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Aug 16, 2023

Dr. Zach Juliano - Core Muscle Injuries

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Dr. Yoni Rosenblatt: I love doing podcasts on topics that I feel are so poorly covered in the sports rehab setting and core muscle injuries and how to rehab them and how to diagnose them is certainly one of them. Zach Juliano works in Vincera Institute, which is the mecca of core muscle injury repairs and rehabilitation. He's gonna tell us everything we need to know, how to rehab these athletes, get them all the way back on the field, and of course highlight some of the mistakes he has seen PTs make, and then what he absolutely needs to see in the rehab process to get these athletes back quicker, faster and stronger. So great conversation with Zach today. I learned a ton.

Dr. Yoni Rosenblatt: So if you have any questions on this topic, make sure you give this a thorough listen. Do me a favor, share this content because I think it'll do the field really well. Of course, it'll also help out the True Sports Physical Therapy Podcast. I'm really thankful that you're tuning in to this conversation. Let me know how we're doing. As always, shoot me a DM, True Sports PT on Instagram or send me an email I wanna hear from you and I want you to share this pod with whoever you think would benefit from it. Thanks for tuning in. Without further ado, Dr. Zach Juliano.

Dr. Yoni Rosenblatt: Welcome back to the True Sports Physical Therapy Podcast. We got Zach Juliano with us from the Vincera Institute, and you're gonna teach us all about, Zach, you're gonna teach us about core muscle injuries, what we should be calling them, what we shouldn't be calling them. We're really excited to have you here 'cause God knows I got a lot to learn around this world, and maybe that means other PTs need to learn it as well. So without further ado, Zach, tell us about how you got to where you are.

Dr. Zach Juliano: Yeah. Yeah, no problem. First and foremost, pleasure to be here. Happy to collaborate with you, your other PTs and just your company in general. I mean, you guys got a great model, a real drive for good sports PT, which I think our profession is lacking. So it's nice to link up with people that I think see the value in physical therapy that we see. So yeah. Anyway, geez. Undergraduate degree from Millersville in Biology.

Dr. Yoni Rosenblatt: Hell yeah.

Dr. Zach Juliano: Not really clear about what I wanted to do afterwards. Actually took a shot at physical therapy assistant school. Went through that, about halfway through said, "I think I gotta be a PT." [chuckle]

Dr. Yoni Rosenblatt: Nice.

Dr. Zach Juliano: Just worked alongside other PTs in my clinical affiliations and just felt like I could be that, I could go back, I could do that. So I finished up my PTA degree. Went back full-time on weekends at Newman University. So I got my PT degree there while working full-time as a PTA. Got lucky enough to get a clinical here at Vincera Institute in my three month rotation and fell in love with what they do, how they do it, people they see, PTs I worked with. Unfortunately graduated in the COVID time.

Dr. Yoni Rosenblatt: Right.

Dr. Zach Juliano: Not many jobs flying around during that. I was fortunate enough to get a full-time job at Main Line Health where I worked as a PTA, did a bunch of traveling for them in their hospital systems, outpatient settings. They had a contract with St. Joe's University. So I worked a lot down there helping out as a PT with the athletic program. And then fortunately found my way kind of back through a little bit of a backwards connection. I was working for a sports performance company out in the Downingtown area and linked up with a gang at Vincera to get dry needling certified. Turned out they had an opening, I interviewed and boom, right back.

Dr. Yoni Rosenblatt: Okay, so...

Dr. Zach Juliano: Back here in October. So I've been back here now for... What's that? Close to a year, 10 months.

Dr. Yoni Rosenblatt: Okay. Awesome. And it's nice to link up on the pod. I've heard just awesome stuff about your style. And that's kind of... And obviously Vincera Institute is known for this core muscle injury world. And so excited to have you on to kind of talk a little bit about that. Now, what I didn't know about you is this high level of, for lack of a better term, grind. I mean, you go in, you're like, "I'll probably be a PTA." And then you're like, "Screw that. I could do this." And then you kind of make your own way. Where does that grind come from? 

Dr. Zach Juliano: I don't know. Yeah, I wanna say my parents. My dad is a real hard worker, self-made company of his own, construction worker my mom, same thing. I'm one of four, so I got three brothers, two older, one younger. So I feel like for them, stuff never stopped. I mean, it probably still doesn't stop. My brothers and I all grew up athletes. They're going here, there, games here, practice here. Just feel like kind of like a head down worker mentality. And I feel like that just passed right down along to me and my brothers. So yeah, just felt like if I didn't do it then, I wasn't gonna do it at all once I got a little bit older, so there wasn't a better time to do it than when I was younger, a little less responsibility and all, so.

Dr. Yoni Rosenblatt: Yeah. But a lot of good lessons in there in terms of the path. Like when you see it and you know it and you love it, you go after it, so kinda love hearing that. Okay, one of the more recent times, I would say, that I got my ass handed to me was in a phone call, 'cause they're so many of them. [laughter] I was on a phone call with an athlete and Dr. Meyers who founded the Vincera Institute, and I said something dumb like, "Hey, Dr. Meyers, I know you're one of the guys who really founded sports hernia surgeries." And he's like, "Oh, let me cut you off right there." And I don't think I said another word for the next 35 minutes. And he went to educate me that that is not what we call it.

Dr. Zach Juliano: Yes.

Dr. Yoni Rosenblatt: It is called a core muscle injury. So tell me...

Dr. Zach Juliano: He's correct.

Dr. Yoni Rosenblatt: He is correct. Of course he's correct. So, Zach, tell me about where did the word sports hernia come from and why do we now live in this core muscle injury world?

Dr. Zach Juliano: Yeah, so it's funny. I don't know if Dr. Meyers told you, but he's part to blame for that. So he shouldn't have cut you off that hard.

Dr. Yoni Rosenblatt: No, he didn't. Thank you, where were you? Why were you not in that convo?

Dr. Zach Juliano: So yeah, I should have been there to help you out, but no, I mean, early on Dr. Meyers and studying this anatomy and this phenomenon and this injury, when you think basic anatomy, a lot of athletes had it of or relating to pain at the pubic level. So Athletic Pubalgia came to be, not really too much of a crazy definition there. And then I think more commonly, it was used as Sports Hernia for folks that maybe didn't understand the whole anatomical or medical side of things. So that was being thrown around as a nomenclature and word and phrase that I think more people can understand, more lay people. And it really came to grow its popularity and exposure to this type of injury. So I think it hanged on and latched on for people for a while, but you come to find out when you look at the basic anatomy, there's not really a hernia going on there. There's no protrusion, there's a weakening of the abdominal wall for sure, but it's mainly related to actual tearing and damage of the muscle. So Dr. Meyers and his team, they worked to hopefully redefine that because I think it was giving a false pretense of what the injury was and how to treat it.

Dr. Zach Juliano: It's not only athletes that get it, it's laborers, it's blue-collar people, it's an everyday recreational individual that might not be characterized as a full-on athlete, but just stays active and exercises. So I think they wanted to work to kind of rename and build a little bit more of a awareness to other providers out there that, listen, this doesn't have to be reserved for a NFL athlete or guy that's playing ice hockey or somebody that's playing in the MLB at a high level. It could be anyone. So they came to redefine it as a core muscle injury, which pretty much defines everything from that lower part of the rib right down to the knee. You think structurally, you've got your spine, you've got your hip joints, and then muscle wise, you've got everything in between from muscles, ligaments, and tendons that play a role in defining someone's core muscle injury.

