all these kind of, I don't love the word compensation but accessory ways to help assist the movement. Yeah, just getting the rear foot and midfoot moving and...

Dr. Yoni Rosenblatt: And then what do you...

David Grey: Doing an isometric probably where...

Dr. Yoni Rosenblatt: Do you give them anything for home? 

David Grey: Yeah, that would be their homework.

Dr. Yoni Rosenblatt: It's their homework. And how often are you see...

David Grey: They've got to do simple stuff five or 10 minutes.

Dr. Yoni Rosenblatt: Okay, how often are you seeing a case like this? How many times a week? 

David Grey: It depends on the person. So I've done a full rehab process for a nasty Achilles tendinopathy where I basically went through my entire rehab process like that program in one week with someone who was playing in a big, huge competition, huge tournament. And they need to be ready for that weekend. So that's where you're seeing them like everything a day, whether it's probably online, in that instance. I'm seeing them every day 'cause they're in some country that's not Ireland. And they're playing with their team.

David Grey: There's that. But most of my clients, I'll see them... Look, if they have lots of money, they can come back every day because it's their job. They're trying to get better as quick as possible. They can come back every day if they want. But mostly if they can go and work on that for a week, because... Two weeks easily. Because they need to get better at it. And what they'll also feel is this stuff is helping me. I wanna give them the least amount of things possible so that they are so clear in their mind that it was these couple of drills that made me feel better than I have felt in five years. And not that I did 30 drills and something must have helped. It's so clear, they can't argue with me. And I won't try and change their shoes in the first session. I won't try and change their diet in the first session. I will see if I can do these couple of things and we just get your heel bone and your midfoot moving watch how much better you feel. And because it's easy to deny it. It's easy to think, especially for athletes who wanna work so hard, it's easy to think like, "This is just a strength problem." Because that's what they've been told, or this is a load management problem, that's what they've been told.

David Grey: But when this has going on for five years and they've managed all the load that they can, they fill out every form, they've got every detail with their sleep and their nutrition and every calf raise, can you keep saying it's a load management issue? And what if it's only on one side and not on the other side? I nailed that one side that the pain is on is stronger, it can do heavier calf raises the other side, but there's no pain on the other side. We have to start to think load management, but you have two legs and you've run on to your legs, but you only have this problem on one side. So does that mean all the sleep that you're getting is only going to one leg and not the other leg, or all the nutrition is only going to one and not the other? So there is biomechanical factors at play, and it's not just biomechanics in terms of movement. It's also the strength in terms of the strength potential, how you load these tissues, when you move your foot, when you move your tibia. How your soleus loads, not just when you actually run and jump, not just how much you can lift in a singular movement like a calf raise. So that will be a simple first session and probably I don't need to see them again that week.

Dr. Yoni Rosenblatt: I love that. Okay, I love that, I love it 'cause you're so passionate about it. And it makes just a ton of freaking sense. Okay, so as not to hold you here all day, 'cause I could talk to you about this crap all freaking day. Let's wrap up with a lightning round so you can get back to treating patients and creating out staying the course work. Ready, what is the number one mistake you see from seasoned clinicians? 1:03:39.1 David Grey: Number one mistake, I don't wanna be preachy, 'cause it sounds like I'm saying everyone does everything wrong and I do everything right, it's not, 'cause it's really not. 'Cause I see people all over the world and everyone's trying their best. So just being closed-minded. That's the number one mistake. Just being closed-minded, just like we all have our egos, we all have our history of like we've gone through certain systems, we've learned certain things. And then just presuming that's all the knowledge there is and I have all the answers here. And if I don't get a result, it was with a client, it was the clients fault or it wasn't a lack of knowledge on my part or with some external factor. So just being open-minded. But I think that's just in general, for all of us, just trying to put our egos aside and just learn.

Dr. Yoni Rosenblatt: It's a good freaking answer. What country houses the best sports PTs? 

David Grey: You know what, every time I've been in. We've done nine or 10 workshops this year.

Dr. Yoni Rosenblatt: Yes, go on.

David Grey: And every single country I go to says that all their like physical therapy is shit in my country. There's so much shit over here and it must be amazing in America, it must be amazing in Australia, it must be amazing in the UK, 'cause they have professional football or soccer there blah, blah, blah. I don't know, I just think the industry as a whole needs to be better. And I honestly, it's not even a cop out, I honestly can't even answer that particularly well. I think there's just good and bad everywhere. And a lot of people somewhere in the middle. And in America, it's probably more obvious because there's so much shit people there, because there's so much more people there. You know what I mean?

