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Dec 04, 2023

How to Wake Up a Quad with Dr Rayce Houser

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Dr. Yoni Rosenblatt: Welcome back to the True Sports Physical Therapy Podcast. Back by popular demand, we got Dr. Rayce Houser, who was a part of one of our most popular episodes in the past, talking about all things strength and conditioning as it pertains to ACL. Rayce, I'm really excited to talk to you about how the hell we wake up the quadriceps after an ACL surgery. So welcome back to the pod, Rayce.

Dr. Rayce Houser: Yeah, thanks for having me on again, Yoni.

Dr. Yoni Rosenblatt: Really a pleasure. So one of the things that I struggle with massively when rehabbing athletes coming out of an ACL surgery is how we wake up the quadriceps. And we've talked a lot about how the quad shuts down, maybe why it shuts down, ways to wake it up after we get all of that motion, and oftentimes, those things are happening concomitantly. I wanna know, Rayce, from your point of view, why does that quadriceps go to sleep after a knee surgery?

Dr. Rayce Houser: So essentially, we'll dive into AMI, or what's commonly known as Arthrogenic Muscle Inhibition. Essentially like that quadriceps, it's still a healthy muscle tissue, but now, it becomes reflectively inhibited. So some of the hallmark signs that we're gonna see typically is gonna be muscle weakness, muscle atrophy, and then essentially activation failure, which essentially is the big thing that we tend to see, is we can't contract the quad. As to why it happens, there are a whole host of factors that we think are essentially playing a role here. One is gonna be tissue damage, so essentially, I think of that as we have surgery, it's gonna include things like the incision, the donor site for the graft, typically we'll see created deficits and quad activation with either the patellar tendon graft or the quad tendon graft, we got bone tunnels and then potentially other injuries or tissues that were involved in the surgery, whether it was like meniscus, ACL, MCL, etcetera. Joint laxity. This, I think is probably less relevant after the surgery, just because we're assuming that this is fixed now because of surgery. We're gonna have effusion, we're gonna have pain, inflammation. And then I think the other big thing with the knee graft is gonna be proprioception.

Dr. Rayce Houser: So essentially, the native ACL has a ton of proprioceptors, which essentially allows your body to understand where your knee is in space. So we have two things going on here. I think the big thing we always think of is, since we don't have that proprioceptive input, now I'm getting less, essentially, sensory information, which is then going to dictate or essentially result in less motor output, or essentially, that quad not contracting. The other thing we have going on is the flip side of things where we have a sensory overload, where essentially we have excessive neural input from the increased nociceptive activity and joint kine receptors. Solution to the two things going on in terms of why AMI is happening.

Dr. Yoni Rosenblatt: I love that you say it's commonly referred to as Arthrogenic Muscle Inhibition, where I commonly refer to it as your quad is asleep. So those are one and the same, right? So when we're trying to geek out or sound impressive, we're gonna call it Arthrogenic Muscle Inhibition, or AMI. Otherwise, colloquially speaking, when we're talking to patients, Your quad's asleep, and we're trying to wake it up. And it's such a massive issue to getting athletes to do anything; to walk normally, to squat normally. That's why I go crazy when I see PTs jump right into, Okay, let's work on your squat form, when the quad is asleep. And you're thinking just by putting force through the limb that it's gonna force the quad on. I've never had success with that, and that's why I think it's so important that we highlight, The quad is asleep. Here's why it might be asleep. From what I just heard from you, it's, we don't have proprioception in the knee yet, so the brain can't really control the muscle around it, is that right?

Dr. Rayce Houser: Yep, and then I think our two big things are probably gonna be the effusion and the swelling, and then the pain as the other two big things.

Dr. Yoni Rosenblatt: Right. So as PTs, we wanna start attacking those factors. So one, we wanna get swelling way under control. We had Dr. Bassett on in the past, and she talked about draining the knee almost immediately as a point of just consistent care following ACL surgery. So I think that's worth thinking about, so as using compression devices, cold compression, intermittent cold compression from our buddies at Preventice, where that will help flush some of that fluid. I've seen a lot of good work from Firefly. If you don't know who they are, check them out. That's a way to just get consistent muscle recruitment to help flush the fluid. By the way, the pain that you mentioned, or nociception, as you call it, is one of the reasons I hate jumping to the squat, 'cause you're loading up this patellar tendon that was just... One-third of it was just removed. You're gonna increase those pain levels. You're gonna decrease our proprioception and our muscle activation. So I think you're kinda cutting off your nose to spite your face when you're doing that. But those are two big things that we have to attack; get the pain down, get the swelling down, then we can start paying attention to muscle activation. So you touched on it briefly as to what the ACL does other than mechanically stabilize the knee. What other functions outside of that stability? You said proprioception. Does the ACL do anything else in that knee that we should worry about?

Dr. Rayce Houser: I would say those are the two big things. I also say, essentially, as a secondary consequence of the proprioceptive input, now we're getting more active stability out of the knee via muscular contractions. So I think all those essentially play heem heem with each other.

Dr. Yoni Rosenblatt: Okay. So those are, I would say, the two big roles of your ACL; so it's proprioception and it's mechanical stability. This also is kind of a callback to a recent conversation I had with Vex, where he's an elite level hockey strength coach. And everything he was talking about was truly proprioception and our brain's ability to understand where we are in space and to stabilize and how important that is. How do you start integrating some of that proprioceptive training so early in ACL rehab? We're talking the first week or two.