Dr. Yoni Rosenblatt: So I love that Dr. Meyers went from a poor definition of Sports Hernia to this, a title "Core Muscle Injury" which by the way, in a study published by Dr. Meyers, he defines it as a core muscle injury refers to damage to any skeletal muscle within the area between the chest and the mid thigh.

Dr. Zach Juliano: Yeah.

Dr. Yoni Rosenblatt: Dude, that's...

Dr. Zach Juliano: Yeah, more than 75% of the body. [laughter]

Dr. Yoni Rosenblatt: That's everything. So thank you very much.

Dr. Zach Juliano: Yeah, it's great.

Dr. Yoni Rosenblatt: It's great. Okay. So because it's so broad, tell me what these things usually look like to you. How do they present?

Dr. Zach Juliano: Usually we're not, we can be, but we're typically not, when somebody comes to our institute, the first ones to be seeing them. But for downstairs, our physician's offices, or someone that might come in off the street to us that says they have maybe hip flexor strain or just been having this diffused pain in my adductors, when we're examining them and they're examining downstairs, someone that comes in acutely, it could be tons of pain obviously on palpation, with certain activities, predominantly anytime you're flexing or activating, let's say, the core area or the abdomen and then same with those adductor or groin muscles. So I think kicking athlete, I think running, twisting, pivoting athletes, they get tons of pain with their simple activity or training. In addition to that...

Dr. Yoni Rosenblatt: So it could be anywhere. It's...

Dr. Zach Juliano: It could be, yeah.

Dr. Yoni Rosenblatt: Front of hip, adductor you said, lower abdominal and they just have pain and so now you're starting to... If they haven't done their homework and they're not in Vincera because they think they have this core muscle injury, then you haven't really narrowed much down, right? That could be a lot of things. That could be adductor strain, that could be hip flexor strain. So how do we start saying, "No, no, no, no. This is CMI." Do you call it that first of all?

Dr. Zach Juliano: We do, we like to use it that way. [laughter]

Dr. Yoni Rosenblatt: Okay. This isn't hip flexor, to know, "This is CMI, let's escalate it." How do you determine that?

Dr. Zach Juliano: Yeah, so as a PT, what we do is we pretty much just look at our basic anatomy. So let's look at muscle action. So okay, hip flexor, are you going to get pain with resistive hip flexion? Are you going to get pain with passive hip extension? So we usually look at three different things. Muscle length, muscle strength, and palpation. Usually if you have pain with two, if not three of them, then we're looking at probably something related to that muscle injury. Now, so we'll just pretty much work through them in some sort of triage and normalized fashion, kind of rule out anyway. So we'll check the hip joints. Okay, doesn't seem like it's impingement. Maybe impingement could be a role, move on to the next thing. Let's check musculoskeletally the other things that attach to that area. Okay, hip flexors ruled out. Doesn't seem like it's some sort of hip flexor or quad strain, it doesn't seem like it's a snapping hip phenomenon.

Dr. Zach Juliano: Okay, let's go on to maybe testing some resisted crunches, some resisted adduction as well as some passive movements in those regards. And usually it'll bring you to the fact that, "Okay, wow, that lights me up, that gives me that pubic plate pain." And then we'll kind of dig from there, ask about their activities. Sometimes you get people that have this stuff with getting out of bed in the morning. Where I have pain with activity, but then it kind of goes away afterwards particularly running or sometimes people are getting it with coughing and sneezing. Those are the things when you think about straining and bearing down at the abdomen that are really those hallmark signs and symptoms that we find lead to, as you correctly called it, a CMI diagnosis.

Dr. Yoni Rosenblatt: Okay. So tell me about pubic plate. Where is that and what does that pain look and feel like?

Dr. Zach Juliano: Yeah. So pubic plate, if you think about that hard wall kind of above the genitals in a male or right in that vaginal area for a female, you got a couple of different attachment and connection points there, got your rectus abdominis, your obliques, and then from a more inferior perspective, you have those adductor muscles. So again, as you're palpating, obviously a hard firm structure, there'll be a degree of, I think, tenderness for anyone there, regardless of whether you have an injury or not, if you're knocking on it hard enough. For other peoples, they're lit up pretty good. Someone that actually has a true CMI injury.

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: So we just work through some palpation there, then we kind of trace along the muscles that attach there. Just because you have a CMI does not necessarily mean you have pubic plate sensitivity or issues at that pubic symphysis. It could be the muscles that are traveling there. So we'll look to just trace those muscles that originate there and attach there. And yeah, that's how we kind of diagnose and differentiate at that pubic plate level.

Dr. Yoni Rosenblatt: Okay. So then tell me the difference because, like you said, there's so much that attaches in there, right? And so you're a soccer player, you pull an adductor or you strain a groin, if you will, right? That doesn't mean you have a CMI, right?

Dr. Zach Juliano: Yeah.

Dr. Yoni Rosenblatt: And then... Right. So how do I make that call to say, "This is a groin strain, I'm gonna treat you with isometrics and eccentrics," and that whole world that we've been trained to treat these strains with versus, "You gotta go to Vincera and see Dr. Meyers."

Dr. Zach Juliano: Yeah. No, I think probably first and foremost, it should be treated as such, from a physical therapy perspective, you're always gonna look at low grade strengthening, obvious modalities, soft tissue work, heat, ice, depending on what your philosophies are, those things could be valuable in reducing inflammation and swelling. But I think most importantly, you need to look at their reactivity and their pain level. So in a short 5-7 days, can they comfortably isometrically adduct? Can you progress them to the isotonics, the eccentrics, these things like that. And if not, you can't do that in the first week to two, then you might be looking at something that's a bit more serious. Imaging obviously thrown around like crazy in different college settings and professional settings. So we do find that we get those people quicker because they may use some sort of image and send it to us, and then we can help to kind of identify as, "Yeah, his seems like a little more than a groin strain. Why don't you come down to us, we'll check it out a little bit more."

Dr. Zach Juliano: But I think if you're just a standard PT or somebody working in an outpatient clinic, high school athlete that comes to you, exactly like you mentioned, you gotta treat it conservatively with isometrics, the isotonics, the eccentrics, and you gotta look at their pain reactivity, and if they can progressively get through those things, work themselves back to a higher level of function or some sort of jogging and sport related activities, then you're looking at a low level strain. And it probably won't require our services. But if you can't get them past like a sticking point of simple isometrics, it just doesn't seem like it's responding to what I'm doing, then I would find that getting to us earlier rather than later is beneficial in your recovery overall.

Dr. Yoni Rosenblatt: Yeah. As I've seen these patients over the years, I think that resisted sit-up test is a major hallmark for me. That's usually a predictor of, hey, there's something more sinister than an abdominal strain or adductor hip flexor. Maybe this is a CMI or a Vincera need for whatever reason. But I wouldn't say that's a million percent, right? Like I would say like I've had people with resisted sit-up work that have gotten back to really high level of sport, never having gone up to Philly. And so I just wish there was a better predictor. By the way, even imaging, like we'll get... Like I recently had a D1 lacrosse player come to me with these symptoms, bad resisted sit-up test, got an MRI and kind of looked pretty clean, and he did really well rehab, right? I've had patients come, struggle with rehab, had an MRI, and then go up to Philly and they do another MRI and they're like, "No, no, no, you have... " What? So please, Zach, that was a big lead up to what the hell is the magic that happens in the MRI at Vincera Institute?

