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Ankle strength

Some people have lost strength in the ankle due to a litany of issues such as:

Nerve damage

Muscle strain

Shin splints

Ankle fracture

Etc

Getting a stronger ankle joint doesn’t have to be complicated.

Some people have the ability to get stronger, but others may not have that ability.

Check with a licensed professional to see if the nerves are working properly before starting a structured exercise program for the ankle.

This is a basic exercise and is intended for general education.

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Great teachers build students to be great

Image: Kaufman SF. The Martial artist’s Book of Five Rings: The Definitive Interpretation of Miyamoto Musashi’s Classic Book of Strategy

I have had many students over the course of my career as a PT.

It is not hidden that I practice with a base of MDT (Mechanical Diagnosis and Therapy). This is the base from which I begin every new patient evaluation. It allows me to keep information in an order that makes sense to me and keeps me thinking systematically.

When I take students, I don’t dictate how they practice. I want for them to learn about what is their passion within this profession.

Everyone has to follow his/her own dreams and goals.

I frequently get students that ask me how did I get to where I am at in this profession.

I tell them about reading textbooks, thousands of pages, two to three times in order to understand the words. The students go from feeling great about the energy that I bring and the mentoring and teaching that I have done through the clinical to telling me that they don’t think they can do it.

I DON’T CARE!

You do you. Don’t try to do the things I’ve done in my career. Becoming better at anything takes work. I can feed you my information and this can put you a little further in your quest for information, but you will never own the information in the same way that I own the information. It takes time and work to own the topics.

I only hope that the students can take from me an inspiration that this profession has a lot to offer. Each professional could be great at any one niche AND there would still be enough information, topics, niches for everyone to be great at something.

In the end, the responsibility is on the person…the student.

It is not on the teacher, for the teacher has already paved his/her own way.

The student must choose the path and forge forward.

What path have you taken as a student…professional?

Training for game day…everyday

Image: Kaufman SF. The Martial artist’s Book of Five Rings: The Definitive Interpretation of Miyamoto Musashi’s Classic Book of Strategy

There is so much to unpack here.

First, don’t do as I do because you may have different goals than I.

When I worked at Sams Club, I could have two conversations: gym stuff and Sams stuff. I was so single minded. I would go to school in undergrad and read Ironmind, Flex, Powerlifting USA and books by authors such as the great Mel Siff, Mike Menzter, Fred Hatfield and others.

I wanted to make myself better at the things I enjoyed and school was just something I had to do in order to eventually make money.

I became employee of the year at Sams Club in 2003 and quit the same year to go work at a gym making half that money and to start PT school.

Once in PT school, I still devoted my time to learning about lifting. I went deeper into methodologies and theories of exercise.

Once I graduated from PT school, I devoted all of my free time to becoming a better physical therapist. I want to be the best (warrior) at this craft (physical therapy) that I could attain.

This is not necessarily healthy. I want to start by saying this because it’s been told to me my entire career.

I studied research between sets at the gym. I read textbooks multiple times over. I sacrificed personal relationships to become better…I won’t even say good, but better than the day before.

I’m glad I put all of that time in during those first ten years.

This does not conform to the thought of work-life balance. Again, I’ve heard this my entire career.

When looking at balance, it has to be what makes you happy. Not everyone has the same definition of happiness. When I go to work, I’m sure my patients are grateful that I sacrificed a decade of my life to get better at my craft. When I believe in something I give it my attention. In giving it my attention, I give my time. In giving my time, I am giving my life.

I understand that not everyone is devoted to their craft, but I would hope those depending on that craft can see the difference between those who do and those who don’t.

Cervical myelopathy: how to test clinically

“… The onset is often insidious with long periods of episodic, stepwise progression, and may present with a vast array of clinical findings from patient to patient.”

Cervical myelopathy is like neck pain to the extreme. It isn’t just a neck issue, but it ends up encompassing anything below the neck. It can cause arm symptoms, leg symptoms, difficulty walking, weakness throughout the body, spastic robot-like walking, and breathing issues.

This is a neck problem that needs to be addressed ASAP!

Let’s take a look at some of the research on this problem, what your therapist should check, and when it’s time for the patient to be sent back to a physician for imaging to determine if the patient is a candidate for surgery…it is that important.

Some quick stories (or not so quick).

I’ve had two patients with cervical myelopathy. One patient had symptoms of this, but also had arm problems from a previous injury. Because of this, the CSM (cervical spine myelopathy) was delayed in diagnosis until the patient demonstrated abnormal gait…10 months later!

The second case was picked up in the clinic immediately on the first day. I performed this cluster, to be learned later, on the patient and he was very positive. We had a conversation about the need for imaging and a consult with a neurosurgeon. The patient essentially said…thanks but no thanks.