Dr. Rayce Houser: I think big thing would be essentially trying to give them references. Dr. Pat Davidson will commonly refer to things as, like, ground... Essentially just like your body is touching some sort of object, and that is then giving you proprioceptive input. So it could be like... Let's say I'm having them do some sort of... Maybe we can do a heel pop here, and maybe I'm just working more of a traditional quad set as our first three, four minutes, just kinda getting that quad warmed up. Maybe I have them have their foot up against the wall, so now, I'm getting contact with the wall. We know the foot has a ton of proprioceptors in it. So maybe that's going to help give them a better idea of where that knee is in space, maybe help lead to better improved quad activation.

Dr. Yoni Rosenblatt: That's a great nugget there. So you mentioned heel pop. I want you to define heel pop, 'cause we use that term so much at True Sports, and we really just kinda made that up, although it seems to be gaining traction in the ACL rehab world. So I want you to describe heel pop, and then I want you to dig into the real goal there, which is including proprioception by putting the foot on the wall before we get into standing. So hit those two points for me.

Dr. Rayce Houser: So first thing with the heel pop, I feel like the most common thing that we'll typically see more, we'll call like, baby PTs or new grads in terms of ACL is just doing traditional quad sets, which essentially, that's just referring to just squeezing your quad, essentially. The big thing with the heel pop is we're trying to add in the hyper-extension and component to be able to control that actively. 'Cause a lot of times, we'll see people who will have... Let's say they have 5 degrees of hyperextension passively, but they can't actually get there actively, which we know in terms of risk for early onset away, that's gonna play a big role in that, so being able to get access to controlling that actively.

Dr. Yoni Rosenblatt: By the way, not just... Sorry to cut you off, Rayce. Not just OA, but I'm also worried about excessive scar formation. And if we can't lock that knee out to that 5 degrees of hyperextension in your example, you better believe that the system is laying down scar tissue in that frozen knee or in that flex position, and we're dead there. 'Cause now you're talking about, you're setting your athlete or patient up for a future scope. So we want proper arthrokinematics, as I always call it, to allow for a decreased risk of OA. That joint needs to get to its close-pack position so that it can flush fluid out, open back up, bring in new fluid, synovial fluid. That'll help with the health of the joint, but also avoiding excessive scar tissue and a frozen knee is gonna help with that. Okay, so that's your heel pop. Thanks for describing that. Now, talk to me about the proprioception that you're beginning to include.

Dr. Rayce Houser: So we talked about early, like, immediate phase, putting foot up against a wall and doing, essentially, a quad set there. I think other Big Bang Theory back things would be like wedging a physio ball into a corner of the wall and essentially doing a closed chain TKE that way, gonna have foot in contact with the ball, they're gonna get, again, more proprioceptive input there, and then we can adjust, essentially, the level of resistance based on how close they are to the ball or how far away they are from the ball.

Dr. Yoni Rosenblatt: Awesome.

Dr. Rayce Houser: Those will probably the two big ones I would end up using.

Dr. Yoni Rosenblatt: Okay, so in that instance, your patient's supined and they're doing a leg press into a ball that's on the wall. Is that what you're describing?

Dr. Rayce Houser: Essentially, yeah. So they might start in like 20 degrees of knee flexion and then essentially just lock out the knee and try to be able to get into that terminal knee extension position, but now we just have a little bit of extra resistance with the, essentially, pneumatic pressure of the ball.

Dr. Yoni Rosenblatt: Okay. And then do you use a band behind the knee that you're pulling up into what would be knee joint flexion, or are you just letting them ride like that?

Dr. Rayce Houser: I'll just let them ride with that, because that ball, essentially, is gonna provide that resistance for them. I think from there, I'm probably going to end up going into a prone position and do more of a traditional plank progression, essentially, as the, essentially, gravity is gonna cause a knee flexion moment, so they're have to use the quads to then keep that knee locked out. We can progress that to a single leg plank, essentially, and then from there, get into a traditional weight bearing progression.

Dr. Yoni Rosenblatt: Love that, because what you're doing is you're accounting for the line of gravitational force. And so my issue with that early squat before they have the ability to control the knee is you're forcing them to try to control all of their body weight against gravity in a squat position. What you're describing, now we're limiting how much body weight they're controlling because of the line of gravitational pull. When they're prone, there's far less gravity, obviously, going through the knee joints. So they gotta be able to lock it out there before they get to closed kinetic chain totally standing, right?

Dr. Rayce Houser: Yeah.

Dr. Yoni Rosenblatt: So I love that. And I haven't necessarily thought that all the way through, but that's a great way to include that in your progression. So your baby PTs, which I would never call them, I would say PTs that are so eager to improve their clinical excellence, those are great interventions you can begin to use in the thought process behind them as to why you're using them. So good on you, Rayce. Thank God you work at True Sports. Those are great ideas. [chuckle] I noticed, you talked about AMI and why the quad goes to sleep. You did not mention tourniquet time and the compression that transpires around the limb during surgery. Does that play a role for you? Do you think that really matters?

Dr. Rayce Houser: It might, to an extent. I haven't dug a ton into this, and all the articles, at least I've seen in terms of AMI haven't mentioned anything in terms of tourniquet time and that having a factor or playing a role in AMI? I'd be curious if you have a suspicion in terms of whether or not it plays a role.