Dr. Zach Juliano: That was. Yeah, I think first and foremost, kind of like dialing back into what you were talking about earlier, using that resistant sit-up test can be a really good predictor in some instances and it can be a bad predictor in other instances. What we find in some of these low level strains is that area is so highly vascularized. So given that it's so highly vascularized, you do have a really good tendency to heal early and often. And a lot of times you can have someone that maybe has pain early on with that test, but is able to recover just nicely because of good PTs or of good care or whatever it may or may not be because they get that good blood flow and they get that really good vascularization of the area for healing. But besides that, when you talk more imaging, our MRI machine here I think is quite different than others from what I've been told. They have a higher magnetic resonance to it. So I think some may be probably somewhere around like a 1 Tesla, something like that. Ours to my knowledge is around somewhere about a three.

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: So it gets a cleaner, sharper image to be able to detect a true tear or a true muscular injury at that pubic plate or core muscle level. In addition to that, they can actually widen what they're seeing too, a standard MRI machine might show pelvis but it might not show more hip, it might not show upwards of the rib area. Here we can kind of draw up or curtail that image to actually be a little bit wider in nature. So then there are our surgeons, Dr. Meyers and Dr. Poor, they get a bigger picture of the core from the ribs all the way down to the knee almost...

Dr. Yoni Rosenblatt: There you go.

Dr. Zach Juliano: Of what things look like and what they're identifying versus small snapshots of different areas. So I feel like our MRI machine here just gives them a broader view and a bigger picture of what they're looking at. It's actually designed by Dr. Meyers and I believe a radiologist affiliate of Thomas Jefferson University. So they built this thing to kind of actually really detect and look very closely at these core muscle injuries. So it helps in diagnosing and recognizing early signs or actual tears.

Dr. Yoni Rosenblatt: Yeah, it gives you a clearer picture. That, the 3T magnitude, I think that's becoming more commonplace. I think, 'cause we definitely have them down here in Baltimore. I think a key is, and this is a good case example. I got another lacrosse player from Penn State who has this like lower abdominal pain, comes to me from his college trainer and they hadn't done much, they hadn't done imaging. He's like, "Hey, I gotta get the MRI before I come to you." Comes in with the MRI 3T from a privately owned radiologist locally, and there aren't many of them. So she's doing...

Dr. Zach Juliano: Wow.

Dr. Yoni Rosenblatt: She's doing all the reads and if you look through her read, it's patient reports, pain and hip. The MRI is of the hip flexor and it's of the hip joint. And so the read is unremarkable. The guy has a rip roaring resisted sit-up test. He's got pain on palpation to lower abdominals. It is about the ability to widen your scope of what's being viewed. But it's important in some states where PTs have prescriptive abilities where they can say, "Go get an MRI." Or if you are buddies with the radiologist to say, "Here's what I am worried about." It's really important that you guide them to say, "This isn't your standard hip. I'm looking for CMI." And I think that's 90% of it, because that's gonna be where they even focus their read. So there's some education or knowledge there. As the PT who's seeing a ton of direct access, if you suspect core muscle injury, tell that radiologist, "Hey, this is what I'm looking for, I'm not worried about his labrum." Radiologists only knows what they know. They're not examining the patient. So I think there's value there. And so when they go up to Vincera, you better believe they're looking for a freaking CMI.

Dr. Zach Juliano: Exactly. Yeah, no doubt. Yeah. You make a good point there. You think PT wise, right?

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: Someone comes in with, let's just say hip pain, for just be... Hip pain, center of the body, great, things could be above, things could be below. Imagine your tunnel vision on their hip. You assess them, you're like, "Yeah, there's nothing here." You know what I mean? But if you're not looking at those spinal levels above, you're not looking at the knee below, how are you really gonna be able to tell what's going on with the patient? You mean hip joint may be great, muscles around it may be great, but maybe they're a twisting and pivoting athlete and they're getting some hip pain and that's coming from the spine because they have poor pelvic and lumbar spine dissociation. You don't know that unless you look at everything above and below that chain. So I think they take that approach in their imaging, which is standard of care. I think that's what everyone should do in their practice.

Dr. Yoni Rosenblatt: Yeah, I think that's pretty cool. And you better believe like the bigger radiology chains there, I always describe it to patients, like my cousin is a radiologist. He's not an MSK radiologist, he is a radiologist. Dude sits in a dark room all day with just images flashing in front of him, and all he does is just write down what he sees. There's no assessment. And he doesn't even... He's not sure where to look except for here's what the doctor said he's looking for. So there's value there. There's even value in just how you educate the patient. Like, I think that's super important to say, "Here's why I think what's going on. Here's the image I want you to get." Or, "Here's what... " Yeah, I know the radiologist said it's clean, but here's why they said it's clean. Here's what they didn't look at. Here's maybe why they have symptoms. Food for thought. Okay. So did you know how to treat this stuff before you got to Vincera?

Dr. Zach Juliano: No. As a student, no. This was touched on briefly in my education at Newman, they do a really good job of musculoskeletal treatments, pathologies, injuries, things like that at Newman University and manual therapy, all that. We cover a really wide range of injuries, but truth be told, I knew it as a sports hernia before I started here.


Dr. Yoni Rosenblatt: You think Meyers is listening to this? Do not say...

Dr. Zach Juliano: He could be, he could be.

Dr. Yoni Rosenblatt: He could. [laughter] Yes, I feel like he is.

Dr. Zach Juliano: He's only listening in this place. But, no, truthfully it was the education and the tutelage of the PTs here as a student that really taught me how to treat this and how to look at multiple systems, multiple areas, and just, they showed me how, guides the whole freaking body. It really is. You described it already and we describe it on our website. Dr. Meyers talks about it at all these different talks and things like that, and summit meetings, and yeah, ribs to knees. When you think about that, that is, you're treating the entire body, you're treating the spinal column, you're treating the core and the abdominal region. You're treating the hip joints, you're treating everything from those glute muscles to the quads, to the adductors. And you're treating every chain, every sling in the body. And it's, I mean, God, you could treat it in so many different ways and it's fun to treat because you can be different with everything and so many different approaches and exercises and modifications, and it's blessed. But no, I did not know how to treat it fully until I came here. [laughter]

Dr. Yoni Rosenblatt: Yeah, it's cool and complex. Okay. But now that you know a little bit about how to treat it, since there's so much going on, dumb it down a little bit for us morons that aren't experts on this and just tell me what would your approach be to treating this patient non-op? Like what are some of the lowest hanging fruit that you can say, "You gotta hit this to get this patient better without surgery."?

Dr. Zach Juliano: Yeah. Absolutely. We get tons of people that... I think a lot of people know us for our operative skills and experience, of course, not mine personally but the institute's.


Dr. Yoni Rosenblatt: You're not good at operating. Exactly. [chuckle]

Dr. Zach Juliano: No. Don't trust me to do that. My God, you would be in a very bad place if you trusted me to do that. But we get tons of conservative patients come to our institute here and imaged, examined by the gang downstairs, and they pass them up to us and they're like, "Listen, no true injury here or small injury, we just don't think it's worth operating on. Healing should be good. I think they just need a really strong foundational core strengthening program or education and knowledge of what they're dealing with." So for me, someone who's non-operative, more conservative approach, I'm looking a lot at those foundational movements. A lot of people can tighten their core, but not a lot of people can activate that transverse abdominis. Rectus is usually pretty darn good in these people that aren't getting surgery. But actually recruiting those obliques and anterior sling of the core and looking at those deeper layers like that transverse abdominis, they can't. I've had tons of different college and professional athletes come up to me and we're spending like 10 minutes on a TA contraction.