David Grey: People give out about the industry and the healthcare and blah, blah blah, and the insurance stuff, and how some of that can be so frustrating. It's just because it's in your face because it's such a huge market. Ireland is a representation of that as well. It's just such so much smaller. So we just have way less people here. But probably percentage-wise, there's a similar amount of really good people, similar amounts of shit people and just a lot of people on the spectrum somewhere in the middle.

Dr. Yoni Rosenblatt: I don't think that's dodging the question, I think it's a great answer.

David Grey: So that's me sitting on the fence.

Dr. Yoni Rosenblatt: No, I like it. But I like it because you've been everywhere. And I think that's a really astute view. So that makes a lot of sense to me. What is your stance on PRP or any biologics specifically for Achilles tendinopathy?

David Grey: I don't know enough about it. I had a PRP injection into my patellar tendon when I was playing a lot of football about 10 years ago. And it literally, like just... I would've been, no, I would've been better off not getting the thing, it just...

Dr. Yoni Rosenblatt: Yeah.

David Grey: It's just a waste of time and money. My bias would be slightly against that. And I think there's a few reasons why it could be helpful. One, it could be helpful for what it says on the tin, potentially it could help someone. Two, like there's placebo potentially that could help people. Three, there's... When I get an injection, maybe I'm forced to take some time off my whatever activity that I'm doing at the moment and focus on rehab. So that can be helpful. Same as... I wouldn't necessarily call that the same as the placebo effect. It would be more like, this just gave me breathing space to focus on my rehab, so I'm not the right person to... I just see people being told it's a cop out from a clinician and not in a bad way, not... Okay. Like, oh, calf raises aren't working. Your only option is this injection, which is just...

Dr. Yoni Rosenblatt: Right.

David Grey: Bullshit. Why would I have expected calf raises to work in the first place, when there's just so many more issues going on here. You haven't tried any plyos, you don't know how to mobilize the foot. You don't know how to strengthen the foot, calf raises don't strengthen the foot. You just don't really build any foot strength. They build a little bit of calf strength, or they can build calf strength, but they don't strengthen the feet. Not the way you see people in my Instagram, every day their feet and ankles are freaking out shaking like crazy calf raises just don't do that to people. Yeah, I don't mind any intervention if there's good clinical reasoning for it, and hopefully it's not just a cop out.

Dr. Yoni Rosenblatt: Yeah. Well, I think it's tough to just answer that because it's different strokes for different folks. Tell me about blood flow restriction. Do you use any of that in your practice? 

David Grey: No. No, I don't because... Again, similar answer, I used... I tore my Achilles, I had Achilles tear, and I used a little bit myself, but so if it's something like that, like a rupture, I think it works a lot better to be honest with the quads than lower leg to be honest, but I think, I wouldn't argue with someone using it at all. But a lot of our work is now online, and these people just don't have access to this stuff.

Dr. Yoni Rosenblatt: Sure.

David Grey: I haven't seen worse results as a result of not doing it. But I definitely wouldn't argue with people if someone said, yeah, I'm using this with my client. I would say Brilliant. Off you go.

Dr. Yoni Rosenblatt: Brilliant. Okay, where is David Grey Rehab in five years? What are you doing with this thing, man? 

David Grey: I don't know. That's what I'm trying to figure out. [laughter] that's my biggest problem right now, [laughter]

Dr. Yoni Rosenblatt: But it's a good.

David Grey: I don't know. I just live kind of day to day, and it's a good, it's a good problem. Yeah. I just... I dunno, we've been enjoying the journey. We've been trying to be consistent, trying to put our thoughts out there consistently, for years. Not tell anyone that this is the right way, or we have all the answers. Just literally never said that to anyone. No one at our... Anyone that comes to our workshops never hears me saying, what you are doing is wrong and what I'm doing is right, or this system is better. I just literally say, here is what I think, and you can take it or leave it and hopefully when you, if you like it, you'll start to use it, and you'll start to see predictable and repeatable results and residual results. Residual is the keyword. Think results that start to last. It starts to change people and yeah, it lasts. I don't know where we're gonna be. I don't know. We're trying to figure out how potentially maybe it shouldn't be my name on the business. Maybe that's a limiting thing, so I don't know.

Dr. Yoni Rosenblatt: What are you gonna call it? What are you gonna call it? You want me to poll the audience and see if we can get some feedback?


David Grey: Yeah, definitely.

Dr. Yoni Rosenblatt: See what they say.

David Grey: Come up with a name for me.

