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Sep 07, 2023

Treating Hypermobility with Jill Zimmerman

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Dr. Yoni Rosenblatt: Hey guys, thanks for coming back to the True Sports Physical Therapy Podcast. My conversation with Jill Zimmerman, she is the owner of Perfectly Fit down in Charleston, South Carolina. She's an outstanding physical therapist who went to school with me a million years ago. And she does... She just has an awesome outlook on the profession. We dive into all things hypermobility, how you treat the hypermobile athlete, how you break things down, how important breathing is in teaching stability, and how to identify that which is hyper versus hypomobile throughout an evaluation. But really, there's some great insights in the way Jill just approaches her business, her life, her patients. She is so authentic in the way she connects. And you see it on all of her social media platforms.

Dr. Yoni Rosenblatt: And you see it throughout this conversation, I really think. So there's so much to learn here, both objectively or, let's say, clinically, from that which Jill Zimmerman shares with us. But also interpersonally, and the way you develop relationships, and how important that is for what we do for a living. I had a great time talking to Jill, catching up, learning about her place down in Charleston, South Carolina. I know you guys will too. So without further ado please enjoy my conversation with Jill Zimmerman.

Dr. Yoni Rosenblatt: Welcome back to the True Sports Physical Therapy Podcast. This, I think, is a first, and you're in for a treat.

Dr. Yoni Rosenblatt: I brought on a classmate of mine, someone who taught me so much 15 years ago when we were slaving away at University of Maryland, Baltimore, trying to figure out how we're actually going to become doctors and take ourselves seriously. And this girl was head of the class, top of the class, someone who I always tried to sit next to during examinations with hopes of passing. And so she finally agreed to come on the True Sports Physical Therapy Podcast. This is Dr. Jill Zimmerman. She is the owner of Perfectly Fit down in Charleston, and she's got a lot of awesome things going on. And one of the things that I loved in digging into her specialties is the way she treats the hypermobile patient.

Dr. Yoni Rosenblatt: This is a patient that has tortured me during my career. And so you're going to shed some light on how we treat this, it's called pathology or presentation? This presentation of hypermobility, because it can be certainly a blessing and a curse. So, Jill, first of all, what did I miss in your bio? Anything amazing? Tell us a little bit about how you got where you are.

Dr. Jill Zimmerman: Not much, but I'm thrilled to be on here. I'm so excited. It's great to see you again. Also to sit near you in class.

Dr. Yoni Rosenblatt: But not because of doing well on exams.

Dr. Jill Zimmerman: More because we just had so much fun. But anyway, no, I live down here in Charleston, South Carolina. I own Perfectly Fit. Not much more to it. I just, I see a broad range of clients. I see, I don't exactly specialize in anything. I like to keep it broad. I like to dabble on a little bit of everything. And, I don't know, I guess we'll just take it from here and see where it goes.

Dr. Yoni Rosenblatt: Yeah, but good intro. And so it's a good intro because when I first reached out to you, I was thinking more women's health. And once we dug into a little bit, I actually love that about you, that you do not "specialize in anything" but you take a really holistic approach to all of your patients. And that resonated with me. That got me excited to talk to you because I think when we niche ourselves really far down, sometimes, what is it? We lose the forest for the trees.

Dr. Jill Zimmerman: Yeah, you're stuck in the weeds.

Dr. Yoni Rosenblatt: You're stuck in the weeds, right.

Dr. Jill Zimmerman: Yeah.

Dr. Yoni Rosenblatt: So thanks for bringing me out of that. And that's why hypermobility, a little bit broad. But tell me how you define hypermobility?

Dr. Jill Zimmerman: Yeah, so hypermobility can be defined a few ways. There can be, obviously, isolated joint hypermobility that we can get through repetition. So swimming is a great example. High-level swimmers, they're going to get a little bit of hypermobility in their shoulder joints just by the nature of the sport. That's a little bit different than what we're talking about when we talk about some of these joint hypermobility syndromes. And there's a large spectrum of what that means. And, but basically, when you're talking about a syndrome, you're talking not just about hypermobility in the joints, which is a excessive range of motion, the joints higher than what we would typically expect. But you're talking about decreased elasticity in all of the connective tissues in the body.

Dr. Jill Zimmerman: Okay, so meaning when a tissue is stretched out, it doesn't necessarily come back to its original length as quickly or fully as a typical connective tissue would. So we have that in our ligaments. We have that in our muscles, our bones, our organs, our lymphatics, our urethra. So some pelvic floor stuff can be going on there. Anywhere in our body where there's connective tissue, our vascular system, so we can see blood pressure issues with people who have some of these joint hypermobility syndromes.

Dr. Jill Zimmerman: And Ehlers-Danlos Syndrome is just one example of a connective tissue hypermobility syndrome.

Dr. Yoni Rosenblatt: So that really opened my eyes because as I was listening to some of your workshops and your webinars on the hypermobile presentation, I never really understood why it was that my hypermobile athletes or my Ehlers-Danlos patients would have these cardiovascular issues, let's call them, but that makes a lot of sense. And then tying in the pelvic floor and tying in the digestive side of things, all of that is because there's just too much elasticity?

Dr. Jill Zimmerman: I think it's not enough elasticity, meaning it doesn't recoil.

Dr. Yoni Rosenblatt: It doesn't come back.

Dr. Jill Zimmerman: It doesn't come back, right? So it stretches, but it doesn't recoil. So for the vascular system, for example, they have trouble with venous return and blood pressure return, where it's like the vessels stretch out, but then they don't necessarily come back together. So blood pools, and they get dizzy, and they get lightheaded, and their body has to work extra hard to pump that blood through their system. So they're pumping out epinephrine to try to vasoconstrict, and then they get stressed out and anxious.

Dr. Jill Zimmerman: So it's like you can see how it bubbles up into these syndromes, and all of these different things are happening. And it's very misunderstood in the medical community, and people really feel that way. And they feel like nobody understands them, and they're just sort of at a loss sometimes by how and why all these things are interconnected.