Dr. Yoni Rosenblatt: Okay. So how do you teach that?

Dr. Zach Juliano: Yeah, lots of different ways. I use some verbal imagery and things like that and trying to teach them, "Listen, it's not about bracing or straining or holding your breath, it's about these lower, deeper muscles on those inner sides of those hips." So I start off pretty basic, hook lying position, trying to get that TA to fire in that position. Once we get that, then I work them through some progressions. Let's go quadruped next. Less degrees, or less... More degrees of freedom to work about, less external aid to actually have it firing.

Dr. Yoni Rosenblatt: Okay.

Dr. Zach Juliano: Taking it from there and then superimposing some activities on top of it. Once they can kind of master that, okay, then we're looking at trying this thing standing. But if they can't get beyond doing that with support of the mat, and hook lying supine, we can't get beyond that.

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: You know, we need to bring out maybe something like a blood pressure cuff. Using that at that lower part of the spine and really giving them that visual feedback of the sphygmomanometer. Okay, great, now you're recruiting those muscles. And I want you to feel the six pack and I want you to feel the ones beside it and slightly deeper. So it takes time and patience, certainly patience.

Dr. Yoni Rosenblatt: And so are you... And give me some pearls there. 'Cause I've seen therapists, I have struggled personally with educating patients on finding transverses. Where are you telling them to put their hands? How do they know when it's properly activated? Are you doing the palpation first? Walk me through that.

Dr. Zach Juliano: Yeah. As a provider, I'm definitely looking first, making sure I'm getting what I want, not overactive in the rectus and good activation in that transverse abdominis. And then I would follow up with them 'cause I'm not gonna be with them and they're at home or when they fly back to work with their ATCs or private trainers or PTs. So I want them as the patient to know what to feel too. Education's half the battle, they gotta know what they're doing and they gotta buy into it so they see the value in it. For me, I like to, I think basic landmarks and anatomy first, get yourself on those iliac crest, come in an inch or two, kind of roll in, press slightly deeper. Alright. To activate it, we're gonna look for a rounding of those muscles underneath your fingertips. And I tend to use a slight pelvic tilt, so I'll tell people, "I want you to act like you have a tail that you're trying to tuck between your legs." And a lot of times they get that tilt perfectly going and they get that TA working.

Dr. Yoni Rosenblatt: Okay.

Dr. Zach Juliano: I think that the crunches, the people that focus on the breath holding, they tend to activate way too much diaphragmatic compensations as well as rectus abdominis compensations. So I try and use a little bit more of that pelvic dissociation to get it firing and I find a lot of success with that.

Dr. Yoni Rosenblatt: Okay. So you get... Tell me why you're giving them a little bit of that pelvic tilt?

Dr. Zach Juliano: I give them a little bit of that because we like them to be in neutral. It's really... And a lot of these athletes, I understand, when they go back to training and they go back to their sport, they're probably gonna be adopting that anterior tilt. It's a given, I mean, to be a defensive back in the NFL, you're in a ready position. You know what I mean?

Dr. Yoni Rosenblatt: Yep. Butts out.

Dr. Zach Juliano: Butts out, chest is up. It's a position you're in. But for me, I find that it's much easier to get somebody into neutral to activate those muscles because when you think about an anterior pelvic tilt, what you're doing is you're lengthening that abdominal region and you're tightening those paraspinals in the low back. So when you're in too much of an anterior pelvic tilt, you're actually shutting down that anterior chain and you're inhibiting those abdominal muscles from working. Are you firing maybe some other muscles that can be valuable like quads, a little bit of glutes? Yeah, but you're actually creating a bit more of an impinged hip position and tilting that pelvis forward, making it tougher to actually fire that abdominal region.

Dr. Yoni Rosenblatt: Now. See, I think that's a great visual to understand like when you're falling into that tilt, that that anterior line is being elongated, right? And thereby most likely as muscles tend to do when they're too long, they are not in an advantageous position to function appropriately.

Dr. Zach Juliano: Absolutely.

Dr. Yoni Rosenblatt: And so by getting them a little bit in that posterior roll or tuck, you're putting the anterior line in a better position to function. Does that make sense? Okay.

Dr. Zach Juliano: Absolutely, correct.

Dr. Yoni Rosenblatt: Dude, I've been doing this a long time and that was actually... Your description of that was really clarifying to me, so.

Dr. Zach Juliano: I appreciate that.

Dr. Yoni Rosenblatt: Yeah, no, I appreciate it. So you give them that, it sounds like there's a lot of art there, less science, like you don't know how much they're tilting, you don't know, but just so they can feel it. Right? Okay.

Dr. Zach Juliano: Exactly.

Dr. Yoni Rosenblatt: And then how do you progress that exercise? They find it, they feel it. How do you make a given, without changing position, are you adding any resistance? Is it just time?

Dr. Zach Juliano: Yeah. Isometric hold times, I think one phenomenal way to do it. I will sometimes incorporate some breathing. So if we're looking for isometric hold time, okay, great, let's go through maybe five deep breathing techniques or a couple diaphragmatic breaths. Let's see if you can hold that while you're doing that. So a little bit more dual tasking in that area, but I tend to, if someone can do it pretty well and it's not taking so long, 5, 10 minutes to get it, I usually bring them right into some sort of lower body movement. So, okay let's, without doing a full on dead bug or anything like that, let's look at maybe a bent knee fallout. Can you control it when you're then introducing some sort of hip mobility? Can you do some sort of heel slide with it? Can you control that TA contraction when we're getting hip flexion work? And I'll progress them that way and then usually work through to some standard progressions of dead bugs, then I'll get them into quadruped, as I mentioned earlier, work through some progressions of isometric holding there with breathing into bird dogs. And then really it just runs the gamut and standing with tons of different anti-rotation and introductions of resistance and multiple different directions or certain pressing type of exercises, and stuff like that.

Dr. Yoni Rosenblatt: Okay. So when do you start introducing adductor?

Dr. Zach Juliano: In somebody that's, we're talking conservative still?

Dr. Yoni Rosenblatt: Yep.

Dr. Zach Juliano: Okay. I introduce that pretty early on. So they come up to me, it's an evaluation. I'm introducing some sort of adduction load already. So if they can get that TA to work, okay let's go over an isometric block squeeze. We talked bent knee fallout, that was just kind of one exercise of a million you could give. You could give isometric hip adduction or abduction and you could give shortened long lever hip adduction. I try and just kind of bulletproof that whole area. Glutes are important as are adductors and someone who has a conservative case, I just find that adductors are a little weaker than they should be. So I do try and introduce that a little sooner than abductor or glute activity.

Dr. Yoni Rosenblatt: Okay. What do you do with these freak athletes that you get to treat that laugh at this stuff? Like, "Dude, how is this gonna help me and I'm not even, I'm not moving any weight?" How do you get buy-in there?

Dr. Zach Juliano: Yeah. I think a lot of times the buy-in happens automatically because they can't activate that TA like we talked about and they get frustrated. Athletes, you, me, anyone who's a professional, doesn't have to be an athlete, somebody who just takes a task or a job seriously and wants to accomplishment, they get like addicted to trying to get that TA to fire. So a lot of times I'll get the buy-in immediately, especially from those athletes that are programmed to just be the best at everything and understand everything and get to the next step. But I tell them like, "Listen guys... "

Dr. Yoni Rosenblatt: Hold on a sec. That did pause me, but that's okay.