Dr. Yoni Rosenblatt: Yeah. I have a massive suspicion. I think you're right, there's not a ton of literature in our world on that. I think this is the gap between PT and MD. The MDs know what standard tourniquet time is. I think the really good MDs and ortho pods are totally conscientious about that and trying... It's almost like a race against the clock, how quickly they can put an ACL in beautifully and limit that tourniquet time. I think it makes a ton of sense.

Dr. Yoni Rosenblatt: I had a great conversation with Dr. Jamie Dreese, where we talked about... And it was actually early, one of our early pods. And we talked about standard tourniquet time, we talked about how he tries to limit that. And I remember very clearly sending him a video of a patient post-op day one or two that had a beautiful heel pop and had a great quad set, and I said, Doc, why the hell do your ACLs... Why are they able to do that? And he said in his classic fashion, Well, why don't you put a tourniquet around your leg, pump it up to 300 pressure and let me know how your quad feels the next day? Leave it on there for 30 minutes and let me know how your quad feels the next day. I bet you, it's not gonna feel as good as the other one. Which is a great point. We just don't think about that. And so for the millions of orthopedics that are listening to this conversation, please start thinking about that. To the tens of millions of PTs that are listening to this, start talking to your surgeon about that. It has to play a role. I bet you it does.

Dr. Yoni Rosenblatt: So if it's swelling, if it's pain, if it's tourniquet time that is shutting our quad down, you're beginning to wake it up with the tricks that you just mentioned. Any other tricks that you're thinking early that's gonna help decrease this Arthrogenic Muscle Inhibition?

Dr. Rayce Houser: So I'll typically use what's called an open and exploit principle, essentially. So essentially, we're thinking with AMI, we're gonna have atrophy of that quad muscle, so I'm gonna have, essentially, less motor neurons to be able to recruit, essentially.

Dr. Yoni Rosenblatt: Let me ask you this though. Is it... It's not atrophy yet, right? That muscle isn't shrunk? 

Dr. Rayce Houser: If we're immediate post-op, no. I think also, it depends on when in relationship to the injury is surgery and stuff, 'cause if we're waiting like that four-week period, we might already start to see some changes in terms of muscle volume. So if it's like, injury happens, they get surgery within the next week, because swelling and range of motion looked pretty great, at that point, I'm not suspecting atrophy to be really implicated as much at that point. But if it's something where they got hurt four weeks ago, we're struggling with swelling and range of motion to get back prior to surgery, I'm gonna suspect that that's gonna have a little bit larger of a role there.

Dr. Yoni Rosenblatt: Yep, that makes sense.

Dr. Rayce Houser: But essentially, prior to exercise, I'm gonna use some sort of non-exercise intervention. I'll commonly use ice in the clinic. Sometimes I use TENS as well. Essentially, if we ice for about 20-30 minutes prior to an intervention, we're gonna get about a 60-minute window for improved recruitment.

Dr. Yoni Rosenblatt: Awesome.

Dr. Rayce Houser: And then with TENS, same sort of thing, you'll probably get about a 20-30 minute window. So if you combine both of them, essentially you'd get it back there, that's essentially gonna give us more access or access to a larger motor neuron pool, and then from there, we'll employ some of our more traditional methods and means in terms of like NMES to help recruit the quad and essentially try and get that as strong as tolerable in terms of contraction.

Dr. Yoni Rosenblatt: Okay. So you're putting ice on these patients for about 20 minutes prior to asking them to recruit their quad, right? And maybe you're putting TENS on at the same time prior to asking them to recruit their quad. That sounds like outstanding home exercise prescription. 'Cause I hate using my time in the clinic for stuff that they could be doing at home. So why is that working? Why does putting ice on a knee help with recruitment?

Dr. Rayce Houser: So the biggest thing it's probably gonna do is alter sensory input, essentially, from both nociceptors and the thermoreceptors, so reduce that nociceptive activity and essentially increase that motor neuron pool excitability. In the clinic, I've done... So I'm just kind of like... I'll call it like messing around, per se, where I'll get them on the Tindeq, maybe set them up like 60 degrees of knee flexion. Essentially, I'll have the app pulled up and everything, I'll have them kick as hard as they can up until like a 3 out of 10 pain. And let's say they get 20 pounds of force on the Tindeq, and then I'm like, Alright, let's ice for a little bit, maybe 5 minutes or so, put them back on it, and it's not uncommon to see their force output double in that 5, 10-minute window of icing.

Dr. Yoni Rosenblatt: It's unreal. And you think that's happening because why? It's essentially numbing the knee and they're not feeling the pain, that's gonna shut down their quad?

Dr. Rayce Houser: Yeah, and essentially, that heightened nociceptive activity that we kinda mentioned earlier, essentially, we're reducing that. So now we're getting a lot better motor stimulation, much of the inhibiting stimulus.

Dr. Yoni Rosenblatt: That is fascinating. Any other interventions that can show that amount of increased force?

Dr. Rayce Houser: I would say like immediately, probably the only other thing that you'll probably be able to use will be NMES in the clinic to get that sort of like, party trick sort of thing. Now, in terms of more like long term changes, essentially eccentric cross exercise trying to use that crossover effect, so doing essentially heavy centric work on the non-op side. And then also using BFR on the op side, one to try to limit atrophy, maybe hopefully get a little bit improvements in hypertrophy, but then we'll get some of the systemic hormonal effects from the BFR.

Dr. Yoni Rosenblatt: That's awesome to know because that now you start thinking when you use the term party trick, this is when I would use interventions in a competition setting where I'm talking to, an NFL athlete and we're talking about ways to ramp up force production and the ability to do that in competition. I'm frequently getting questions of how do we increase our force output? How do we decrease the chances we have an injury in game almost. These are great ways where you can teach the athlete, Hey, throw some ice on that knee immediately prior. Work the hell out of your contralateral limb immediately prior.