Dr. Yoni Rosenblatt: And so that definitely describes a lot of the Ehlers-Danlos stuff that I've seen. A patient comes in, they're invariably anxious, on edge, sometimes more type A. It's interesting to put a pathophysiology on that as to why that is. So that clarifies a lot of things. And then also, that does, it's super helpful with the cardiovascular side. You're taking me back to school when we had to learn all that crap. Okay, so all of that starts to make sense. Now, in my world, the hypermobile patient, they're awesome at sports, their ability to reach end ranges, develop force or torque from those end ranges can be really impressive. I worked with a lot of professional baseball players, catchers, who are hypermobile, and they just sit in that squat like it's the easiest thing in the world. Or the gymnast, they have to be so mobile in so many ways, and then they come down with all these presentations. And that's what I wanted to dig in. So I wanted to present you this case of the adolescent gymnast who is so hypermobile and comes in talking to me about their low back pain. And maybe they have imaging showing a spondy of some sort, but their back hurts. And, how do you approach this hypermobile, clearly athlete, and how you're going to diagnose their low back pain? Walk me through that evaluation.

Dr. Jill Zimmerman: Yeah I think it depends too on whether or not you truly do have somebody who has one of these hypermobile syndromes, or if you have somebody who's really worked hard at their hypermobility. So do you have a hockey player who has really stretched out their groin so that they can get... Do their sport? Exactly. Do you have a baseball player who's worked on their splits and getting that range of motion at the end ranges that they really need? That's different sometimes than somebody who has a genetic hypermobility component to their entire system. So I would treat those two things differently. But if we're talking about somebody who does have more of this full genetic composition of hypermobility, somebody comes in, they have a spondy, I'm not exactly treating them or assessing them the same way that I would a typical client. I think you can appreciate that. You've said that this population is tricky.

Dr. Yoni Rosenblatt: Yeah.

Dr. Jill Zimmerman: They're tough. And the reason I say that is that they're gonna blow through range of motion tests. They're gonna blow their strength tests, their... Muscle-testing is not going to equate to what they're actually fully capable of. It's not going to match out. So you can't really go off of some of those objective measurements. And I go a lot more off of what I see. I watch people a lot. I watch them the minute they walk in the door. I watch how they're sitting talking to me. I watch their mannerisms. Are they holding their head up with their hands? Is their head on their chin? Are their legs crossed in their chair? Are they folded up and twisted up into a little pretzel? These are all symptoms of hypermobility. These are all ways, all that twisting, folding, knees up, that's ways to regulate their blood pressure. So they're all there for a reason. And it's just giving me information.

Dr. Jill Zimmerman: I'm looking at their posture. How are they holding themselves up against gravity? What is their strategy there? Not just is it upper cross, lower cross, whatever, but what is the strategy? What tension are they holding? Are they gripping? Are they in some sort of gripping or tension-holding pattern just to manage their body against gravity? Because they lose, they're sort of just constantly... Their tissues are constantly creeping. And they're not able to sort of hold that tension. And sometimes they'll over create tension in other places to compensate for that.

Dr. Yoni Rosenblatt: Let me ask you a question, Jill.

Dr. Jill Zimmerman: Yeah, go ahead.

Dr. Yoni Rosenblatt: Why is it so important to start noticing everything? What do you do with all that information?

Dr. Jill Zimmerman: It's just... What do I... That's a really good question. It just starts my brain thinking in terms of where I want the rest of the assessment to go. 'cause literally you could assess... I know everybody has their typical assessment. But you might want to tailor it into different places depending on what you see the minute they walk in the door. You'd be like, "You know what, I don't need to do range of motion tests. And if I do, I'm going to do it super quick because it's not really going to tell me a whole lot." So let's just do it to do it. I know it's going to be blown out of the park. But let's focus on some other things. So let's focus on, for example, with a hypermobile client, how does their pelvis move? How does their ribcage move?

Dr. Jill Zimmerman: Those are areas, to me, that are typically very restricted and don't move well in a hypermobile client. It's the reason why they've blown out the range in their joints because they don't move well proximally. And therefore, all the muscles that attach to the ribcage, all the muscles that attach to their spine and their pelvis and their sacrum, I'm sure you've seen this, they tend to be on lockdown a little bit with these hypermobile clients. And so they're weird because they're very bendy and flexible, yet they feel so stiff in certain areas and they feel like they have these knots everywhere in their body.

Dr. Yoni Rosenblatt: Okay, super interesting. I want to get back to what sounds like can be hypomobility in the face of this global hypermobility. But you make a great point with why you notice things because it's going to direct where you go next. And so this is something that I talk a lot about with my students, which is, "Stop just doing things to do things. Notice where you want to go and be exacting, be a surgeon, be a sharpshooter with what you do next because we only have so much time on the planet, let alone in your evaluation. And so you better be exacting." And that's what... Sounds like you do an awesome job of. As soon as they walk in, you're figuring out what happens next. What I also like to preach is I want to make the case to them when we're done with the evaluation. And so if I can say, "Hey, you know why you're sitting like this wrapped up like a pretzel? It's because of X, Y, Z." Now you've enhanced buy-in. Now they know, one; you give a damn 'cause you noticed everything. And two; you see all of them and not just their low back.

Dr. Jill Zimmerman: That's a really excellent point. That's an excellent point. I agree with that 100%. And it's not like, "Oh, I'm just trying to get buy-in." It's legitimate. It's real. It's authentic. It's there. But it also directs you, maybe I'm not going to do table tests and I just need to look at gross movement patterns. So I need to look at their squat, their hinge, their split squat, their bridging. It's like skip all the table stuff and let's just see how this person moves. Let's get to the meat of the issue and why they're here.

Dr. Yoni Rosenblatt: And I think that makes you a vet. I think that takes time to build that and realize, "Hey, this doesn't matter. This does matter." But to start out, you've got to notice everything. Now, does your spouse get on you like my spouse gets on me about noticing everything? Because I just, it's just a sickness, just like hypermobility.

Dr. Jill Zimmerman: I think about that though, and I think that there's certain brains and there's certain reasons that you and I have gravitated towards the field we're in and tend to do well at it. And it's definitely a big part of it.

Dr. Yoni Rosenblatt: Yeah, 'cause we're lunatics. So after you've noticed everything and you're thinking about working through that algorithm or your evaluation, so you know that the presentation standardly or often is hypermobility distally. And at times you can find these hypomobility proximally. So how do you start working towards that and identifying what is hypo and what is hyper?