Dr. Zach Juliano: Sorry bud. I'll have to blame my wife on that one.

Dr. Yoni Rosenblatt: No, you're good. Don't blame your wife.

Dr. Zach Juliano: Anyway, picking up where I left off. No, I won't blame her. She deserves that. [laughter] Good. I'll kind of hang it in front of them as like, "Listen guys, you wanna get to the stuff that means something, we gotta accomplish these basics first." And then when they get to the basics of the lying down stuff and the quadruped stuff, you can always make it more engaging cognitively for them. So you're doing something standing, add some sort of sport related task with them. Add some sort of cognitive counting task or color identification task. Anything that's really gonna challenge them in a dual tasking way. Doesn't need to be as simple as, "Okay, you got this, now we have to do it single leg. Okay, once you accomplish it single leg, we'll do it with single leg with a ball toss," it's, you can do something single leg and add that cognitive motor and those other types of tasks that are a little bit more engaging for the individual. So I tend to do that early and often for people too. Rehab shouldn't be boring, it shouldn't be one dimensional. Should include all those things.

Dr. Yoni Rosenblatt: Yeah. That's really good advice. When do you start moving... I know you kind of walked me to standing up. When do you start thinking frontal plane control? When do you start thinking about incorporating rotation? How do you know you're ready for those things?

Dr. Zach Juliano: Yeah. I look at movement quality a lot. I think sagittal and frontal plane first of course. I think it's easier for most people to move in the sagittal plane. So I tend to start there. When you're looking at standing activities and you're looking at maybe a standard squat or a standard lunge or hip hinging, things like that, I like to start there. I think those movement patterns and qualities, they resonate and mean more to somebody, athletes and not, they tend to move better in those positions. And then I'll work frontal plane after that. So if I see that their sagittal plane stability looks great, movement pattern and movement quality looks great, I'll tend to move them into frontal plane before I even give load in sagittal plane. 'Cause I think that that's just as paramount, being able to get movement quality, stability in those frontal planes at a body weight level.

Dr. Zach Juliano: And then I'll start to introduce loads in both of those planes. Again, once I find that they've mastered that stuff, movement quality looks good, I'm getting effective strain, muscle activity upon palpation is good, they can do these things without a mirror, can they control their body without that external aid and feedback? Great. Then I'm mixing in those transverse plane rotational patterns in the same fashion. Let's look at movement quality and pattern first. Okay. Then we'll introduce load. So that's the way I work as a PT. I think everyone's probably a little different. Some people kind of like to throw things out there, see what sticks, and then maybe stick to that and then progress them to the other stuff. I try and exhaust kind of all options in each plane and make sure they can understand and really move these patterns before I'm rushing them to that next stage and next level.

Dr. Yoni Rosenblatt: Yeah. I think that makes a lot of sense. I think that's well thought out and formulaic so that's a great way to approach it, I would say. What do you think the biggest misconception is concerning CMI?

Dr. Zach Juliano: I don't know. I truly don't know. I'd say that there's a lot of things that can be overlooked. I think there's some misconceptions out there in the general treatment of it that it cannot be a real injury to some people. I think some people view it as maybe like a last resort. Like I got this athlete, I don't know what's going on, he's still got pain. Maybe it's core muscle. Whereas other people are like, "Oh God, these symptoms are jumping out. It's definitely core muscle." So I think there could be a misconception of it's kind of a treatment of last resort. There's a lot of research out there, there's a lot of evidence out there. There's a lot of athletes out there that have had this surgery and are playing and have returned to a high level because of the surgery. Or even the treatment of these people conservatively. So I feel like that could be a huge misconception. If we're talking people that are overlooking certain things in the rehab, that's probably a whole different discussion, things that I think are commonly missed. But as far as misconceptions go, I feel like that could be it.

Dr. Yoni Rosenblatt: Tell me what we're commonly missing?

Dr. Zach Juliano: Yeah. I think your folks, I've had great conversations with and they're picking up on a lot of things that I am, which is awesome to see. A lot of other trainers, PTs, they must have learned from you.

Dr. Yoni Rosenblatt: Yeah. They learned from Tim Stone.

Dr. Zach Juliano: Okay. Even better.

Dr. Yoni Rosenblatt: Yeah, exactly.

Dr. Zach Juliano: But, I think some of these folks, maybe people that aren't as educated as I once was in the treatment of this, they're not treating above and below the pelvis as much as they should. I think they're looking mainly at, okay, we gotta treat the core, gotta give modified crunches, gotta give these six pack exercises. Glutes are important, gotta hit glutes. Great. I get tons of people that come to me and maybe they're out of town and they come back for a follow-up visit at week two, week three, and I'm trying to get an idea of where they've been, what they've been doing. And I'll ask, "Have you... You're naming a lot of good things. Have you done any anti-rotation or rotational strengthening?" "No, I don't think so." "Name a couple exercises." "No, I don't even know what they are." Same thing with adductor strengthening.

Dr. Yoni Rosenblatt: Yeah, fore sure.

Dr. Zach Juliano: You know, "We had you here for a adductor repair. Are you doing any groin strengthening?" "Asymmetric stuff, I've been squeezing the blocks. You told me the day after surgery." I'm like, "Okay. Did they build on that?" "No, they haven't." You know what I mean? And for me and for anyone else, the other PT here, Kara and other folks out there that are treating this injury, that can be frustrating because at that point someone comes to you two, three weeks, they should be further beyond that. The isometric stuff should be somewhat in the rear view or at least progressed upon. We should be working isotonics at that point, we should be working concentrics, we should be getting this adductor firing through its range of motion.

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: Be like treating a bicep strain, but never actually having someone lengthen and strengthen their bicep at the same time.

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: So I feel like those are the biggest missed things. People, they know it's an adductor repair, but they don't strengthen them. I don't get it. I'm like, "The answer is in the diagnosis."

Dr. Yoni Rosenblatt: I think people are scared, yeah. I think people don't know. And I think as a guy who's pissed off Dr. Meyers, they just don't wanna piss off Dr. Meyers.

Dr. Zach Juliano: That's true.

Dr. Yoni Rosenblatt: So they don't wanna touch it. But...

Dr. Zach Juliano: That's true.

Dr. Yoni Rosenblatt: Yeah, but that's really good feedback. So if you're listening and you get a core muscle repair, think about what is weak, strengthen it, think about what is tight and stretch it, it's no different. Like those are the basics of what we do. Okay. Let's get a little bit towards surgical because I think that, kind of like we were just touching on it, does freak a lot of people out.

Dr. Zach Juliano: It does.

Dr. Yoni Rosenblatt: What does he do in there?


Dr. Zach Juliano: Anyone who's listening that has met Dr. Meyers or listened to anything that he talks about, he uses a great analogy of a baseball. So just to make this easier for everybody out there and yourself if you haven't heard this before. If you can imagine that pubic plate like a baseball, inner layer of that baseball, nice and hard, firm, outer layer of it, surrounded by leather, stitching, all of that. Imagine the baseball as that pubic plate. Imagine the leather surrounding it is that fibrocartilage lining of that pubic plate in that bone. And then any stitching would be muscles that are kind of coming down and attaching to it. So what Dr. Meyers does during that surgery is, we'll check that pubic plate and make sure that fibrocartilage lining is fastened and then from there he'll look and identify the muscles that are torn.