Dr. Yoni Rosenblatt: We know that it's gonna increase the force of your affected limb, and decrease the chances. One, you injure, and two, it's gonna increase performance. This is when sports PTs become essential. They become performance PTs on the sideline as opposed to, go try some quad sets. It's so different. Okay. So that's where you become essential to have on the sidelines. That's where it's helpful to be in a locker room in a clubhouse trying to get the most out of your athletes. How much do you see of AMI non-op? Is this a player in your patellar tendonitis? Is this a player in your quad tendonitis?

Dr. Rayce Houser: There's been some studies and I... Since the vast majority of research has been more dedicated towards ACL research, there's been a handful of studies that have looked at other conditions like OA at the knee, like essentially subacromial pain syndrome, the shoulder. And we do see some of these kind of AMI related features that are implicated in some of those other pathologies. This is my personal kind of bias in terms of, let's say I see someone who's coming in for shoulder pain and let's say I measure ER on the Tindeq.

Dr. Rayce Houser: And let's say their non-affected side is 20 pounds and their affected side is let's say 12 pounds, and let's say in six weeks they're pain free. I'm thinking I probably didn't actually strengthen the muscle. If they're now at 100% symmetry, I'm thinking I probably now have essentially like they're not getting that inhibition because of the pain, and that's now the improvement that we see versus like a true strengthening effect.

Dr. Yoni Rosenblatt: Okay. So what happens then in your rehab?

Dr. Rayce Houser: After they're essentially like pain-free?

Dr. Yoni Rosenblatt: Mm-hmm.

Dr. Rayce Houser: Essentially from there it's, whatever they need to get back to doing. Is it overhead lifting? Is it being able to throw a 90 mile an hour fastball? Essentially from there it's like, okay, this is what we've been doing. You haven't thrown a baseball in, let's say two or three months. Now I need to start to progress the stressors to essentially approximate closer to those throwing stressors, and then just kind of gradually build that up.

Dr. Yoni Rosenblatt: Okay. So it starts to become more task specific.

Dr. Rayce Houser: Yeah.

Dr. Yoni Rosenblatt: Once they're out of pain. Once you get this, let's shoot back to our ACL case. They're able to recruit their quad beautifully, you've gone from that plank position to a single leg plank. You've gotten them up in weight bearing. How are you including proprioceptive inputs in your early strengthening phases?

Dr. Rayce Houser: So I think big thing, I'll typically be a big fan of either one, reducing base of support contacts, maybe going like a, a bridge the gap sort of method. Or I'll commonly employ some sort of thing where I wanna keep the foot stable. But now I want to try to be able to like alter center of mass by either like having them move the kettlebell from side to side, or maybe see if they can do like a hip airplane where now they have to rotate their hip on a stable leg. I'll typically include stuff like that more so than traditional like unstable training. But that's just kind of my bias in terms of how I end up going about it.

Dr. Yoni Rosenblatt: Why do you do that? Why do you err towards that?

Dr. Rayce Houser: So my biggest thought would be, and this will be kind of like relating it to like the CTSIB essentially in terms of like doing all of the, the neuro testing based, like essentially trying to determine is it like visual feedback issue? Is it like more of a, why am I blank vestibular system issue or proprioceptive issue? My thought would be if we're on an unstable surface, let's say an Airex pad, like, I'm now diminishing proprioceptive input and now I'm having greater reliance on my other two systems. So my thought would be, is there a way that we can alter essentially the other two systems and then essentially be able to then bias more proprioceptive feedback. So I think like maybe I do some sort of like head nods or do some sort of like visual occlusion sort of stimulus, to be able to essentially try to bias or hone in more on the proprioceptive side of things.

Dr. Yoni Rosenblatt: Yeah. So I love that because you did a really good job of highlighting when we talk about balance or control, there are really three players here. It's visual, it's vestibular, it's proprioceptive, and I think as a profession, we just jumped to this Airex pad where we're only really attacking one of those three. You're talking about hitting those others, making sure you're hitting vestibular, making sure you're hitting visual. How do you play with an athlete's visual system? I think you said visual occlusion, which is a really fancy way of saying, messing with what they're seeing.

Dr. Rayce Houser: Yeah. Essentially you'll see some people use like strobe glasses essentially, where like they'll like flicker light on an off, essentially more or less. And so now they're not getting that similar sort of visual input. I might also have them do some sort of thing where they have to like be able to like track something with their eyes because you'll notice that people who since, like if I'm trying to balance, I wanna focus on one point, some sort of like horizontal probably. And if I start to essentially adjust visual input, like now I have to essentially rely more on other systems, whether it's vestibular or proprioceptive, to be able to maintain that sort of single limb stance.

Dr. Yoni Rosenblatt: This is such a holistic approach to challenging an athlete. Too often I think we get into a world of we just gotta get them stronger and stronger and stronger. And what you're highlighting here is we gotta get them controlling that limb in addition to strengthening and loading. So in your session, how do you split those up?

Dr. Rayce Houser: So it might be like, let's say we've introduced some weight bearing stuff. So let's say maybe we're, I don't know, three or four weeks swelling, range of motion looking pretty good. Pain's good. They're able to heel pop, do straight leg raises. So it's like, all right, we've hit that. So I'll probably still utilize a little bit of NMES, maybe start off with some like leg ascension, ISOs, maybe overcoming ISOs to tolerance, get that quad warmed up a little bit. And then from there I might go through like a locomotive series, maybe it's like a single leg march. Start to get them a little bit more comfortable with like single leg stance time.

