Dec 14, 2022
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Dr. Yoni Rosenblatt: Let's get a little bit more clinical if that's the business side. Clinically speaking, give me something that you've changed your mind on in the last five years.
Dr. Kelly Starrett: I don't know if I've changed my mind. I went back. So there's a few things that I think are reservoirs of capacity and performance that are untapped because we yet haven't known. Breath is one of those. So if you followed our work for a long time, you can see that I've become very interested in the amount of volume you can move and your ability to maintain that volume. And it turns out Gray Cook said for a long time if you can't breathe in position, don't own that position, but we expanded that to say, not only can you ventilate, but can you maximally ventilate in those positions? So we end up using breath as a way of understanding positional competence, ventilation, VO2max. We saw a lot of opportunity there and then also weighs into the nervous system to dethreaten, to desensitize, to help people down regulate that we could take all the classic PNF contract-relax, add in some breathing, add in some loaded isometrics which are what if you're doing like static hold on a roller 'cause you find like a trigger point or an area of sensitivity or whatever it is you want and I just have you flexing there, that's an isometric contraction, that's all you're doing. You're just putting a different load.
Dr. Kelly Starrett: Instead of lengthwise, you're putting a vector load into the tissue, asking that tissue to contract around that single spot, integrate the breathing and suddenly, we can get a lot of stacking done where we can get people feeling better right away. Does that resolve their movement dysfunction sometimes, but sometimes it just makes them feel better and athletes that feel better tend to do better.
Dr. Yoni Rosenblatt: Yeah, absolutely.
Dr. Kelly Starrett: So breathing is a big one.
Dr. Yoni Rosenblatt: Okay, so breathing you've added. As an example, I came out of graduate school a million years ago and I'm teaching people, okay, let's squat in front of the mirror. Make sure your knees look straight ahead. Don't let them go past your toe. Obviously that's gone to the wayside, right? First I went to the wayside with Kelly Starrett and driving his knees out and creating torque off the ground. Now, knees over toes has changed. I'd say as a profession or outlook on that thing, is there anything like that that sticks out to you where you used to teach something?
Dr. Kelly Starrett: Yeah, absolutely. So one of the things I didn't do a good job of is explaining that we were never coaching these out. We were coaching these out to maintain an arch, and extra rotation is an isometric contraction and it's how the whole body creates stability. So if you wanna have a stable pelvis on femur, that's done through an external rotation, ROM movement. That's why you do monster walks and why you try to get people's clamshells better, is that you're trying to teach the tissues to be able to create a force that makes the pelvis more stable on the femur. And so one of the things that was happening is we were seeing people turning their feet out and collapsing their arches and just I was like, "What is that?" You can't jump maximum at that position and actually you're contributing to the problem and epidemic of ACL injuries and lower extremity injuries. And we're seeing more and more, the research is coming out, they're like, wow, that foot turned out, arch collapsed, that Achilles has a lot of translation and a lot of sort of lateral vectorization. Plus the loads on the posterior horn of meniscus plus, I mean, just keep checking the boxes. This is less effective.
Dr. Kelly Starrett: Again, I think one of the things that we've gotten better at it, and I inherited this language from Mulligan movement fault, and if you see the book, it says movement fault. It's not a movement fault, it's a strategy or a compensation. Like you're using that and I don't think that there are bad positions, comma, that position sucks. That position is less effective, position that's less transferability, that position challenges tissues in a way that eventually is not gonna be as effective. So I can say unequivocally that position is dog shit, but it may be the only position you get in so let's ride this horse today, comma, there's probably a better position. So we're always teaching to the highest expression of the movement, and one of the things that we saw was when I started, I was working with this young, I don't know, like five or six years ago working with them, maybe longer. I was working with this young like shit-hot paddle sports team and I was teaching them to respect their squatting based on their foot position and their foot balance, and I was also coaching my daughter's team at the same time, and all of the traditional coaching cues around squatting I found weren't as effective with children because they weren't good at being cues and taking those cues. They're really good at feeling.