Dr. Zach Juliano: Say we're looking at rectus abdominis, couple of the adductor muscles, pull that, actually somewhat peel back those layers, find those healthy attachment points of the muscle and he'll pull them back up and refasten them to that fibrocartilage layer of the pubic plate. Stitch them there, figure out if he needs to reduce any restrictions in scar tissue, maybe some heterotopic bone ossification. Take that all out, maybe shoot some sort of corticosteroid injection in there to help with some inflammation. Stitch them back up internally. And then, yeah, they're done. Steri strips on, gauze reinforced with some, and that's the repair.

Dr. Yoni Rosenblatt: And that's...

Dr. Zach Juliano: And there are some other things that he does. For kind of dumbing it down for some people and making it make sense, that's really what it is at a smaller level and more of a simpler understanding and form of it. Yeah.

Dr. Yoni Rosenblatt: Well, I appreciate that. Here are the things that I've seen in post-op notes that freaked me out. Ready?

Dr. Zach Juliano: Yeah. Let me hear it.

Dr. Yoni Rosenblatt: Number one, what's an adductor release? What's he doing?

Dr. Zach Juliano: So adductor release...

Dr. Yoni Rosenblatt: I'm picturing an adductor like flapping in the wind, what's actually happening?

Dr. Zach Juliano: So what he is actually doing is he's creating little cuts in that muscle 'cause what you think about is that tug of war, right? So what you can have, while one may be torn in regards to that connection between the rectus and the abdominal muscles, one can be tight trying to do more work. So if you think adductor release, he's just giving a little bit of length to maybe one of the adductors that isn't torn, but maybe overly tightened and trying to do too much of the work. So that's pretty much what that is there. So he is just making some small cuts in that muscle to give a little more length of it.

Dr. Yoni Rosenblatt: Okay. That...

Dr. Zach Juliano: What else are you hearing?

Dr. Yoni Rosenblatt: That's good. That freaked me out. Pelvic floor repair. I personally get nervous when I hear the words pelvic floor, but when you talk about repairing a pelvic floor, that's something I don't wanna mess up. What does that mean, Zach?

Dr. Zach Juliano: Yeah. So if you just think about the pelvic floor being supported by almost like a sling or a hammock of muscles, he's pretty much just repairing those muscles. It's really no different from the adductor muscles, it's just that, it's just how they support that pelvic floor area. So he's just speaking to anatomy there. So pelvic floor repair, meaning the muscles that are helping to support the pelvic floor.

Dr. Yoni Rosenblatt: Okay. So he's suturing them back to what? The pelvis?

Dr. Zach Juliano: He's putting them back on that pelvic plate, yes. So you have that nice attachment point and that control of your pelvis.

Dr. Yoni Rosenblatt: Okay. Over your pelvis.

Dr. Zach Juliano: Yeah.

Dr. Yoni Rosenblatt: Okay. So those are the two I'd say big things. He uses the word reinforce a lot. I've, do you know what's going on surgically there when he will talk about reinforcing rectus?

Dr. Zach Juliano: Yeah. Not to speak too much for him, but I have to imagine that in his notes he's just referring to refastening or stitching the actual muscle attachment to its origin. So when you think about the tears, what happens is you can have full on avulsions where that whole muscle is torn off, or you can have partial tears that he's identifying. So when he's saying reinforcing, he's taking anything from those small tears to the large avulsion tears and he's pulling the healthier layers of the muscle and tissue back down to the pubic plate and re-fastening them to that fibrocartilage outer lining.

Dr. Yoni Rosenblatt: Okay. Super helpful. And then, okay, so this patient wakes up and they were told that they have a core muscle repair. And from what I understand, Vincera loves early yoga.

Dr. Zach Juliano: Love it.

Dr. Yoni Rosenblatt: Love it.

Dr. Zach Juliano: Love it. Early yoga and PT, they do both in the same day.

Dr. Yoni Rosenblatt: Awesome. So walk me through the life of this athlete that just opens his eyes. When are they doing yoga? What exactly transpires in that yoga studio? And then what happens with Dr. Zach Juliano with that first visit?

Dr. Zach Juliano: Yeah, definitely. So day zero, wake up, recover in our postoperative care room downstairs. Sometimes depending on the athlete, what sport they may have... What sport they may play, I apologize, what insurance they may have. We actually take them up day off surgery. So I'll get an evaluation in, obviously then with somebody else given that they're bit under the influence there. And we go over simple mobility skills. It's pretty much like an acute level eval, can they walk, can they get in and out of bed safely? Can they get up and downstairs? Do they know what to expect tomorrow? Give them a little of ice, that'll control some of the inflammation, send them on their way. For a large majority of people we may not see them till that first day post-op. So they walk in that day likely hunched over, likely not knowing what to expect, scared of PT, scared of the fact that they have yoga.

Dr. Zach Juliano: And it begins with just some simple mobility, some walking, some sidestepping, some backwards walking. Really just introducing them to movement patterns that are important for their everyday life. From there we have a list of usually table exercise that we go over. Again, let's find transverse abdominis, let's activate it and then let's build on it from there. Let's try and activate hip adductors. Let's try and activate abductors. Let's try and activate anything related to the glutes. Really the first day, and the first we'll say five to six depending on patient tolerance is all about activation. We're not overly concerned with strength building. So for me, I stress that with a lot of folks because they're gonna have pain and a lot of the exercises I give them, seeing as though they're an athlete, they want to do to fullest capacity and fullest capabilities.

Dr. Zach Juliano: I place a block between their knees, they wanna bust that thing in half. So it's on me to tell them, "Listen, I want activation. I'm not looking for strength building. Can we wake these muscles up? Can we turn them on? That's all I care about." So we'll go through short and long lever adduction, nice symmetric form. We'll go over clamshells, side-lying hip adduction, I apologize. Bridging, transverse abdominis or abdominal bracing. And that's pretty much it aside from the standing functional exercises. And that's all day one. And then beyond that, if these folks, professional, college level athlete, even the high school ones, they'll then go to yoga. So yoga instructor, Biz, she's phenomenal. You gotta get her on your podcast next.

Dr. Yoni Rosenblatt: I would love to.

Dr. Zach Juliano: She would have a million things to talk about. She's been doing this forever. She works with tons of professional teams, Eagles, tons of different athletes in this Philly area. And a lot of yoga is, again, finding body awareness, finding ability to activate, putting them in different positions to find this activation, putting them in different positions to be able to understand movement quality, the body awareness I talked about and to be able to help manage that pain and move in a way that can be a bit more free without actually overstretching anything early on. And that's all in about, PT is about an hour, yoga's about 45. Yeah. It's about a two hour morning that they're with us.

Dr. Yoni Rosenblatt: That's amazing. What are their restrictions?

Dr. Zach Juliano: Early on, we don't like them to over-lengthen the area. We don't like them to brace. We want them tightening muscles, but we don't want them to excessively bear down or perform things like Valsalva maneuvers or deep flexing, deep flexion of the trunk. So we avoid sit ups, teach them a lot of growing technique, for instance, getting in and out of bed or on and off our tables for easier movements. Beyond that, infection prevention and control, we don't like them to soak the area. They could shower, but we don't want them in pools, hot tubs, oceans. Really nothing crazy beyond that. Obviously you're not gonna lift anything heavier beyond 10 pounds. You're not gonna jog in the first day or week, that will come after that. But we keep it pretty simple to lifting and straining restrictions. And then infection prevention control restrictions of soaking and stuff like that.