Dr. Rayce Houser: And then from there I can get into more of like a traditional single leg, I don't wanna call it balance exercise, but motor control exercise. Working on being able to control like center mass, or being able to do some sort of like dual task essentially trying to be able to devote less cognitive resources to like maintaining single leg stance and more accomplishing the secondary task. And then from there we might get into more traditional kind of strength training means, per se.

Dr. Yoni Rosenblatt: Okay. So it's within one session you're trying to fill all these buckets. You're ramping it up. Let's say with stim, I would say that's a great example of your open intervention because you're increasing your access to the... And increasing the motor neuron pool. And then you're moving towards your exploit side, which is we're gonna load them towards the end. So it's one session where you're accomplishing all these things. Is there ever a case where you totally split it up where it's like you're gonna spend, Monday doing all of your open interventions. You're gonna be doing a ton of that stim, you're gonna be doing a lot of the proprioception work, and then Wednesday they're gonna come in, they'll get warm on a bike and you load the F out of them.

Dr. Rayce Houser: So I'm gonna typically do what I'll consider, essentially this is how I'll frame everything for most patients, is essentially a concurrent training model where essentially I'm gonna hit a bunch of different qualities within one session, and essentially how much I bias that's gonna depend on them individually and where they're at. I would say if I'm gonna pull more from like the motor learning side of the things, in terms of blocked versus randomized.

Dr. Rayce Houser: So I know blocked practice within session, I'm gonna have great improvement in probably that skill. But in terms of long-term retention, I'm not gonna have as good. So I'll typically do more of like a randomized model in terms of like with that concurrent model, just so I have better long term retention. The other thing you have to balance too is essentially the motivational trade-off. So if I'm having them perform a task and they are failing eight out of 10 times, like they're probably not gonna wanna keep doing it. So you're gonna have to have some sort of balance of blocked versus randomized just because blocked, I'll probably get a little bit higher success, a little bit higher motivation, but also want some randomized in there to keep them motivated, and still have a little bit of failure and challenge them in terms of progression.

Dr. Yoni Rosenblatt: Okay. I love that you're using motor learning principles. I took that class in undergrad and I'm... I probably haven't even thought about that, since then, which was about 20 years ago now. So I think that's great that you're looking for that massive motor learning and carryover because that's what this is about, right? Getting them to function as, at high of a level as possible. So I think that's, that's really powerful and I think it's a lens we don't often look through. I think we just don't... I don't think enough about that. I think that's super valuable. Can you think back like over the thousands of ACLs that you've rehabbed of an instance where, man, you were just struggling to wake that quad up, and maybe something you were missing?

Dr. Rayce Houser: So I think, I have one patient, heck, we were struggling for six months to be able to do a heel pop. And some of it was, I think on the patient's end of things in terms of like discharging crutches too early. Like I mentioned, Hey, let's progress to one crutch. And then next thing I know, she comes in the clinic with no crutches. I'm like, Hey, we talked about this. She's also a business owner too, so she constantly is up on her feet, have to go places and have meetings and stuff. And we had a heck of a time trying to get that swelling down for the longest time, struggled with extension for the longest time. I tried to hammer home and I probably didn't do a good enough job on my end in terms of like an education standpoint of being like, Hey, we need to work on extension, like I really need you to focus on this.

Dr. Rayce Houser: And it wasn't until the doctor ended up saying essentially, Hey, if we don't get extension back, like, I'm gonna manipul you or scope you that she's like, oh shit. Like I better start really working on this. So made some improvements in extension, but just because of the amount of activity that she was doing, like swelling was still there. We weren't able to get a quiet knee in terms of pain and swelling. And it took us probably... We probably got our first heel pop at probably four months.

Dr. Yoni Rosenblatt: Wow.

Dr. Rayce Houser: And then she lost it for a little bit. And then I would say the past, she's probably like six months post-op now at this point, we're probably able to consistently perform a heel pop. Like I'll just have her go in the back real quick, like, Hey, heel pop. Good, okay. We'll head out to the gym and start doing stuff.

Dr. Rayce Houser: But I think it highlights the importance of one, like as a PT, like making sure you're providing like good education in terms of like, Hey, if we don't get this quad back, like your rehab timeline pushes out drastically. And then, two, also making sure that the patient is doing what they're doing on their end, because I can only do so much in 45 minutes twice a week. Like, ultimately it's gonna be up to them as well in terms of what they're doing outside of PT, those other however many hours are in the rest of the week.

Dr. Yoni Rosenblatt: Yeah. Yeah. And I think that's a great point. The education that you provide your patient and the import and stress you put on how important the quad set is, how important the heel pop is. I oftentimes will tell the athlete, I know this is not fabulously fascinating. It's even really boring, but the quicker you get this, the quicker you get on the field, it's that correlated. Because like you said, you get to month three, four and you're still struggling with that heel pop, but they've been able to do their Bulgarians, they've been able to do their RDLs, they've been able to squat. But if you don't have that end range stuff, now you're playing catch up and no one wants to be in that position. The patient doesn't want to be, the PT doesn't wanna be, you gotta stress to your athlete from day one how important these principles are.