Dr. Kelly Starrett: So we started doing, for example, is saying, "Hey look, I need you to keep 50% of your weight on your front of your foot and 50% of your weight on your heel and keep your ankle right in the middle of your foot. Every kid could look down, make those corrections, feel the changes, and then they all squatted, and I was like, whoa, whoa, whoa, that's perfect squatting and I didn't actually cue squatting. I just said, keep that balance down and based on your anthropometry or the load or your position, you will have to have higher degrees of tension. So if you're gonna squat with a really upright torso, your knee is gonna look a lot more out than if you're squatting with a forward lean because there's more demand to keep the pelvis connected to the femur. And so, what you're seeing is like in when Ben Patrick is squatting, there's very low torso demand and that foot can be very straight, but it's still roughly the same organization, knee is tracking little toe or towards the outside to maintain the integrity of the foot. So we threw out all of the knee stuff because I was like, that's like me coaching you a bench press based on your elbow. This doesn't make any sense, more elbow in, more elbow out. Like why aren't you teaching a feeling?
Dr. Kelly Starrett: How can we get people to tap into their interoception so that they can connect to the skills more effectively? So when I'm teaching squatting, I'm really teaching a step up or a jump and land or an Olympic lift or receiving position, so that that foot position transfer beautifully to so many other things. So that's something we evolved on and I'll say we just continue to evolve because we're still practicing. I'm still working with the Niners and the All Blacks and the English national soccer team, the Brazilian women's national soccer team, and I have two college teams over at Cal and I have a team at San Francisco State and I still am where the rubber hits the road trying to reevaluate, reassess what is essential and how do I solve this problem in a more elegant way. So I'm still a user very much.
Dr. Yoni Rosenblatt: I love that. Yeah, and so you still have your hands, obviously, in the clinical side which certainly resonates with everything you say. I think you make a great point with trying to teach these complex movements. If you start getting too microscopic or myopic, it's impossible to stack those things, right? And so I think that's your example of like just squat, like keep your weight even and squat and the body's gonna find a way to do it. I see that a ton with all my baseball staff. When you're teaching back to throwing, return to throw, it's less about keep your elbow here, keep your wrist here, keep your fingertips here. It's like, here's a couple of drills. This is gonna cue you to do it appropriately. Okay, get on the hump and throw, right? Versus break it through.
Dr. Kelly Starrett: And you're absolutely right. Now, we're more modern at speed and volume, right? How fast am I throwing, how heavy is the thing I'm throwing, how much volume am I throwing? And what we can start to do there is... I don't know anything about baseball. I've just worked with like 17s, and CY Young Award Winners, but I don't get into the mechanics. I understand what the essential shapes are. One of our friends calls it keynote types. Like if you hit kind of that classic stop motion, you could see essential pictures. That's Stuart Millen's language. We talked about archetypes, what is it the body should be able to do? Well, if you don't have hip extension and internal rotation of the hip in extension, I can't even tell what's going on, and so oftentimes what we see... Yesterday I was working with some Olympic swimmers from San Jose State and one of the things we found was a lot of those athletes really were lacking capacity in the anterior line. So they had a hard time creating global extension, and when I put them under a little bit of extension load, but turned off, couldn't squeeze their butts, which meant that they ended up hinging in the. Solve that movement problem, and then that shoulder lost its rotational capacity, and that's a problem if you're a swimmer, right? That's why that streamlined position being able to kick.
Dr. Kelly Starrett: So if you don't have a root language, you can chase. I think your distal pectineus is stiff and let me activate. Like you can play that game, but if you can't see the components for the whole and you don't have a movement language, it turns out the strength and conditioning is a really elegant way to understand what you're seeing in complex movements because that's what we knew is that if I can get you into the shapes, it transfers better, and now we can start to say, well, what's fundamental or how much of these essential shape should I have as a benchmark or a vital sign? Now, we suddenly have moving vital signs that everyone can understand. That is how we dig ourselves out of this.
Dr. Yoni Rosenblatt: Yeah, I love that and I think the truly skilled clinician takes that complex language and dumps it down to the athlete so that not that they can't understand it, but when you're moving 150 miles an hour, they shouldn't have to try to understand it.
Dr. Kelly Starrett: Oh yeah, you can't.
Dr. Yoni Rosenblatt: They should just be able to groove it. Right, you can't. So I think that's a skill in the great sports PT. So you mentioned some of the like measuring velocity and total volume, total load. You know, we've come a long way as a profession since the pain cave. So how much tech do you now use? How different is a PT practice if you were to form it today, then you then it looked back in the pain cave?