Dr. Jill Zimmerman: Yeah, it's interesting 'cause you can do a toe touch on somebody, "Bend over, touch your toes." And a hypermobile person is going to absolutely haul on the floor, no issues, elbows even sometimes. But when you really break down where in that... What's really bending, what's not, you may find that there are areas that bend or curve more than others. And that's where you start to identify which part of the body maybe isn't bending quite so easily. So maybe even have them bend their knees, take their hamstrings out of it, and then see what their toe touch looks. Take out the areas of hypermobility so that you can see really where the hypomobility lies. And that's really my key, not just with the assessment, but it's the assessment that's gonna direct where the treatment goes 'cause that is the treatment.

Dr. Jill Zimmerman: The treatment is to calm down the areas of hypermobility, to limit, constrain, restrain that hypermobility. So we can focus a little bit more on those areas of hypomobility because the hypomobile segments and areas and just areas of lockdown and that gunky, not moving well, that's where the pain and the issues usually set in.

Dr. Yoni Rosenblatt: Okay, so, love that. So are you looking at this athlete and really just trying to identify what is tight because that's where you want to be?

Dr. Jill Zimmerman: Yeah, I don't know if it's... It's not really tight. It's not like I'm going around doing, finding trigger points and all that and like, "Oh, this is tight. Let's release that." It's more like I'm thinking more bones like, "What bones move well? What are the muscles that attach those bones? What do they look like? Is everything moving as a chunk or are we able to get that dissociation of movement?" And I'm trying to clear out some of those... That lack of dissociative movement in some of it and also create tension in areas that need it. So that's another component of it. So it's like freeing up the hypomobile areas and then building the necessary tension in the areas that just can't find it.

Dr. Yoni Rosenblatt: Okay. So what moves too much? What moves too little? And that which moves too much, you're going to try to do what? 'cause that's where I struggle. I'm good with, "Hey, you don't move enough. Here's how you move it."

Dr. Jill Zimmerman: Sure.

Dr. Yoni Rosenblatt: What do you do with that which moves too much? Their hamstrings are just like sloppy rubber bands.

Dr. Jill Zimmerman: You create, well, one; a sensory... People with hypermobility struggle with proprioception and sort of connecting with their sensory environment. So I'm trying to create restraints on a system that allows them to access the areas that they're unable to access or find tensioning. They're sort of taking that path of least resistance, and you want to help them find that point of resistance. So somebody might need to do, if they have those overextended, overflexible hamstrings, you need to find them some hamstring tension.

Dr. Yoni Rosenblatt: Okay. Yeah.

Dr. Jill Zimmerman: So when they do a forward fold, for example, instead of... They're just gonna flop over, and then you're gonna tell them to come up, and they're just gonna pull themselves right back up. From wherever they're pulling from, and they're not really connecting with the ground. They're just sort of flying through space. They're not... It's hard to tell where it comes from because they're such good movers. They're just like whee, right? So forward fold, have them bend their knees forward so they feel their weight go out of their heels and go more into their midfoot. Now they're grounded. Now they're in their midfoot. Now they're getting that internal rotation through their entire system. They're getting that compression that their body so desperately needs. And then you say, "All right, I want you to press through the floor, and I want you to push yourself back up without extending your knees."

Dr. Jill Zimmerman: So keep those knees co-contracted at that little bit of an angle. How does that feel different? And they can barely get up. They can barely move an inch because all of a sudden you are asking them to create tension in their system. And they're like, "What the heck's going on?" So it's really just dialing into some of their compensatory strategies and not letting them go there.

Dr. Yoni Rosenblatt: Okay. Yeah. Well, those are really awesome cues. And I see that a ton, that forward fold and that flop right back up. So I think that's a great way to approach that. And then I'll let the sports medicine... Everyone in the sports medicine community that's listening can... There are a million ways to take that. And how to load them, and how to progress that and how to regress that. Let's go all the way. Let's go one segment up towards the pelvis. 'cause that's something I struggle with is approaching someone like this with this presentation and teaching a core stability maneuver. What is the first core recruitment you go to? How do you teach it?

Dr. Jill Zimmerman: I love this question 'cause my thought process on this has changed so much over the last 10 years just...

Dr. Yoni Rosenblatt: You're better off.

Dr. Jill Zimmerman: Yeah. Right. Just completely changed. First of all, I look at the strategy they're currently using. So I always just start there like, "What's going on here?" So say we're doing, I don't know, a plank? What do you wanna look at? A bird, dog, a...

Dr. Yoni Rosenblatt: Dead bug.

Dr. Jill Zimmerman: Dead bug. Okay. Okay. So you look at a dead bug and you look at their strategy. Okay. So they start moving their arms and legs. What are they doing? Are they pressing their back down hard into the floor? Are they tucking their whole pelvis under? Is everything moving? Are they able to maintain that kind of stacked alignment? Are they losing the floor? What's happening there? It could be a number of different things there that's happening. Are they able to breathe and create a rib cage that's mobile and three-dimensionally breathing while they're holding that dead bug position? If not, then they're not at dead bug status quite yet. They're at like "Just lay on the floor with your feet on the ground and just figure out how to breathe in this position." And so I'm really looking at breathing. Yeah. Hypermobile people are great at... They're sort of that whack-a-mole they're just going to press their bodies into different ways to sense and feel. "And if I drive my back into the ground, then I can feel my abs working." That ain't the right strategy.

Dr. Jill Zimmerman: So sometimes if I see that, I'll put my hand underneath their back and I'm like, "All right, I want you to lift your leg. I want you to keep your pelvis neutral, I want you to lift your leg. And I don't want to feel any more pressure, the same contact pressure you feel in my hand right now. I don't want you to increase that pressure at all as that light comes up." So I'm going to take away their strategy of pushing their back into the floor, which is over-contracting rectus, upper abs and get them out of that strategy. And all of a sudden they get the reflexive stability that they're looking for. And they're getting those transverse abs to turn on because they're... I'm just taking them out of their current strategy of just trying to feel everything.

Dr. Yoni Rosenblatt: Their compensation, right?

Dr. Jill Zimmerman: Yeah, their compensation.

Dr. Yoni Rosenblatt: So, okay. Once you do that, how do you then take that... What's your cue for them to take that home?

Dr. Jill Zimmerman: It's actually surprisingly easy, they can put a very thin towel or even just sense... They can sense their own back on the ground because I'm going to where their back is touching the ground anyway, and I'm going to where maybe their pelvis and their sacrum is touching the ground anyway. And I'm saying, "All right, as you lift your legs, don't get heavier into the ground. Don't increase that pressure. Literally just lift your leg and breathe while you're doing that." And it's creating constraints to the system and a sensory experience that allows them almost to let go and just go with it.