Dr. Yoni Rosenblatt: That's why we say any athlete inside of our practice should be able to be pulled aside and asked, Hey, where are you in your arc of rehab? And they should be able to tell you, like, I'm at month X, but what I'm working on is Y, and the reason I'm working on Y is because this is how it's gonna translate to the field, or to my goal. And that's all about education and how you communicate and talk to that patient. So keep that front of mind, front and center.

Dr. Yoni Rosenblatt: Now, your sessions sound amazingly scripted. So talking like more nuts and bolts. You treat a million patients a week. When do you prep these sessions?

Dr. Rayce Houser: I don't know if this is gonna sound bad on me. I'll typically have a pretty broad like structure of what sort of things I want to hit, what movement patterns I want to hit, what qualities I want to hit. And then from there it's just essentially plug and play. Like I might have like, Alright, maybe I wanna preferably do like this exercise for this sort of quality and movement. But if for whatever reason, like let's say I wanna use the Keiser machine and do a split squat on there. Let's say it's taken like I can easily just lateralize to a different modality in terms of barbell or dumbbell and still get the same thing that I want.

Dr. Rayce Houser: I think that allows me more affordance for adaptability and being able to modify things versus if I have like this very rigid and specific program laid out for the individual in the day and something goes awry, it's like, Oh, my gosh. Like, what do I do next? So I feel like that's given me like the, like in terms of prep time, it saved me a ton because I don't feel like I have to spend a ton of time prepping. It's just, Okay, I wanna hit X, Y, and Z. Here are all the exercises that can fall in the sort of realm of what I want to hit. And then we just get after it.

Dr. Yoni Rosenblatt: Yeah. And even now, I've been doing this for a long time, even now, I will keep like that loose framework on my phone. Say I have a major league baseball player coming in. I know I want to work on loading the cuff, I know I want to work on trying to do that open chain, close chain. Here are all the options. I can go through. What, what is my bag of tricks for open chain? What, what is my bag of tricks for closed chain? Like you said, maybe a machine is taken or there's a dumbbell missing or whatever. Well, I have all these other exercises that I can go to and try to challenge them. And then within that exercise, maybe it's too easy for them. Okay let me grab another weight. Maybe it's too hard for them. How do I scale that movement?

Dr. Yoni Rosenblatt: Just having that rubric, gives you the flexibility to, what'd you say? Lateralize, to lateralize your exercise intervention so that they're getting an awesome session. And what you have to do is a therapist is lock in and see are they performing it exactly the way we want it? Are they flying through it? How do I make it harder? How do I make it easier? And then you can move. We have, as part of our True Sports interview process, when we bring PTs in very often they'll treat me as the patient. And I will show them like, I'm not getting my heel pop. I'm not getting my quad set. How are you gonna adapt? Stop... No, no, no. Squeeze harder. No, no, no squeeze. Like, that's not usually the answer. The athlete's trying to squeeze as hard as possible.

Dr. Yoni Rosenblatt: What other interventions can you throw at them to try to get them to your goal? To their goal? It's also gonna decrease the stress of the therapist. Looking at you, I don't know how many people are watching you on this pod, but they're definitely listening to you. You look insanely calm and relaxed. And I think that's because of that rubric, that foundation. I can adapt, I can adjust. I'm gonna be fine with whatever comes in. Just because they can't hit their quad set. I got a million ways to try to coach them to do that. I think that's why you look so relaxed.

Dr. Rayce Houser: Yeah.

Dr. Yoni Rosenblatt: Is that? You think so? Okay. [chuckle] That's what you think? Okay. So that's really.

Dr. Rayce Houser: Preparation and confidence.

Dr. Yoni Rosenblatt: There you go. I like that. Talk to me about dosing. How many reps, how many sets are you prescribing, say, of that early exercise recruitment intervention to decrease Arthrogenic Muscle Inhibition?

Dr. Rayce Houser: So I get a lot of people or a lot of patients that will actually think I'm crazy or kind of like chuckle a little bit when I say this, but let's say I see them, they're two days post-op and I see them for the initial eval. I will typically say, I need at least a thousand reps per day for the heel pops.

Dr. Yoni Rosenblatt: That's insane.

Dr. Rayce Houser: And when I look at it from like a motor learning perspective too, because like it's such a low intensity or stimulus overhaul exercise that like I can do a ton, a ton of reps and really not cause any sort of like overtraining or essentially anything like that. I'll typically start there with that. Commonly, I'm probably having them use some sort of strap assist to help them get into that hyperextension. And then depending on how that looks within session and how that kind of progresses, we may go to they'll use the strap to get up, squeeze the quad, release the strap. But a thousand reps per day, at least. And then...

Dr. Yoni Rosenblatt: How long are they holding?

Dr. Rayce Houser: Probably three to five seconds, somewhere in there. And then depending on how the quad looks that first session, I may hold off on providing straight leg raises maybe until like that second visit or maybe third. But typically, I'll commonly prescribe 250 straight leg raises and then I'm going to progress to 500 in a day.

Dr. Yoni Rosenblatt: Wow. That's a lot of reps, dude. How do you keep that out of their hip flexor? 

Dr. Rayce Houser: My thought would be if we start at 250, we gradually build our way up to 350 or sorry, 500. That will help with that. I also... I don't know how other people will have them do the straight leg raise. I will maybe have them go like upto at most maybe like 45 degrees of like hip flexion essentially. Just because I'm thinking in terms of the moment arm, in terms of gravity, like as that leg is going to get higher, like the line of pull is going to be less and less. I don't need them to get all the way to like 60 degrees. I think if I have more time under tension in those like higher level or higher lever positions, like that's probably going to give me a better indication of quad. And then from like a timing standpoint, like typically I'll be like hey, if you can heel prop beforehand, get into that passive extension.