Dr. Kelly Starrett: The difference now is I have some rollers that vibrate because I have people who are super sensitive to compression for recovery like kids.
Dr. Yoni Rosenblatt: Okay.
Dr. Kelly Starrett: I think that that's super great. People who are very sensitive or children, we can just get some input. I believe wholeheartedly in the sanctity and the power of blood flow restriction cuffs. If you don't have integrated BFR and I think it was New York that took away BFR from their physios, and they said this is not in the skill of care. What it makes me think is, well, you're not a physio. You're like, I no longer identifies a physio if that's what happened, right?
Dr. Yoni Rosenblatt: And by the way, they do the same thing with dry needling which is crazy to me.
Dr. Kelly Starrett: Well, I can understand that more because there is a dry needling society called acupuncture and, right, there are people doing that. Don't run. I think we should be able to do that, but there's no BFR society, you know what I mean? So it's crazier. We'll leave it there.
Dr. Yoni Rosenblatt: Okay, fair, fair.
Dr. Kelly Starrett: Crazier 'cause these are all just tools, and I think the danger, of course, for any person is that you become so adopted to your tools instead of saying, well, what are the other tools? It's cool, I have matches, but I have a lighter. Show me how that lighter works. I'll use the lighter instead of the matches. It's more reproducible. We believe very strongly in NMES, neuromuscular electrical stim, predominantly for post surgery and post trauma, because we cannot get enough... So I've become even more obsessed around tissue health where if you show up, and like, literally, there are plenty of PTs who busted my balls for caring about swollen. Like, "The joint is swollen." "You don't need to worry about that." I'm like, "Yeah, you do. You need to worry about the swelling." And it's not an emergency, but if that tissue is swollen, it doesn't heal. If that tissue is swollen, we see neuromuscular inhibition. If that tissue is swollen, we see altered joint mechanics.
Dr. Yoni Rosenblatt: And vice versa, right?
Dr. Kelly Starrett: We see the whole thing is off. What's that?
Dr. Yoni Rosenblatt: And vice versa, right? Vice versa, right?
Dr. Kelly Starrett: Yes.
Dr. Yoni Rosenblatt: If you have inhibition, then you're gonna see swelling, and so that's an awesome use for NMES, right?
Dr. Kelly Starrett: And the question is, who owns that? And I think the real interesting part is when you see physios say things like, percussion is dumb, percussion, and I'm like, "Well, are you using percussion on your patients? Are you teaching them to do percussion themselves?" 'Cause anytime I can say, here are some tools that are super sticky, make you feel better. You can do it on your couch. They have non-threatening input to the body. I don't ever want to use percussion on you in my clinic. I got other things I wanna do with you. Let's move that stuff elsewhere.
Dr. Yoni Rosenblatt: So I love that. That sounds like a speech that I give my new evaluations, which is, "I'm gonna teach you three, four, maybe five exercises. I'm gonna take a video of them. I'm gonna put them in our exercise app. You're gonna have them on your phone at home. You're gonna do them at home. Do not come back in here and make me watch you do those. That's not gonna happen. [laughter] That waste your time, that waste my time. Don't do it. Do it on your own. Take a lacrosse ball and do whatever you need to do at home. Take care of your own business." I think that's what I heard you say.
Dr. Kelly Starrett: That is really the key here, is the shift of, I'm trying to figure out how you never see me again, and in so doing, asking, well, how much of this, and what should I be doing? Like this notion that manual... We went through that phase a couple of years ago. Like manual therapy is the devil. Doesn't do anything. I'm like, "Well, are you only talking about pain and PAIVMs? Am I mobilizing your T spine to get you out of pain?" That seems like strange to you. So I don't do that, right? But I do see that. I have this young Olympic lifter who's T spine was super stiff, and was affecting her shoulders and her shoulder functioning and lo and behold, and she's a national champion lifter which if you got over her head, should get this electric zingy feeling. That was easily remedied with what? The rest of mobilization that I did.
Dr. Yoni Rosenblatt: The rest of mobilization.