Dr. Yoni Rosenblatt: Figure it out.

Dr. Jill Zimmerman: Figure it out. Yeah.

Dr. Yoni Rosenblatt: Figure it out. And most of these people, like you said, they'll learn, they're quick movement learners. So I think there's value there. Okay. So let's talk a little bit about breathing and tell me where does this fit in and why it's so important in teaching core stability?

Dr. Jill Zimmerman: Well the core isn't the abs. It's not... What makes up the core?

Dr. Yoni Rosenblatt: Jill, tell me what makes up the core.

Dr. Jill Zimmerman: All right. Well, the core is like your house. Okay. You got the top of the house is the diaphragm. And then you got the sides of the house, which is the transverse abs. You got multifidi in the back and then you got your pelvic floor on the bottom. That's the foundation, right? So that's a canister. It's a pressure management system. And we need proper excursion movement down of that diaphragm contraction down, which is going to create a lengthening or descension descending of the pelvic floor. And this is sort of this pistoning-type action of pressure moving up and down. And then an abdominal wall that expands and contracts to allow for pressure changes within the abdominal cavity. All of that has to happen. If we don't have all that happening, which by the way, requires a rib cage that moves well, if a rib cage doesn't move well, a diaphragm does not move well. And then the whole rest of the system doesn't move well, but we need all of that working together to get proper synchronization of the abdominal wall and that core working together dynamically.

Dr. Yoni Rosenblatt: Jill, there's so much there. So how do you tell, where do you start? Where do you start? Someone's not breathing well, they're locked up. They got a tight-ass T spine, they have a spondy because of it. What's your first breathing intervention?

Dr. Jill Zimmerman: Sometimes just bringing awareness to the fact that they have a rib cage. 'cause, I don't know if you remember, but in PT school it was sort of that wasn't talked about very much.

Dr. Yoni Rosenblatt: None of this was talked about.

Dr. Jill Zimmerman: Like a rib cage wasn't part of the human body.

Dr. Yoni Rosenblatt: No. We skipped that part.

Dr. Jill Zimmerman: It was like the heart sits in there, cardiac, but that's it [laughter]

Dr. Yoni Rosenblatt: They teach that rib stuff in Delaware. They don't teach it in Maryland.

Dr. Jill Zimmerman: Yeah, no, it was wild. So the fact... Anyway, so one; it's being aware of it as a clinician and then two; teaching your client that the rib cage does exist. Here's why it's important. Your scapula sits on your rib cage. So any kind of shoulder, neck mobility type stuff is going to require a rib cage that moves. And so just a simple one is just lying on their side, go ahead, put your hand on your side of your rib cage, cupping the bra line area and just breathe into your hand. And can you feel your ribs move? And where do you feel your ribs move? Front, back, sides? Are you getting it all? Or is it just moving in one part and not the other. And so can you inhale, can you get it to expand fully? And then on the exhale, can you feel it recoil back together? And if people can't feel that on themselves, which often they can't, I've had practice. So I'll actually get, with permission, tell them to put their hand on my body and I'll say, "Feel this, feel that." And all of a sudden they go, "Oh, okay. Yeah. I get it. I get what that means now." So I'm real hands-on because I want people to really be able to understand and appreciate some of these concepts.

Dr. Yoni Rosenblatt: Now, do you see interventions like that, teaching a patient... Teaching this patient, they can't breathe, they have the low back pain, they're high-level gymnasts, teaching them how to breathe decreases their symptoms?

Dr. Jill Zimmerman: Yeah. [laughter] It's actually, I do more rib mobility... Rib cage mobility breathing stuff than I do manual therapy now, because it's more effective.

Dr. Yoni Rosenblatt: Okay. And where'd you get that education and know-how?

Dr. Jill Zimmerman: Well, a lot of it started about 10 years ago. I started taking PRI courses through the Postural Restoration Institute. So I took a few of their classes and then that sort of just opened my eyes. And, that the fact that there was a rib cage, that the fact that there was a diaphragm, the fact that the things that's happening inside of our body is affecting the way that our outside of the body moves and functions and operates. It just really opened my eyes and gave me sort of permission to start thinking a little bit differently than what I learned in PT school and to start going in other directions after that. And I've just really dabbled in a bunch of different ideas after that. But it was the first time where I was like, "You know, this is different and it actually works. It's... "

Dr. Yoni Rosenblatt: There's something here.

Dr. Jill Zimmerman: There's something here. I don't have to spend 30 minutes breaking up soft tissue in the peck peck minor and scaling area. If I can just get somebody to expand better through the front of their rib cage.

Dr. Yoni Rosenblatt: Fascinating.

Dr. Jill Zimmerman: It's like you take the ribs, what's connected to those ribs, all of those muscles, they're not going to move well, the muscles are not going to change their length and the position that they're in. If their attachment point is not moving. Just think about origin insertion. So it's like when you breathe, you're changing that attachment point. All of a sudden you're getting more dynamic flow and less stagnation out of those muscles.

Dr. Yoni Rosenblatt: Okay. Now pull this all the way forward for me, they're out of pain, you're teaching a performance side of things. Does this become in competition or does this become warmup? How are you making this a piece of what they do? Their breathing patterns. How do you incorporate that?

Dr. Jill Zimmerman: I don't incorporate it until... I wouldn't incorporate into their actual training. But I think you can incorporate into warmups and I think you can incorporate it into accessory work. So you can... Say somebody is doing a row and say they're in a little bit more of this down chest, their pump handles dropped. And they're just... That's sort of more... Their shoulders kind of roll forward. That's the position they're in. Instead of rowing and exhaling. You might typically cue, you might cue a row and an inhale, because as they pull and they retract that scapula and they expose that chest wall, you want to go ahead and put some breath into that and encourage that expansion into that area. You can do that, but sometimes it's too heady and it screws people up even more, but if it seems to work well, you can do that, but it's more of the recovery accessory work side of things that I think that you could really throw it in there.