Dr. Yoni Rosenblatt: Hip extension, hip internal rotation, any restrictions there from range...

Dr. Zach Juliano: Not really. No. We actually like to get them in those positions early and often for gentle stretching. With that being said, we don't like to overly lengthen without the stability part. It wouldn't be in someone's best nature or interest to get someone into hip extension if it means they have an excessive lordosis or anterior pelvic tilt. Again, it's just gonna shut down the abdominal wall and shut down that whole anterior sling of stability. So, we usually avoid that. As far as internal and external rotation go, I like to stabilize people in those positions. I like to have them find the awareness of that movement pattern of the hip and really isolate and fire those rotators.

Dr. Yoni Rosenblatt: Yeah. Okay. What are some secrets if you're getting this patient very early post-op, not at Vincera, right?

Dr. Zach Juliano: Yep.

Dr. Yoni Rosenblatt: What are some secrets that you have seen predict to an outstanding outcome down the road?

Dr. Zach Juliano: Yeah. Following the protocol is one, we give people a, you may have seen it, a pretty detailed packet. And we try and make it simple. We understand this is not widely seen. We understand it's not widely treated. So we really list things week by week, day one to seven, day eight to 14, day 15 to 21, so on and so forth. And we give sample exercises. So following that plan and giving variety based upon that plan usually is a really good indicator of someone's success. Beyond that, you're a PT with a good cerebral mind, think foundational postures. I feel like quadruped has skipped a lot, getting people on all fours, really finding and spending the time in that first week to build awareness in that position. It shouldn't always be supine or side-lying. So I find that those are really important things to do. They give people a lot of success early on. 'Cause they find that body awareness and they find great ways to activate and stabilize themselves through their spine and through that anterior core portion. And then jogging. People may not wanna hear this, jogging early on is key. What I'm talking early on, I'm talking like day 10 to 14.

Dr. Yoni Rosenblatt: Okay. You want them jogging?

Dr. Zach Juliano: I want them, interval jogging. I should clarify that.

Dr. Yoni Rosenblatt: Interval jogging. Define a jog, how's that?

Dr. Zach Juliano: Jog 20 yards. I tell people imagine like someone's letting you cross the street and you're hustling up to get across the street, but you're not actually running. That's the best way I can describe it. It's like a 50% effort.

Dr. Yoni Rosenblatt: Why is that so important?

Dr. Zach Juliano: It gives them that really good stretch in a transverse plane. We're not looking to over-lengthen or overstretch. It's giving them what I usually characterize as a functional stretch. A lot of times people that are jogging less tend to build more scar tissue. They tend to have more difficulty getting back to jogging if they're waiting three, four weeks to do it. Same thing with kicking, soccer athletes they have a tougher time getting back to kicking it weeks three and four if they haven't been jogging early. It really provides just a nice gentle lengthening and slight firing of the muscle in those, I don't wanna say over lengthened position, but somewhat lengthened position. It really works that length tension ratio of the muscle.

Dr. Yoni Rosenblatt: Yeah. Yeah.

Dr. Zach Juliano: So it really helps with turning on adductors and making sure they're not getting overly tight to the point where you can't fire them. Same thing goes for those abdominal muscles and the other structures in the anterior wall of the core.

Dr. Yoni Rosenblatt: Yeah. I think that makes a lot of sense. That's really good. First of all, I love the cue of crossing the street, but also why it's important. I work with a lot of NFL specialists who end up going through the Vincera world because they're always at this end range of punting or field goal kicking. And so they get a very broad or very rapid, I should say, return to sport. Like a lot of them come out saying, "Six weeks he said I'm ready to go." Right? So how often are you seeing that six week mark hit and what causes it to take longer? 'Cause I've definitely seen it take longer.

Dr. Zach Juliano: Oh, absolutely. I do always give people the caveat of this is a six week protocol, meaning the fastest it moves is six weeks. I do not expect to accelerate much beyond what we've given you, but potentially expect to take it longer. I usually give people six to 10 weeks as a range just to not get their hopes up. Kind of under promise, over deliver sort of methodology there and theory. I've seen plenty of athletes return at that six week mark. My goal for high school, college and professional athletes is usually some sort of instructional practice with their team at week four, more participation in organized practice at week five, or return to some sort of game and competition by week six. Now, there are a million other things that can happen along the way that delay that, but that's my personal goal that I've had success with. People expect to not be involved in these things. Week six hits, go on the field and do something. I just think that's unrealistic. There needs to be this graded progression and graded introduction to sports specific drills, positional specific drills at their sport. How a cornerback plays versus a running back is going to be totally different.

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: Same sport, totally different movement pattern. Totally different goals and totally different job on the field. I found that people that are trying to get back at six weeks that have maybe more scar tissue that breaks up early on, things that result in maybe a little bit more reactivity to pain, have a more difficult time returning at that timeframe. I've also found that people that come in longer length of time from the initial injury, again, could have a little bit of a delay.

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: You have someone that's on the field, complete avulsion fracture, comes in that week, gets surgery, they're actually gonna be the best candidate to get back on the field by six weeks or ice or whatever surface they're playing on. Some of these people, unfortunately, it's three, four years. "I felt this in college." Now they're a five year pro and now they're getting it taken care of. They're gonna have, unfortunately, a little more scar tissue that may have formed, a little more work during surgery, which could lead to a little bit more trauma to the area. No, I'm not saying all those people don't get back in six weeks and play, but to me just a little bit of an indicator of, "Okay, we might have to take this a little bit slower in regards to getting you back on the field at full speed." But I've had tons of people that return at six weeks and they're still seeing PT. So, yeah, you can get out there and play, but you still might need maintenance and recovery and other strengthening from PT. It's just gonna exist while you're playing.

Dr. Yoni Rosenblatt: So that's something that I would love really, I guess, our sports medicine community to get better at, which is when we give these timelines, too often the patient or the athlete and the clinician think that they're done. Right?

Dr. Zach Juliano: I know.

Dr. Yoni Rosenblatt: So they return to sports in six weeks.

Dr. Zach Juliano: So frustrating.

Dr. Yoni Rosenblatt: And I've seen a ton of athletes like NFL and professional lacrosse get back to playing in this six, I usually say six to 12 weeks.

Dr. Zach Juliano: That's fair to say still.

Dr. Yoni Rosenblatt: Yeah. But God knows they still have symptoms. They're probably better than pre-op, but they still have symptoms. And I think the more our community learns that, number one, the symptoms doesn't mean the surgery failed. And number two, the symptoms don't mean that you can't be on the field, but we build it in terms of the expectation. I think that'll go a long way to kind of get a better understanding to the patient and the therapist of what is actually transpiring. I think we can do a better job of educating that.

Dr. Zach Juliano: Yeah. 100%. I have a kid that's at Oklahoma maybe, going to be incoming freshman for Oklahoma baseball.

Dr. Yoni Rosenblatt: Nice.

Dr. Zach Juliano: Contacted me just the other day. He's like, "Hey, man, headed to school, things feel okay. I'm at that seven week mark. My PT told me I'm good. I'm discharged, but I'm still feeling some pain."

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: And I just hear that way too often, "I've reached six to seven weeks, they discharged me. They said that I'm at the end of the protocol." That does not mean you're at the end of your rehab, so.

Dr. Yoni Rosenblatt: It's painful.

Dr. Zach Juliano: It can be frustrating.

Dr. Yoni Rosenblatt: Yeah. Yeah.