Dr. Rayce Houser: That's thing number one to do. Once we've kind of opened that range, we'll backtrack a little bit. When they're in that position, let's say for maybe 10, 20 minutes beforehand, like put on ice, put on the TENS. If you have a home unit, do that. That way we get the extension. We now open up the motor neuron pool a little bit. And that's when we then get into the thousand reps per day essentially. I always tell them if it's not feasible or like timing-wise it doesn't work, regardless, just get your reps in. But in an ideal situation, if we can go passive range of motion with the ice and TENS and then get into the quad exercises, that will be sort of our best progression there.

Dr. Yoni Rosenblatt: And ideally, how many sets are you giving them to reach that almost unattainable rep count?

Dr. Rayce Houser: I won't actually give them a set or a prescribed set count. I just want them to hit a thousand reps. So if we needed to break it down into you have a 10-hour window, like I want you to get 100 in every hour, like we could do that as an easier way to track things. But my biggest thing is just like more trying to get a thousand reps in per day. Typically, I remember one of my first post-op ACLs I had here. She's a pretty tall, lengthy, like high school basketball player. And remember I told her day one on the eval, I was like, Hey, a thousand reps per day. She came in the next session, maybe a couple of days later, maybe the next day actually, and was heel popping immediately. And I know there's going to be some like nuance there in terms of like not everyone's going to be able to have that quick of a turnaround. But generally speaking, I will tend to see a much faster improvement in quadriceps recruitment with a much higher dosage of heel pops versus those who have lower. I've seen some PTs who will prescribe like 100 to 200. And like I said, my thought is just it's such a low stimulus exercise so I can dose this at a much higher volume essentially.

Dr. Yoni Rosenblatt: And that's because you're thinking far more motor recruitment or muscle recruitment than you are about a loading stimulus. So I think that makes a lot of sense. And for those listening at home, play with that hip joint angle because you'll feel your quadriceps work very differently when your butt is up against the wall. If you're sitting on the floor, how that quad works with a hip at 90 degrees when you're trying to do a straight leg raise, then you will when supine. And so playing with those angles, I'll also really dig my fingers into superior, like just above patellar distal quad, let's call it. Force them to try to focus on that, like try to squeeze that portion of your quadriceps so you know the patellar is locking down. That's I feel like a hallmark of patients being able to get that heel pop too often, they're pulling on their quadriceps but they're not setting their patellar down. And so that's when you're going to feel your hip flexor screaming as opposed to focusing or trying to focus on distal quad. When you tell them to set up their electric stim for NM rehab at home, where do you put those pads?

Dr. Rayce Houser: Typically, I'll go like kind of Superolateral thigh and then I'll go kind of distal anteromedial thigh.

Dr. Yoni Rosenblatt: Why do you do that?

Dr. Rayce Houser: I'm trying to get the largest sort of coverage across the quadriceps as I can. And I think essentially anything that's going to be more proximally located and more distally located, I think will be fine. But I'm thinking in terms of like volume, if I go a little bit diagonally, I'm probably going to get a little bit larger of a recruitment area versus just pure linearly essentially or in a straight line.

Dr. Yoni Rosenblatt: Two leads, one lead. What are you doing?

Dr. Rayce Houser: Well, I got two... One lead, two electrodes. I think they're like the 2x4 inches. And then yeah, just one on that distal aspect kind of inter-medially and then one kind of more Superolateral there.

Dr. Yoni Rosenblatt: Okay, any benefit to just smothering their entire quadriceps in pads? 

Dr. Rayce Houser: With like the two leads and like the four small ones or?

Dr. Yoni Rosenblatt: Four pads. Yeah, or even going four big ones and just covering their entire quadriceps.

Dr. Rayce Houser: I haven't seen anything in terms of the four big ones per se. I know they typically want the largest area covered in terms of like electrode size. I know at least University of Delaware's protocol I think is 2x6s. But I haven't seen anything in terms of using the 2x4s or 2x6s and going with four pad placement. I think one, it just might be too large of a stim pad unless you went vertically with it to essentially cover like that area essentially.

Dr. Yoni Rosenblatt: And then does there continue to be a benefit to keeping this electric stim and NM rehab process through your loading phases?

Dr. Rayce Houser: Research will tend to suggest that you should be using it probably up to like an 80% quad LSI. Which I mean for some people might take, could be four months, could be six months. So I mean it kind of depends on the individual. I will, if we're kind of struggling with like maybe we're like at four month mark and we're like at 70% symmetry. And like from there like quad strength is kind of progressing slowly. At that point I'm probably a little bit more inclined to start to reintroduce some of that again with NMES. I'll probably use it more like isometrically first or with some sort of isolated quad movement. But there's been a handful of times where I've used it with more like I'll quote functional based exercises with like squats.