Dr. Kelly Starrett: And then I was like, "Here's a peanut. Go home. Make sure you handle this yourself. If I ever see you again and your T spine is this stiff, I will flog you." And I think that's really the key here, is thinking where are these interventions gonna work for people, what tools do we have? So if you're only getting 20 minutes of decongestion in my clinic twice a week, that doesn't seem like a really good use of our time therapeutically, but if I can get you decongested with NMES 20 hours a day, you show up and you have less pain and the tissues are more ready for it to be loaded and you have all this non-threatening input into your body and neuromuscular education is taken care of because I had you do your quad sets with the... Suddenly I'm like, wow, we can really get to the bottom line here.
Dr. Yoni Rosenblatt: Yeah, and get to the next step. Like don't come in and just spin your wheels. Like I say to my 14-year-old, I don't want to have to have this conversation again, right? [laughter] So why should we have a session again?
Dr. Kelly Starrett: And what you really are hitting on is... One physician said that if you want great outcomes, choose great patients. It was like some surgeon, right? He was just like, "Hey, if you want to have really good surgical outcomes, just make sure that people are appropriate." And something you said early on was, really helping people learn what is required and what is happening in the session. "So this is what we're gonna do today. This is why and here's what's gonna be on your job to-do list, and here's how I can support you." Right? And that conversation is more important than the other thing. I mean, Juliet breaks my balls all the time. She's like, "You're probably just an average physical therapist, but you're really good at giving people permission to move again and to own their own therapeutic experience." You know what I'm saying? "Hey, it's okay. You've got this. This is on you and you're not fragile and you're not... " We have a lot of complex conversations about potential mechanisms of pain, but ultimately, I'm like, "Can I see your sleep data? Did you eat a gram of protein per pound body weight? Do you have micronutrients? Do you sleep? Are you stressed?" We have to have all of those conversations along with, "Dude, your knee is super swollen. What is your plan to deal with that 'cause it can't be coming in here once a week?"
Dr. Yoni Rosenblatt: Yeah, yeah. I mean, it sounds like that's one of the things by the way that I think you should put on your list. What is it?" Morning smoothie, morning smoothie. That's my guess.
Dr. Kelly Starrett: That is our espresso machine. Julia is passive-aggressive when I'm on podcasts, and she slams the door, she puts the dishes away, she makes coffee, and just everyone know, we're a real family.
Dr. Yoni Rosenblatt: What kind of beans you got over there?
Dr. Kelly Starrett: We run Stumptown Holler Mountain.
Dr. Yoni Rosenblatt: Of course you do.
Dr. Kelly Starrett: Holler Mountain Stumptown. Look, I'm sure everyone else has their favorite coffee.
Dr. Yoni Rosenblatt: It's not any bad.
Dr. Kelly Starrett: I am on a search. When I was a younger man, I worked at Port Espresso as I was trying to race on the national team. That was my day job, so that I could race in the evening, and in the morning, and I became obsessed with all things coffee and check this out, self-soothing. Turns out the caffeine is a xanthine which is very close to Theophylline which is one of the medications for asthma. When I found out is when I drank a lot of coffee, it was a bronchodilator, I felt better. So I became obsessed with coffee, and then I had kids and a job and then I was like, oh coffee is life. So I've been on the search for the perfect bean. This is my closest one for the things I like, caramel, chewy, but people tell us in your comments, what is your go-to coffee?
Dr. Yoni Rosenblatt: What's your go-to? Okay, mine is Ad Astra PT's, ironically PT's Blend. It is so good. All the right parts of smoky and oily.
Dr. Kelly Starrett: Oh wow, Astra?
Dr. Yoni Rosenblatt: Oh, it's so good.
Dr. Kelly Starrett: Ad Astra?
Dr. Yoni Rosenblatt: It's called Ad Astra, yeah.
Dr. Kelly Starrett: Yeah, okay.
Dr. Yoni Rosenblatt: And get the PT's Blend. The guy who taught me about Stumptown is a guy named James Hurst who's an offensive lineman for the Saints. No one knows coffee more than that guy. Go follow him 'cause he'll tell you beans that you've never even heard of.
