By Ansley Bucknam, MTI Contributor
As a PT student in 2023, I am inundated with the internet as a means of learning alongside my didactic education and clinical experiences. This is a blessing, as I can find a podcast, blog, or social media post on virtually any topic I learn about in the classroom.
But it can also be a curse, as I learn about exercises in my lab courses that Instagram “warns” against doing. I learn about modalities that the internet swears are simply a placebo. Furthermore, the limited number of patients I have treated and my infinitesimal experience in real world treatment have taught me the nuanced aspects of rehab that sharply contrast with the concrete “black and white” answers I so desperately crave as a student.
One of the education requirements for obtaining a doctorate degree in physical therapy includes going out and getting clinical experience. Essentially, it involves taking the theoretical knowledge gained in the classroom and applying it to some crucial and much-needed practical experience. For my program, we are required to spend 40 weeks on clinical rotations before we are able to graduate and sit for our national board exam.
I just got back from my first 8-week rotation in an outpatient orthopedics clinic. 8 weeks later, and I am by no means (nor will I ever be) an expert on all things PT. 8 weeks later, and I don’t feel “all the wiser.” Ironically, it’s quite the opposite. I found there is more out there that I don’t know than I actually do know, but that fact in and of itself is the beauty of a career in PT. I’ve reflected back on my experience and compiled a few (of the many) mistakes I found myself making and some of the insights I gained from them.
I can remember learning about pain provocation tests in my second semester of PT school and asking my teacher why I would ever do something that would hurt my patients. She looked at me pretty confused, and replied, “If we don’t know what provokes their pain, how can we even begin to help them resolve it?”
Fair enough. Fast forward a year later to my first clinical rotation, and I was still pretty hesitant to give my patients any exercise that brought on their pain. My thought process? I wanted my patients to like me and thought they sure as hell weren’t going to like someone who hurt them. So for every painful shoulder or knee that came in, I’d start off with pretty low-level exercises (think isometrics and bands that were way too light) to avoid any reproduction of their pain. If pain was the front door, I was standing in the yard, maybe even across the street, as far away as I could get from it.
Now, these low-level exercises were a great first step when using them as an entry point while pain levels were heightened and injuries were highly irritable. But once the pain calmed down, we had to progress past this entry point. I began to realize that we were going to need to push into this pain a little bit if we wanted to make any headway. Did I need to kick the front door down? No, as kicking the door down would be just as productive as standing across the street. But I did need to start walking up the steps to the door, maybe even knocking on it.
Towards the end of those 8 weeks in clinic, I became more comfortable knocking on that door, peeking into the window at their pain. I still utilize those isometrics and banded exercises early on, but once we start pushing into more of their familiar pain, our conversations when doing an exercise sound more like, “Okay cool, that’s your pain? Good– let’s find a tolerable level and hold there.” If the pain increases exponentially, I’ll chime in with, “Alright, let’s back off a little bit.”
And then we monitor pain responses over the next 24 hours. Tendons, a pretty common source of pain in the shoulders and knees, tend to respond 24 hours later to treatment. So I ask patients to monitor what their injury feels like at that 24-hour mark and report back. Super painful? We may have stressed the area too much. Does it mean we further damaged the area? Nope. It’s just the body sending us a message, one that gives us a map to guide our next session.
Pain is the primary reason patients seek out PT. Of course, pain shouldn’t be the aim in rehab, but it can (and should) be my guide in rehab. I won’t (ever) promise that I have the magic solution or quick fix to “solve” your pain. But we are going to chase that pain a little bit, knocking on the door of it, and pushing into a tolerable amount. Through this chase, we can leverage pain as a means to elevate the pain threshold and enhance an individual’s capacity for movement.
Stretching Every Patient Who Complains of Stiffness/Tightness
A large majority of patients come in with the primary complaint, “My (hammies, quads, calves, back, you name it) feel tight or stiff.” So I would just do some contract/relax to help “loosen” the muscles, thinking that these small contractions were enough to make a change in their tissue tolerance.
Now, there are some of these people for whom prolonged stretching can be indicated, instances where there is a true mobility limitation or tissue restriction. But even in this situation: only stretching the tissues likely won’t create lasting change. We can stretch, but we have to then load the body in that position of newly gained mobility for it to stick.
What do I do differently now? I help patients understand that stiffness is just a message your body is sending you. Those tissues could be truly lacking mobility, or (and this is more likely), those tissues are weak or underloaded, so your body sends signals of stiffness in an attempt to “protect” the area. Thus, we can load it and patients often report less feelings of stiffness and familiar pain as rehab progresses.
What can this look like in rehab? Let’s take the dreaded tight hammies.
- We load the hamstrings with something like an RDL. RDLs load the hamstrings in a lengthened position. This forces the hamstrings to overcome the demands of the external resistance while simultaneously moving through their full range of motion.