Dr. Yoni Rosenblatt: Poll a name. I feel like it should involve the word Yoni in it somewhere. I feel like that would, that's a seller.


Dr. Yoni Rosenblatt: Maybe not.

David Grey: Yeah.

Dr. Yoni Rosenblatt: Maybe not.

David Grey: I like it. I like it [laughter]

Dr. Yoni Rosenblatt: You like it? David, I'll tell you this much. We have a younger clinician on staff and anytime I have a guest on, I bounce the name of the guest off this clinician 'cause the guy is just like a maven at following those in the social media spheres. So I said, "Oh, I got this guy David Grey coming on." He's like, "Oh yeah, no, I've heard some good stuff. You know what you have to be careful about, Yoni is like guys that just attach their overall ethos to one line of thought. And I don't know if this is David or not, but like those things just make me nervous." And I'm like, "No, no, no. I've just done a deep dive on everything David Grey has ever produced in his goddamn life, and he's actually the opposite of that." And you just proved it.

Dr. Yoni Rosenblatt: You really are. And I think it's... I think in five years clinically you could be doing a podcast talking about how the only way to cure Achilles tendinopathy is with heel raises. You might be doing that because that's where your experience in literature would've taken you over the next five years. And I respect the hell out of that. Keep that up is what I would say to that 'cause that really lands, that really resonates.

David Grey: That's right.

Dr. Yoni Rosenblatt: Tell me David, or tell the audience how do we get in touch with you? How do we get your course? How do we follow all things David Grey Rehab.

David Grey: I just wanna say one thing about that. Anyone who thinks that we attach something to one thing is looking at our stuff from a complete surface level. We had someone else the other day saying like, "Oh, some of this stuff is fluff." And it was just so obvious to me that that person had never done any of our work.

David Grey: It's a criticism. And I don't mean that this regards to your, the person that you're speaking about, but it's a criticism coming from insecurity because they're insecure that they might hear me saying something that they don't know about. So they're saying, oh, he just talks about this one thing. And this is what I'm saying, you have to stay open minded, I'm trying to... I've been lucky enough to, I've never said I know everything. People think because I talk about it that this is a massive problem in the industry.

David Grey: If you talk about biomechanics, that automatically means that you think pain is linked to posture or something like this. If you think manual therapy is worthwhile, that automatically means that you don't strength train people. People wanna put people in boxes. And the answer for all of us as clinicians or trainers is you got to be better at all this stuff. Talking to your clients, communicating, having empathy, listening to people, exercise selection, assessment, coaching, progressing through plyometrics on working with a strength and conditioning coach, knowing when to refer out. It's all of it.

David Grey: I don't want to go to a medical doctor who only can prescribe me drugs or only can say like... I want them to be able to speak to me and figure out what the thing that I need most is. And any of those criticisms towards me, some of them, I don't mean any criticism at all towards me, but anyone who's saying is attached to one thing, it's 100% coming from their insecurity and they haven't dived deep into our work because of that insecurity. So that's what I'm going to say on that. And I wanna say thank you so much for having me on, I really enjoyed the conversation. And if people want to check out more, they come to Instagram and check out David Grey Rehab. That's probably the best place. And there's some visuals there for some of the stuff that we spoke about 'cause I know it can be hard talking about biomechanics on a podcast or movement on a podcast. We're movement people, visuals are very helpful for us. So there's lots of visuals there and people might hate it, people might love it. I don't mind. It's completely up to them.

Dr. Yoni Rosenblatt: Yeah, and but it also gives everything you put on Instagram such great context. Because just to listen to you talk about that, by the way, my question to you of what's the number one mistake a seasoned clinician makes? And your answer being that they are closed minded. You gotta listen to a pod to hear that and to hear you extrapolate that and pull on that. And I think that's what whoever's throwing shade your way is not doing that, they're not doing the deep dive, they're not listening to your train of thought and how open minded you are.

Dr. Yoni Rosenblatt: So keep doing that. It is so apparent to me. I did a deep dive in prep for this, so that was totally obvious to me. I've heard you say the words, I don't know, man, more than I've heard a number of clinicians say. And I think that is a testament to how open minded you are and I have full faith that you're gonna do the work and that's what I want out of my clinician. Hey, I don't know everything, but I'm gonna go research and figure it out or we're gonna try this. And coming from that angle, really sows rewards. So, Dave, thanks for your outlook, thanks for your time. Thanks for all you're doing for the profession. Really appreciate you being on.

David Grey: Thanks Yoni. Love you, man.

Dr. Yoni Rosenblatt: Talk soon.


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