Dr. Yoni Rosenblatt: Yeah I think that's really powerful. You think about all the things that PT sprinkle on top of our patients, whether it be warmups or cooldowns or readiness and things like that. I think too often breathing is not emphasized enough. What a great way to affect all of these tissues in terms of the way they move and the way they affect all the joints, especially the offending joints. So let's shoot all the way back to the core. And so I think you did an awesome job of walking me through how to teach a dead bug properly, or at least those beginning steps. How do you then with all of these theories in mind of keeping that core and that cylinder solid and isolating or accentuating the proper muscles to provide that stability, walk me through how you get them to standing and then to loading.

Dr. Jill Zimmerman: Yeah. I don't know if I quite... I don't think about it as much like that anymore. I don't totally think about, "Let's create this solid chunk of core stability and then let's stand them up and keep this perfect alignment." To me, it's more like the whole system is working together like I talked about before with the forward folding coming up out of it. When you find that pressure through the ground, you are going to get that reactive reflexive stability that comes with it. So, I think I just teach now more... I don't know how to quite answer this, but I think that when you...

Dr. Yoni Rosenblatt: I don't know if that's a sign of a good question or a bad question, but noted.

Dr. Jill Zimmerman: So say you're doing a deadlift, my focus is not so much on... Obviously if you're lifting extremely heavy weight, fine. But if I'm just teaching your average person to deadlift something, some sort of weight off the ground, I'm not necessarily hyper-focused on "brace your core". I'm probably going to be more focused on, "Let's make sure that person can hinge really well. Let's make sure they understand how to set up into a hinge with their pressure through their foot." And they are getting that good tension in the ground. They're working on eliminating that muscle slack. They're really connecting to what they're doing. And reflexively that core will just kick on, especially if you're allowing them to breathe. And so maybe the only thing I do is while you're sort of set up in this isometric at the bottom, perhaps start there. And let me just have you take some breaths. And as you're breathing in, I want you to just focus on maybe just that rib cage just expanding laterally. And then when you exhale, just let soften back in side to side and just let those ribs come together, come together, come together, come together, come together, hold. All right. Take another breath. Let that breath go into the sides. And the breathing while they're in that position tends to do the work for you because core canister.

Dr. Yoni Rosenblatt: That's what it's made to do.

Dr. Jill Zimmerman: That's what it's made to do.

Dr. Yoni Rosenblatt: Yeah. And then how do they know they're doing it properly? What are they supposed to feel?

Dr. Jill Zimmerman: Something different. So they're typically going to feel something completely different than they've ever felt before. Whenever they've done this exercise with anybody else that they've done it with. Oh, and they'll gas out like that. They'll be like, "Oh my God, my... Ah I could feel my butt muscles and my glutes and my... And I feel my abs and I've never felt my abs," and it's, "Usually I feel my back." And that's their feedback. That's their internal feedback that they are in the right position. And if they can't find the right position, there's a thousand different sensory cues and modifications and restraints you can put on them. And that's a whole different rabbit hole, but that's the idea is to try not to use as much of that stuff as possible and just use the internal system to figure it out.

Dr. Yoni Rosenblatt: That's super cool. Now, how are you measuring their progress? Like you said, this is tough because they have all the motion in the world and depending on how you test them, they might show good strength. How do you gauge progress?

Dr. Jill Zimmerman: That's a good question. How do I gauge progress? Yeah. 'cause I'm not taking objective measurements so much. Sometimes what you'll actually see is a loss of mobility and that's probably not a bad thing as long as they're feeling better. So they're feeling better is one, two; they might actually get a loss of range of motion. The reason is you're starting to build more tension in that system and it's holding some of that tension in a good way. In a way that's sort of supportive. Mostly they'll lose range of motion a little bit, maybe perhaps, but mostly they'll feel better. They'll feel less of those tensioning knots. They'll feel stronger. They'll feel more supported. They will be able to lift more without some of these compensations. You'll just see their movement patterns change, which to me is progress. That's huge. All of a sudden they're not so sinky and droppy in their hips when they're on one leg or a split stance position there's just... You start to see they look more organized and they look more supported. And to me, that's a win.

Dr. Yoni Rosenblatt: Yeah. I think that's awesome. Have you looked into adding any objective measures for this population that you think, hey, I can come back to this and retest it and show them, show the insurance company or show someone that they are objectively improving?

Dr. Jill Zimmerman: I know, it's a tough one, isn't it?

Dr. Yoni Rosenblatt: It is.

Dr. Jill Zimmerman: It's a super tough one. I struggle with objective measurements 'cause everybody's just so... Especially with this population, it's just very, very difficult. Because even if you just do a standing rotation test, they're gonna blow through it. It is a quality of movement thing for me. I don't know. I don't know. I'd have to really sit and think about that one.

Dr. Yoni Rosenblatt: Yeah, I wonder...

Dr. Jill Zimmerman: I know.

Dr. Yoni Rosenblatt: What does something like isometric hold...

Dr. Jill Zimmerman: I suppose, I was just going to say that. An isometric hold, you could time an isometric hold and measure it until they lose form or something. You'd have some sort of force.

Dr. Yoni Rosenblatt: Or a force. If you're using a 10 deck or you're using a crane scale, if you don't want to get so fancy that you don't want to get any force plates or anything like that, how long can they hold a given output? You got to get really good at pulling away their variables by taking away their ability to cheat. I had a professional field goal kicker, and he had a torn rectus. And so I rigged up the force plates that we have so that he's sitting in the couch stretch, but driving his knee into extension on a plate that's elevated behind him. There are a million ways to try to achieve that, but you try to put the foam roller here and then how can you recreate that to show him, to show everyone, "Hey, this guy's better." Or, "By the way, he's ready to get back kicking field goals from 65 yards." So it takes time. Not everyone has forest plates.

Dr. Jill Zimmerman: Yeah, it's a tricky one. I think it'd be cool to do. In both, a yielding capacity, but also an overcoming capacity and compare the difference between those.

Dr. Yoni Rosenblatt: Yeah, love that. And I think that that would be really interesting. I saw, DorsaVi, have you used any of their stuff?

Dr. Jill Zimmerman: Mm-mm.

Dr. Yoni Rosenblatt: They're like... They are a wireless marker system that looks at movement and we use it for runners. It's awesome. You can put... It takes like five minutes to set up, if you put a couple markers up and down their legs on their low back and they can go for a run, and then they come back and you have all this data. So our running experts down in Fell's Point use it, which is awesome. But they also have a readiness return to sport. So it looks at side plank, it looks at front plank and it will measure the smallest amount of movement for these hypermobile people. Maybe that's worthwhile to look at how long can they properly hold it. 'cause I think the eyeball test, these guys are gonna teach it.