Dr. Zach Juliano: It's frustrating.

Dr. Yoni Rosenblatt: I really think that is the delineation between physical therapy and sports physical therapy. Physical therapy follows that prescription and they're done thinking at week six. Sports physical therapy says, "How do I make these guys elite, guys and girls elite or better than pre-op?" Now, you made a great point of the ones that take longer are those that have dealt with it chronically. I think it's actually a movement pattern. Like how long does it take to fix the reasons they needed this surgery. Right? And if they've built up years and years and experience of poor movement patterns, you better believe it's gonna take a really long time to fix those things. Again, we gotta, as a sports rehab community, we gotta educate our athletes on that. Hey, he's putting a band-aid on it, we're gonna work together to make sure it doesn't happen again or the reasons you had the surgery are mitigated.

Dr. Zach Juliano: Yeah. No, I didn't even touch on that. That's a phenomenal point. These movement patterns that people build, they're strong freaking athletes.

Dr. Yoni Rosenblatt: Yeah.

Dr. Zach Juliano: These guys and girls, they can move a lot of weight, but can they move it the right way?

Dr. Yoni Rosenblatt: Sure.

Dr. Zach Juliano: And unwinding and untangling those movement patterns to get paraspinals to not be as active and let's actually turn on glutes versus these low back structures can take a while. And PT should continue to exist until they understand how to move correct again, otherwise this repair they've gotten might not withstand their 5, 10, 15 year career.

Dr. Yoni Rosenblatt: That's it.

Dr. Zach Juliano: You make a great point there. I'm happy you touched on that.

Dr. Yoni Rosenblatt: Yeah. Thanks. Okay. Why is Graston such a no-no in the Vincera Institute?

Dr. Zach Juliano: I mean, it's written all over our protocol. It's great.

Dr. Yoni Rosenblatt: Jesus.

Dr. Zach Juliano: I mentioned earlier highly vascularized area, cupping, Graston, those tools, unfortunately, they continue to bring blood flow to that area and early on, a lot of times we want blood flow for healing, of course, but they tend to just aggravate that level. So when you think muscles and you think what attaches at that pubic plate region, continuing to scrape and rub and aggravate that area tends to give people a little more discomfort when you're then trying to fire those muscles. Which I know seems to be opposite to a lot of other theories and things that we do for rehab. Hamstringing injury, we're gonna scrape and cup the heck out of it and we're gonna strengthen it and get it better but this area just seems to have such a higher vascular flow to it that it tends to irritate and aggravate a little bit more.

Dr. Yoni Rosenblatt: I think if we had to amend or update that protocol, I think it should just come with like don't be a dumb ass.

Dr. Zach Juliano: Exactly.

Dr. Yoni Rosenblatt: Don't be a dumb ass, don't go crazy with a... It doesn't make sense to use a Graston tool really aggressively on a newly injured area, but it doesn't mean that Graston is gonna ruin or re-injure your core muscle.

Dr. Zach Juliano: No, it does not. I've used it on several different occasions, I know. Dr. Meyers probably just heard that. [chuckle] Am I using it over the area of the repair? Absolutely not. I'm using it maybe a little more distally to get a little bit more length in the muscle, or maybe I'm using it on upper abdominals because they're complaining of this restriction or tightness. And I find it valuable in a lot of different ways. To me, I did not rate the protocol, but I'd imagine if we put in there that you could use it, there would be a large population of people using it inappropriately. So it's a lot easier to say don't use it. And these people reach out to us and have a good rationale of potentially wanting to use it and why they want to use it. Dr. Meyers and Dr. Poor always open to hearing that.

Dr. Yoni Rosenblatt: Yeah. I'll tell you, I am super impressed with his communication. It's really amazing, like he's given every athlete his cell phone number.

Dr. Zach Juliano: It's unbelievable.

Dr. Yoni Rosenblatt: It's unbelievable.

Dr. Zach Juliano: Yeah.

Dr. Yoni Rosenblatt: And like a quick plug for Zach Juliano. So easy to communicate with and to collaborate with.

Dr. Zach Juliano: I appreciate that.

Dr. Yoni Rosenblatt: It sounds like it's just endemic to the Vincera Institute. So good on all you guys for doing... By the way, Jimmy McCrossin, is that a guy who's still up there?

Dr. Zach Juliano: No, no, Jimmy's no longer here. He had some affiliations early in the institute when the rehab side of things and the surgical side of things weren't as connected as they are now. But, Jimmy McCrossin has moved on from here. So no longer affiliated with the rehab or the institute, but great individual and...

Dr. Yoni Rosenblatt: Great individual.

Dr. Zach Juliano: Unbelievable character in the NHL world.

Dr. Yoni Rosenblatt: Oh, awesome.

Dr. Zach Juliano: And well respected in Philadelphia for sure.

Dr. Yoni Rosenblatt: Oh my God. And obviously down in Baltimore too because, just because of the level of communication. So if there's only one thing that comes out, there's so many pearls that we covered, I think, but if there's one thing that comes out, it's how well you are building up that network and just communicating from a sense of humility. You clearly come from that ilk, obviously so does Dr. Meyers, and we've had nothing but awesome things to say about Vincera. So we've definitely appreciated your outlook. I appreciate everything you taught me today, I appreciate your time 'cause I know it's a minute...

Dr. Zach Juliano: No problem.

Dr. Yoni Rosenblatt: And I know it's valuable. Tell the audience of the millions of sports PTs how they can find you.

Dr. Zach Juliano: Yeah. So easily Google Look us up. We have a rehab page on there. Different pieces of information about the treatment, diagnosis of the injury, what we do here. We are so easily accessible across the country. We get tons of people that are contacting us. Dr. Meyers and Dr. Poor, they review imaging from people across the country, people outside of the country, it's crazy. We are accessible through phone, through email, through so many different forms of communication. We try and make it work for everyone. We understand not everyone can drive here, not everyone moves in that Philly area, flying in, whatever it may be. We have, tons of different patients from all over that come here. So don't hesitate to reach out to us.

Dr. Yoni Rosenblatt: How do we find you?

Dr. Zach Juliano: Phone numbers on the website. Me personally? 

Dr. Yoni Rosenblatt: Yeah. That's who I wanna see. If I go up there, that's who I wanna see.

Dr. Zach Juliano: Yeah. I mean, I got my cell phone number that I give every one of my patients.

Dr. Yoni Rosenblatt: Good. Don't do that...

Dr. Zach Juliano: Same thing, I have that... [chuckle]

Dr. Yoni Rosenblatt: Give me an email.

Dr. Zach Juliano: Yeah, I got an email. So that's

Dr. Yoni Rosenblatt: Awesome. A wealth of knowledge. So, I feel far better equipped to treat core muscle injuries.

Dr. Zach Juliano: I'm happy.

Dr. Yoni Rosenblatt: Now I know what that means. So I appreciate your time, I appreciate the education. I look forward to doing it again, Zach.

Dr. Zach Juliano: Yeah, definitely. Yeah. You guys, your team, you've all been great. I've really enjoyed collaborating with everyone of the PTs that works for you guys that has seen this injury and talk through and communicate different ways and methods to getting their athletes back on the field or ice or whatever it may be.

Dr. Yoni Rosenblatt: I love it.

Dr. Zach Juliano: So I appreciate you having me.

Dr. Yoni Rosenblatt: Yeah, man. Alright. Looking forward to...

Dr. Zach Juliano: Alright, bud.


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