- Thus, when we try to touch our toes the next time, without the barbell or DBs, it may feel less stiff/tight.
- Why? Because over time, our body adapts to the stimuli we expose it to. Are we truly changing the length of the hamstrings when we do RDLs? Likely not. But challenging the hamstrings – by adding external load through the muscle’s lengthened state- contributes to a greater mental and physical capacity for that “stiff/tight” sensation- a major win in my book.
Not Doing the Basics First
When scrolling through social media accounts featuring fitness and PT, I often found myself saving the super complex movements and the nitty gritty, sport-specific glam to a lovely little collection, eager to try them out on my patient the following day. None of these methods or videos were inherently bad. It’s just the context in which I used them, and oftentimes there was a more straightforward way for me to accomplish the task at hand.
All the fancy stuff I saved? It was just upping the complexity, and I often upped it when patients weren’t quite ready or simply didn’t need complexity as a progression to achieve their goal. Complexity is simply a way to progress, and should be utilized for just that: to progress movements (not to make something more complicated just for the sake of it).
It’s still tempting to rely heavily on these more complicated collections I’ve saved because this is the stuff that sells, the movements that make you stand out in the clinic or gym. It’s different; it’s novel; it’s cute. But that’s all it is: cute. And cute doesn’t build resiliency. Cute doesn’t address the basics that help us get back to our mission, sport, and baseline athleticism. So before adding in a bunch of complexity, I try to ask myself if the same tasks could be accomplished with the basics: the hinge, squat, push, and pull. Basically: Let’s pick heavy things up. Carry odd objects. Squat low. Move fast. Regress and progress as needed.
Overemphasizing and Misusing “Functional”
Along the lines of skipping the basics, I often found myself using the word “functional” in every other sentence as I explained exercise relevance and execution.
Sounded a little something like, “So we’re going to incorporate some functional movements that mimic what you’re trying to get back to at home!” I would say this at least 8 times a day during my first rotation. Probably because it sounded good and made it feel like we were accomplishing their goals.
But what does “functional” really even mean? It’s a buzzword. An overused catchall phrase. Arguably, anything can be “functional” if it relates to your goals. I missed this point. Stated beautifully in Episode 114 of the E3 Rehab podcast, functional is anything that is, “preparing you for the demands of the task.” Functional sounds like:
- “What is your goal?
- Does this exercise help accomplish that goal?
- If so, it’s functional” (Surdyka and Hughen 2023).
Many will argue (I did) that single joint movements like bicep curls or sit-ups aren’t functional because we don’t move in these isolated patterns during real life. But as discussed in the podcast above, if your goal is to get shredded arms and abs: then yes, hypertrophy based movements like bicep curls and crunches would be functional for you.
Leg extensions get the same negative view. But if our goal is to improve what Erik Meira calls the “knee extensor mechanism” (Meira 2021), then there is no better way to target this than doing isolated leg extensions.
Let’s take one of my first patients- my 80 year old with back pain and balance deficits. She has to carry her laundry up the steps, so I had her hold a DB and do step-ups. That’s “functional” right- because it looks like the task she’s doing at home?
Well yes, but she’s already doing that at home. Maybe a better use of our time would have been some isolated strength work that would carry over into a stronger, more stable position when carrying that laundry up the stairs. Instead of talking about and performing these so-called,“functional movements” during our session, a better use of our time may have been loading through challenging positions and ranges of motion that she doesn’t typically get in at home.
Pathologizing Normal & Saying Certain Postures or Positions are “Bad”
School teaches us: here are the signs and symptoms that point you to a diagnosis. Now it’s my job as a physical therapist to FIX this diagnosis. We learn the “normals” and the “abnormals.” A problem that needs fixing or a structural/mechanical pathology that needs a solution.
I wrote a blog in college on the perils of “tech/text” neck. I laugh at the thought of posting something like that now. The same concept applies to things like flat feet, the anterior pelvic tilt, and knee valgus. These positions are villianized and people begin to think they are doomed if they adopt any of these positions.
But our jobs as PTs isn’t to categorize people just for the sake of a diagnosis. And there is no “bad” or “perfect” posture or position (contrary to what a quick Google search will tell you) that I am going to educate you about in the clinic. A wrong context for a posture, position, or movement? Maybe. But our bodies are pretty damn smart and wouldn’t give us the capacity to actively move through these postures or positions if they were as damaging as the internet makes them out to be.
Because I don’t have years of experience in the clinic, I reached out to several seasoned clinicians in my town. I pitched the question, “What are some mistakes you’ve made in practice and how have you changed?” to hear their take on the topic. Stay tuned for part two of this series, where you will hear insights from multiple experienced PTs!
Ansley is a certified sports performance coach, nutritionist and is currently working towards her doctorate in physical therapy.