Dr. Jill Zimmerman: Yeah. Yeah. But it's tricky. 'cause then you're still adding in a non-objective component. How long can they properly hold it because yeah they can teach it, it can look really good. And that's why a lot of these people go under the radar and they end up with injuries because they're like, "Yeah, even though I've been doing all these classes or whatever, and everybody says I look great." And I'm like, "Well," [laughter]

Dr. Yoni Rosenblatt: They don't know what they're looking at.

Dr. Jill Zimmerman: "Let's break this down a little bit more." It's easy to just look at something and think it's, but it goes deeper than that.

Dr. Yoni Rosenblatt: Yeah. Yeah. For sure. So maybe there's something there. I can't wait to see the Jill Zimmerman scale or something where you come out with a way to do that. [laughter] I think that would be really, really freaking helpful. Okay. Let's get a little bit more general. Tell me some of the mistakes that you see when teaching core stability.

Dr. Jill Zimmerman: Well one I've kind of already mentioned, too much focus on isometric core contraction. I think that's an error. I think not thinking about it dynamically, thinking too static, like I said. Not addressing the mobility and its just going... It just keeps going back to the same stuff. Not addressing the mobility of the ribcage, mobility of the pelvis in all three planes of motion. Do they even have it available to them? Because if they don't, then that dynamic core function it doesn't even know where to go. It doesn't even know where that range would be...

Dr. Yoni Rosenblatt: You're not gonna get it.

Dr. Jill Zimmerman: In a controlled way. Exactly. You're not gonna get it.

Dr. Yoni Rosenblatt: Yeah. And I think you're right. As a profession, we do such a good job of getting ahead of ourselves where we get too fancy, we miss the basics and the athlete can't do this baseline and we're asking them to do this. So how the hell are they gonna be successful up here? You make a great point with, "Can you breathe? And if you can how are you teaching that?" So I think there's gold there and I love hearing your kid in the background. Don't worry about that [laughter]

Dr. Jill Zimmerman: Yeah. You heard that? Yeah. And, yeah. And just thinking about just the anterior posterior tilting. Do they really have control of that pelvis? Or when they go into an anterior tilt, can they really eccentrically, lengthen their abs? Or do they just start pulling from their back? It's like the whole system works as sort of this pulley system so it's really understanding all that too.

Dr. Yoni Rosenblatt: Yeah. And you know who does a good job of that? Have you taken any TPI courses or OnBaseU.

Dr. Jill Zimmerman: I haven't taken any courses, but I've sort of dabbled with speaking with people. Yeah.

Dr. Yoni Rosenblatt: So that stuff is awesome. It looks at the quality of control of your anterior and posterior pelvic tilt and your rotation. What does it look like and how well can the athlete maintain that? It's huge with pitchers. And so much of that, that which we see. So that's cool. Now, to move away a little bit, clinically, one of the other things that I just have loved about watching your career is your endeavor into private practice. So tell me a little bit about that. Did you always know you were gonna do this and open up your own practice in Charleston? Not in Charleston, but.

Dr. Jill Zimmerman: Anywhere? No, I did not always know I was gonna do that. I think that there was a part of me somewhere deep that knew that that was gonna happen. But there was the other part of me that was like, "You're never gonna actually do this."

Dr. Yoni Rosenblatt: Yeah. 'cause you never told me when I was planning it you never told me that you were gonna...

Dr. Jill Zimmerman: No, no, no, no. It wasn't something I ever... I was always like, "Yeah, that's what other people do." But then I got into working with... In outpatient clinics and all that, and I just... I never quite got along with my bosses [laughter] I always had sort of something to say, something that I thought could be done better. Something... [laughter] I always had opinions [laughter] on the way the business was run. And I don't have any business background, but I started to realize, "Maybe I do have a say in this," and, "Maybe I do care about the way that I practice and don't wanna be told how to do it a certain way." And it really started to affect me personally. I was really struggling with work and I loved helping my people and I loved my patients, but I really struggled with the job...

Dr. Jill Zimmerman: Of working for other people. And I just said, "I gotta do something." And I just got really lucky with the situation I'm in. I actually ran into my friend Dr. Sarah Duvall, who runs Core Exercise Solutions. She's a big pelvic floor therapist. And she was running Perfectly Fit before I acquired it. And I ran into her and I just moved to Charleston, she already had it up for a year, and she goes [chuckle] she goes, "You're not like the other PTs here." She's like, "You, you're different." She's like, "Let's chat." And so her and I started chatting and she's like, "Let's partner." And I was like, "Okay." And then we're talking about partnering and she's like, "Well I'm pregnant and my husband lost his job and we need to move. So, can you just buy it." [laughter]

Dr. Yoni Rosenblatt: Jeez. Okay.

Dr. Jill Zimmerman: And I was like, "Uh, well okay, yeah. I'm going to, I'm gonna figure this out. I'm gonna make this happen." I'm totally freaked out and I'm totally nervous but I have to do this. There was a part of me that was like, "You cannot say no to this, you are a total dumbass if you say no. You have to make this happen." And my husband was super supportive. He was like, "I'll do your web... He's a graphic designer, I'll do your website. I'll do all the branding stuff." He just started taking things off my plate and I was like, "Huh, okay. I can do this now." But it was intimidating.

Dr. Yoni Rosenblatt: Yeah. It's super intimidating. Okay, so that was how long ago?

Dr. Jill Zimmerman: 10. It'll be 10 years in October.

Dr. Yoni Rosenblatt: 10 years. Congratulations.

Dr. Jill Zimmerman: Thank you.

Dr. Yoni Rosenblatt: That's incredible. And so tell me about Perfectly Fit. What's it like being a patient there? What's it like being a PT there?

Dr. Jill Zimmerman: Yeah, so it's a very small studio space. It's not a big gym. We don't have a ton of equipment. It's just very one-on-one, very hands-on. Very... People come there and they know that somebody's gonna listen to them. Okay. They know that somebody is going to think differently than some of the other professionals or medical personnel that they've seen. Someone's going to look a little bit deeper, look outside of the area that hurts, figure out some other things that are going on. Someone's gonna look at them globally. And not just look at the issue at hand, but look at, "How can I get this person moving better and functioning better in their life in a variety of different areas." And feeling better for a lot... For like a lifespan.