Dr. Kelly Starrett: It's a small world. My daughter went out the door this morning wearing the star at Saint Jersey's. So yeah, that's awesome. All right. Dude, I'm in. I think that's great. I think one of the things that is really fun is, if you're in this profession, you're a nerd straight up, an obsessive nerd and you think about this, there's no edge. Like I'm never not a physical therapist. Like Juliet will be like, "You ruined me. I can't watch people walk or run." And it's not that we're judgy. It's just that I'm like, wow, we haven't taught people how to do anything. It's not like I'm worried that you're gonna keep a perfectly neutral great spine. That's whatever. Have you ever worked with an athlete? Have you ever done a sport yourself? I mean, your spine is gonna flex. We were really into like spinal flexion very early besides just the Jefferson Curl. So all our friends train. We love to exercise, we love to talk about performance, we love the soft tissue care, there's no edge, and in that nerdiness, people will find you the best coffee because it's the same thing and the way you obsess about one thing is sort of the way you obsess about everything and then that, you've crowdsourced this problem out to the greatest set of nerds on the planet.
Dr. Yoni Rosenblatt: There you go. I love it. Kelly, this was awesome. I'm so thankful for your time. More importantly, I'm thankful that you kept me in the profession 'cause you better believe, I would be a lawyer today if it wasn't for Dr. Kelly Starrett. So thank you for that.
Dr. Kelly Starrett: Well, let's pass the thank you. I'm sure that's not true, and I'm not trying to be... Let's just pass it on to everyone who inspired me, because really I think it's easy to point negative and to talk about what you don't like. I want more transparency in the profession. I would like to see what your sessions look like. Your patients be like, yeah, you can videotape me and put me on. I see people shouting at each other, beating each other, research, and yet I still don't know what their practice looks like. I don't even know if they have a practice. I don't know if they actually work with people and they certainly don't work with the people I work with. So show me, improve my practice, help me understand better because I have... I read Gray Cook's book or Stuart McGill's book about back pain. I kept it in my bathroom and read it cover to cover 100 times. So I was in physio school, you know what I mean? I really started to think nervous system first, whether I liked it or not. I was highly influenced. So we're all part of this cabal and what I'll say is, and hear this everyone, we're getting an F. In our vertical of super fancy people, we are doing a good job of people taking care of themselves, but we've left everyone else behind.
Dr. Kelly Starrett: E.O Wilson says the highest calling of science is to improve the humanities. The highest calling of sports and sports performance and sports rehab is to transform communities. And if there's a kid who shows up with Osgood-Schlatter, it's because volume wasn't managed, tissues weren't managed, nutrition wasn't managed, sleep wasn't managed. That seems like a preventable disease to me, and then we can have all the apologists out there who say, oh it just happens sometimes, and yes, freak accidents happen. You do land funny and twist and tear your ACL, but there are a whole lot of things that we need to get better at and teaching, and I challenge us to see if we can actually move the ball in the next 10 years. It's gonna maybe take a 20-year project, but let's see if we can change something out of 10 years.
Dr. Yoni Rosenblatt: I love it. I think you're such an example of that. So thank you for your time. Thank you for your honesty. I look forward to continuing the conversation. I bet we can do this again.
Dr. Kelly Starrett: Anytime. Yeah, yeah, for sure. Bring all the people in and the nerds in. The other thing I think we need to say is, are we physical therapists? What is a physical therapist? I have a hard time understanding what that is. I think adding the word sport helps to differentiate what is the way we think about this return to play. Again, I'm not sure what we're doing is physical therapy anymore, you know what I mean?
Dr. Yoni Rosenblatt: I think what we're doing...
Dr. Kelly Starrett: I'm not saying I've transcended it. I'm just saying I'm not sure I identify with my original education. That's what I'm saying.
Dr. Yoni Rosenblatt: I think it'd be crazy if you did, because the stuff that you've added since you've come out, it has made this thing a different profession. The sports physical therapist is an outstanding strength coach, is an outstanding PT on the physiology side, is an outstanding psychologist, right? It's all of those things.
Dr. Kelly Starrett: Yeah, it's really true. That part of it, boy, I probably don't lean enough. I just put, The Body Keeps the Score on to listen to it again on my [chuckle] phone, I think you're absolutely right. The brain continues to be the limiting factor here for so much of this. Man, I really appreciate this conversation and thanks for keeping me in it 'cause there's definitely some times where I was like, maybe I'll just let my license lapse. It doesn't matter. No one cares.
Dr. Yoni Rosenblatt: No. No.
Dr. Kelly Starrett: I'm not even a PT anymore.
Dr. Yoni Rosenblatt: That's the least I could do for you. Thanks for all you've done for the profession. We'll keep rolling and thanks for your time, Kelly.
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