Dr. Yoni Rosenblatt: Okay, so you will start to continue to include that or maybe even dust them off and bring it back in to force that quadricep on. I think that makes a lot of sense. I think that also bodes well for your chronic issues, right? Your tendinopathies, you better believe that that quad is not being totally engaged and using them in a functional manner. You don't just have to use stim with your quad sets or your straight leg raises. Like put them on there. And that's why I love some of the when you're able to use a trigger like a therapist help trigger that can turn the stim on and off. And you can put them in their ranges. It's also incredible. I'm doing this a lot with post-op Achilles now. Where I'm putting it all over their gastroc, the stim and having them move through functional movements. Even when it's not ankle dominant, even when it's an RDL, they should be able to use that quadricep or sorry that gastroc to prevent the forward force into force planar flexion. I'll be at isometrically to pull them out of their RDL. I've seen a lot of benefit there. So worth certainly worth thinking about. Okay, Rayce, you need to treat a billion patients at 10 AM. So we're coming up to the end. I just want to conclude with our Eric Cressy lightning round because I think there's, man, so much more knowledge between those years that I want to pull out. Ready?

Dr. Rayce Houser: Ready.

Dr. Yoni Rosenblatt: Here we go. Who is the absolute best physical therapist currently putting out social media content?

Dr. Rayce Houser: Best physical therapist putting out social media...

Dr. Yoni Rosenblatt: Don't repeat the question Rayce. Just answer the question.

Dr. Rayce Houser: It's so hard. I would say right now Zach Atwood has been putting out some good information in terms of ACL rehab. I know. I think he was a former guy who had ACL surgery. He's always put out fantastic information in terms of like AMI, quad strength testing numbers. So he's been a great resource for individuals who want to get more information in terms of ACL rehab.

Dr. Yoni Rosenblatt: Okay, so we got to check that guy out. Now, let me ask you this. If you tore your ACL, who's rehabbing your ACL? Don't say me. Don't say Tim Stone. Who's rehabbing it?

Dr. Rayce Houser: I'm probably going to go with my boy Joey Scambia down at IMG.

Dr. Yoni Rosenblatt: Okay, Joey Scambia. Well, we got to pull him up here to True Sports. Let me ask you this. Is it possible to isolate the VMO?

Dr. Rayce Houser: No.

Dr. Yoni Rosenblatt: Okay, that was so easy. Thank you for not repeating the question. Thank you for answering it directly.

Dr. Yoni Rosenblatt: So it's nuts. I'm working with NFL athletes currently that are, Yeah, I'm doing step-ups because that isolates my VMO. You think that is just total eyewash?

Dr. Rayce Houser: Yeah. Typically, I know from like the... I think maybe it was in the '70s or '80s or whatever when that research came out was saying like the last 15 degrees was like primarily VMO. But I think some of the newer research suggests that it's just like quad activation in general and we can't isolate essentially the VMO. So I'm not as concerned about that per se. Like I know in terms of like muscle bulk or girth, it seems to be the most affected. But I think some of that might be in relationship to AMI in terms of like which nerves are affected. So I think the big one that tends to be affected is the medial articular nerve, which innervates that anterior medial joint capsule. So that would be my suspicion in terms of why it seems like we get a little more atrophy in that muscle compared to other muscles of the quad.

Dr. Yoni Rosenblatt: Okay. But you're attacking that just by loading up the quadriceps with everything we've spent the last hour talking about.

Dr. Rayce Houser: Yeah.

Dr. Yoni Rosenblatt: Okay. That makes a lot of sense. Last but not least, what's your best advice to a newer clinician trying to figure out how to manage their time? You are a guy that has kept up with remote strength training, that has kept up with your own personal strength and conditioning, that keeps up with a busy caseload treating one patient every 45 minutes for 24 hours a day. What's your best advice as to how to manage it all?

Dr. Rayce Houser: I'd say the biggest thing is, one, I have so much stuff going on outside of just work itself that essentially I know I have to be pretty structured with my time in terms of I have this set of time or this much time allotted to being able to work out. I know during the weekend I need to devote X number of hours to be able to get these other obligations done. So I think having a looser structure in terms of how many hours you need to set aside for certain things that you want to get done in your life outside of PT can be helpful. You don't need to have a strict schedule all right, every morning I have to wake up at 4:00 to do X, Y, and Z. But it's just more hey, I need to devote four hours out of the week to do X, Y, and Z. I'll get it done as I have time. I think that will probably lead to a little bit less burnout. So that's probably my biggest advice, I would say.

Dr. Yoni Rosenblatt: Well, that's really good advice, and you've given a ton of it throughout this conversation. So thank you for your time, for your expertise, for your knowledge, for explaining to us how it is you do it all and keep it all straight. I think there's great stuff there. Tell this audience how they can find Rayce Houser and all the great content you're putting out.

Dr. Rayce Houser: So a big platform will be Instagram. You can find me @the_frontsquat_doc on Instagram. And then also me, Joey, and then two other residents, Taylor and Rob, we all started kind of essentially a PT platform together called Rehab Renaissance. So we are on Instagram there trying to put out some good quality information there. So those will be the two biggest places there.

Dr. Yoni Rosenblatt: Yeah, and it really is. It's unbelievable content. It's a great knowledge base. It truly is a renaissance of rehab. So thank you so much for sharing it with all of us, for all of us PTs that are trying to get better. Thank you so much to the audience for listening and for begging me to get Rayce Houser back on. He's a busy guy, but he is awesome at time management. So I appreciate you carving out some of that time. As always, please let us know what you want to hear more of, what you want to hear less of, who you want us to bring on. We got a list of some awesome guests coming up and thrilled to launch our ACL masterclass from table to field. So sign up for that. You can find that on all of our True Sports PT channels. Thank you so much, Rayce. Thanks, guys.

Dr. Rayce Houser: Thank you, Yoni. I appreciate it.

Dr. Yoni Rosenblatt: Yeah, man.


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