Dr. Jill Zimmerman: It's more of a lifespan idea. And it's about trust. I have very very very close relationships to all of my clients. It's very much a place... It's a safe place, I would say, people feel really welcome there and really listen to, and really I can't tell you how many people are just like, "I wish I found you like 20 years ago... "

Dr. Yoni Rosenblatt: That's awesome.

Dr. Jill Zimmerman: "I can't believe I wasted all this time and money doing all these other things." And not that I'm... I'm not the best PT ever.

Dr. Yoni Rosenblatt: That's right.

Dr. Jill Zimmerman: That's [laughter] but I care a lot. And I have taken courses that up my skill level. But, the point is, is that you just have to be there for people. And that's what I really try to hone in on.

Dr. Yoni Rosenblatt: How'd you figure that out? Because I agree with you, it's 95%. It's 95% getting a patient better. So how and when did you figure that out?

Dr. Jill Zimmerman: I don't think it was an epiphany. I think it just, honestly, and I don't wanna sound like... I'm not arrogant about it, but it's something that comes naturally to me. And I think that's why it... I just knew when I made the transition into being my own boss, I knew it would work for that reason. I knew I could hold onto clients more for my ability to connect with them than for my... I could learn, I can learn whatever. I can go and take more classes, I can learn more things. But I knew that I would have client retention based on my ability to connect with people. And I just, I don't know, it's just part of who I am and I'm grateful for that 'cause I think that it has really, really helped me keep and grow my business.

Dr. Yoni Rosenblatt: Yeah. Well it comes across in this conversation. It came across in school obviously, it comes super natural to you. I do think it can be learned. I think you're lucky that it comes really naturally to you. How do you now balance your clinical and administrative duties?

Dr. Jill Zimmerman: Well, I keep my administrative duties very, very minimal.

Dr. Yoni Rosenblatt: That's awesome. How the hell do you do that? We need to do a separate part on that. So I get to...

[overlapping conversation]

Dr. Jill Zimmerman: Well, I don't have a ton of employees. I've purposely not grown my business in that way. I have a touch of a little bit of a control issue. And I like to keep it small. I like to have... I just like to know what's going on. And I don't like to be pulled in too many different directions because I become very easily overwhelmed. So I have to keep it very simple. And I have a accountant and I have a biller and I have a system that I do my scheduling through. And I pay the people to do the things that I don't wanna do. And, I have a couple employees that I just keep the way that I pay them very easy and simple. And I've just sort of streamlined the process. 'cause that was a concern with me when I was transitioning. I was like, "I don't know how to do any of this stuff." And Sarah was just like, "I've already got it. It's so simple. I'm gonna show you how simple it is. So you have nothing to worry about." And I've just tried to keep it that way the whole time. So.

Dr. Yoni Rosenblatt: That's awesome. And...

Dr. Jill Zimmerman: I just know myself and I know I can't... I just know where my limitations are and where my overwhelm will come from and I have to keep it simple. [laughter]

Dr. Yoni Rosenblatt: That's awesome. And a great lesson in and of itself. So where is this practice in five years?

Dr. Jill Zimmerman: Well, the practice has not changed much in 10 years. I have changed a lot, I would say. But the physical space, the equipment we have, I don't buy a ton of equipment. I like just keeping it very simple, like I said. So the physical space has not changed much. What I bring has changed. I am, ever since the pandemic, I've started doing a little of online side gig business, trying to grow a online business where I teach and mentor other professionals and also provide some coursework and classes for non-professionals as well. I would like to grow that a little bit to get to the point where I have some supplementary income that doesn't require me physically being with people. I do want to continue to do that. I will not give that up. But, as you get older, you wanna maybe do a little bit less cut down and still feel like you're comfortable [laughter]

Dr. Yoni Rosenblatt: Yeah. Yeah. For sure. For sure. Okay. So are you in-network with insurance when you're treating in the office?

Dr. Jill Zimmerman: I am not.

Dr. Yoni Rosenblatt: Okay. So How long are sessions?

Dr. Jill Zimmerman: An hour.

Dr. Yoni Rosenblatt: Okay. One-on-one for an hour. How many PTs?

Dr. Jill Zimmerman: I myself, and then I have a PTA and then I have a trainer. So I have this model of... We move people around.

Dr. Yoni Rosenblatt: That's super awesome. And do you sell memberships, you sell packages?

Dr. Jill Zimmerman: I do. So I sell... Most of my clients have committed to packages and I do packages of 10, and then the trainers will do packages of 20.

Dr. Yoni Rosenblatt: Okay, and where are you getting patients from?

Dr. Jill Zimmerman: Word of mouth.

Dr. Yoni Rosenblatt: Word of mouth.

Dr. Jill Zimmerman: Yeah. I have very few doctors who will refer to me 'cause they'll be like, "Oh, I'd love to send people to you, but you don't take insurance, so I can't." And I'm like, "Well you can, you just won't." Let's just call it out. It's [laughter] yeah, so I don't go that direction. It's not worth my time. I will have some clients who are like, "I told my doctor about you." And I'm like, "That's great I'll see if they read... " But it's mostly word of mouth through patients talking to each other. Massage therapists, acupuncturists, other people in the industry who would see my clients. So I have a cash pay client. Where is my cash pay client also going to, well, they're probably seeing a massage therapist. Maybe they have a tennis coach, maybe they have a golf instructor. Who are those people that they're also seeing? Acupuncture, whatever. And then maybe I can network through them and we can pass people around. Yeah.

Dr. Yoni Rosenblatt: Yeah. Yeah yeah. Smart. Okay. So first of all, man, you should have done your own pod because you're so good at this.

Dr. Jill Zimmerman: Thank you. [laughter] I still can.

Dr. Yoni Rosenblatt: You still can. Well, you didn't mention on your... Okay. So let's do a lightning round. I want quick answers to the following questions. You ready?

Dr. Jill Zimmerman: Okay.

Dr. Yoni Rosenblatt: What's the biggest professional mistake you've made and what did you learn from it, Jill?

Dr. Jill Zimmerman: My biggest professional mistake might be just kind of going a little too deep down into some rabbit holes and not really pulling myself out quickly enough to see the very obvious answers. You just kind of get down these rabbit holes and you're going, "God, I'm so tangled up in the weeds." Like, "I'm missing this obvious stuff." So I think what I learned from that is that you gotta sort of stay in the present moment sometimes, and you can't get too in your head about these things that you've been learning and what you've been doing or things you wanna practice or try out and just see the person in front of you.

Dr. Yoni Rosenblatt: So is that clinical or is that professional?

Dr. Jill Zimmerman: Well, define professional for me. [laughter]

Dr. Yoni Rosenblatt: Is that clinical or is that business?

Dr. Jill Zimmerman: I would say it's clinical.

Dr. Yoni Rosenblatt: Clinical. Okay. Give me the biggest business mistake you've made and we'll learn from it.

Dr. Jill Zimmerman: Oh, man. Business.

Dr. Yoni Rosenblatt: Business.

Dr. Jill Zimmerman: My business, my business. [laughter]

Dr. Yoni Rosenblatt: Don't date yourself, Jill [laughter] that's gonna be our number one downloaded segment.

Dr. Jill Zimmerman: Wow. I don't make a whole lot of business decisions. This is the funny thing, Yoni.

Dr. Yoni Rosenblatt: How do you do that? How do you do that?

Dr. Jill Zimmerman: It just runs itself. I hate to say that. It's just, it just like... Well, and I'm not sitting there like you, I'm not building seven... How many different locations do you have now?

Dr. Yoni Rosenblatt: Jill that's not important.

Dr. Jill Zimmerman: Right. But my point is I keep it very, very simple.

Dr. Yoni Rosenblatt: That's a freaking skill. Give me a mistake. Remember that time you bought the blah, blah, blah, and you wasted all that money?

Dr. Jill Zimmerman: I don't buy a lot of things. I'm trying to think. I mean, the biggest mistake I can say is... They're personal mistakes through my business. Like I showed up at work after having a baby and I shouldn't have and I...

Dr. Yoni Rosenblatt: There you go.

Dr. Jill Zimmerman: Didn't... I should've listened to my body and that was a big mistake of not sort of saying, "Do you know what it's okay to walk away from this business. It's okay to take some time. Trust that the business will run itself. Everything will be okay. You're gonna come outta this." I didn't, I was totally freaked out and I pushed myself too hard and I should have trusted that everything would've been okay at that time instead of pushing myself.

Dr. Yoni Rosenblatt: I'm so happy I pushed you on that question, because that's an awesome answer. And there's so much in that answer. And it's something that I fight all the time is how do you let go? How do you have faith in the decisions you've already made? And the sacrifices you've already made, that you set something up for longevity and for success, and it doesn't need you in that office at all times. Your kid does, or your husband does, or whatever. Or you do, you need your own space. So.

Dr. Jill Zimmerman: And I learned a lot from that. And it made me set better boundaries afterwards of time off and my own needs. I came outta that experience going, "Wow, I did not handle that well. And I need to set better boundaries moving forward because I've got a kid now and a family and other... And it's just it is what it is, and we all have to share. There's only one me [laughter]

Dr. Yoni Rosenblatt: Yeah. And it's a great thing. Okay. So that's awesome. Give me the biggest misconception of private practice.

Dr. Jill Zimmerman: That they're all the same.

Dr. Yoni Rosenblatt: Yeah, they're not.

Dr. Jill Zimmerman: Yeah, they're not. They're not.

Dr. Yoni Rosenblatt: Okay. Good answer. What's the best book you've read in the last three years?

Dr. Jill Zimmerman: Had a couple. I liked that 'Breath' by James Nestor, talking about all sorts of breathing stuff.

Dr. Yoni Rosenblatt: Of course you'd love that.

Dr. Jill Zimmerman: I know.

[overlapping conversation]

Dr. Yoni Rosenblatt: I'm surprised you didn't write that. [laughter] What's the other one?

Dr. Jill Zimmerman: Jill Miller actually just came out with a book called... Oh, what is... Oh, shoot. Something about Breath.

Dr. Yoni Rosenblatt: [laughter] Yeah. Oh really?

Dr. Jill Zimmerman: [laughter] And then I had this other one actually. Oh, Jill Miller... Oh, 'Body By Breath'. And then there's this other one called 'The Revolutionary Trauma Release Process'. And it was all about releasing trauma through physical movement and shaking of the body. And I just loved it 'cause it was so outside of... It's probably not like super based on a lot of research, but I was like, "You know what, these are things that if they feel good in your body and they provide a sensation and a feeling that you're typically not holding in your body, then who's to say that that's a bad thing?" I think it's probably beneficial. So I just like to read things that kind of challenge the norm a little bit.

Dr. Yoni Rosenblatt: That's cool. And I'm not surprised by that, but that's really cool. Okay. So for someone who it sounds like is really specific or exacting about what they do buy for their practice, what purchase have you made for your practice that has been impactful?

Dr. Jill Zimmerman: Continuing education courses. [laughter]

Dr. Yoni Rosenblatt: Good answer. That's a good freaking answer. You think you're not answering my question, but you really are. Because it's about the service we provide. And I harken back to, I had this annoying-ass conversation when I was your classmate with a business owner because I was obsessed with trying to open a business and he owned the PT clinic. And I went over to him and I said, "Hey, how do we do this? How do we do that? How do you charge? How do you bill, how do you market? How do you... " He's like, "Just go become a good PT."

Dr. Jill Zimmerman: [laughter] Solid.

Dr. Yoni Rosenblatt: "Shut up and become a good PT."


Dr. Yoni Rosenblatt: So, but that's what you're saying too, Jill. That's what you're saying too. That's what it's about. If you can provide outstanding services, you're gonna have an outstanding practice. So you...

Dr. Jill Zimmerman: And connect with people.

Dr. Yoni Rosenblatt: Connect with people. Show 'em you care. Show 'em you fucking care. Okay, Jill, you have been a revelation just like you were 15 freaking years ago in downtown Baltimore. So thank you so much for your time...

Dr. Jill Zimmerman: Yeah, thank you.

Dr. Yoni Rosenblatt: And for your knowledge. This was really freaking awesome and I know the audience got a ton about it. As always, give us your feedback. Jill wants to know how she did. I wanna know how I did. Hit me on Instagram True Sports PT, or send me an email on Thanks for listening guys.

Dr. Jill Zimmerman: Thank you.


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