Unfortunately this patient lost use of his hands and developed a walking pattern that was very abnormal before he decided that surgery was the right choice.

Here’s a quick Video describing CSM.

“May involve lower extremities first, weakness of the legs, and spasticity”

Spasticity is an issue that could be seen in walking for some people, but is testing using movements under speed like in this Video

What we will see is that the body reflexively slows down or stops the movement from happening rapidly.

“lower motor neuron findings in the upper extremities such as loss of strength, atrophy, and difficulty in fine finger movements, may present”

This means that we may see generalized weakness, loss of muscle mass (smaller muscles) and difficulty with picking up pennies and buttoning buttons.

“neck stiffness, shoulder pain, paresthesias in one or both arms or hands, or radiculopathic signs”

Neck stiffness is self explanatory. The neck movement may not be fluid or it may be restricted due to pain. There may be symptoms such as pain, tingling or numbness radiating into the shoulder(s) regions, arm(s) region or down to the hand(s) region. We may also see changes in sensation or reflexes.

“An MRI is most useful because the tool expresses the amount of compression placed on the spinal cord, and demonstrates relatively high levels of sensitivity and specificity.”

There is little reason for a PT to recommend an MRI, unless there are specific conditions found during the evaluation. The type of presentation notes above is one reason for a PT to recommend an MRI to the referring physician or the patient’s primary care physician.

X-rays do not do a good job of demonstrating any soft tissue (muscle/spinal cord/disc/ligaments/tendons) abnormalities.

Mind you, this presentation is not common and for the most part, an early MRI is not indicated for neck or back pain.

“The tests, when used alone, are not overtly diagnostic and may lead to a number of false negatives and in rare occasions, false positives”

It is recommended that, when CSM is suspected, the physical therapist use the cluster (groups) of testing in order to strengthen the likelihood of this suspicion. One test used alone is not enough to consider other testing.

“in reality, the diagnosis of CSM involves MRI findings and clinical findings, with equal weighting of both results”

Because the clinical exam is so important for this diagnosis and subsequent imaging, it is important that the PT and physician be familiar with the testing described.

“Of the 10 variables included in the regression modeling, the tests of Babinski and Hoffman’s signs, the Inverted Supinator sign, gait Abnormality, and age > 45 years were retained.”

I’ll be honest. In my first 10 years, I never tested for the inverted supinate sign or Hoffman’s sign until I read this paper. This is a testimony to continuing one’s education beyond taking courses. I don’t recall (those that know me know that I have a pretty good memory) ever learning this cluster through any of the coursework that I took since 2007.

After reading this article, I practiced these tests on a bunch of healthy individuals, those with neck pain in which I didn’t suspect a spinal cord issue, so that I could get better st the test and understand the normal response. This way, I learned the test mechanics and felt confident performing the test on anyone. It enabled me to understand the difference between the “healthy” patients on which I tested this specific cluster and the few in which had a positive test.

Rant: I hear it from so many students and new grads that they feel like they haven’t learned how to perform the tests or what to see as a result of the test because they only get to test healthy individuals. Having gone through the mechanics of this cluster for years, I hope that students understand that they must become confident at performing the mechanics of the test (kinesthetic learning) and know how a healthy response looks. One may go his/her entire career without ever seeing this presentation, but that doesn’t mean that one can’t perform the test and understand a normal result. I bring this up because I hear the same type of arguments regarding vestibular testing and ocular testing.

Every patient that has a history of stroke gets a vestibular-ocular exam because there may be lingering positive testing after the neurological event. This again strengthens my ability to perform the test and increases my likelihood that I will see positive testing…so I know what it looks like for future patient evaluations that may come in off of the street through direct access.

“A finding that included three of five positive tests yielded a positive likelihood ratio of 30.9 and a post test probability of 94%”

Even if you’re not a statistician, this is important information.

A positive likelihood ratio greater than 10 is an indication that your testing is giving a result that increases the chances of that being the diagnosis.

A post-test probability of 94% indicates that there is less than a 10% chance that the diagnosis or classification is incorrect after testing.

This is a much better percentage than we have of most orthopedic issues.

“”this study found that selected combinations of clinical findings that consisted of (1) gait deviation; (2) + Hoffman’s sign; (3) inverted supinator sign; (4) + Babinski test and (5) age > 45 years were affective in ruling out and ruling in cervical spine myelopathy.”

If you are a student and plan on treating patients…you must know these tests.

If you are a therapist treating these patients…you must know, be confident administering and understand the repercussions of a positive test.

If you are a patient…know that not all therapists have the same training and some may not even know these tests exist. I hope this makes you take a more thoughtful approach in choosing your next PT.

Article

Reflections on “The Alchemist”

“The shop is exactly the size I always wanted it to be. I don’t want to change anything, because I don’t know how to deal with change. I’m used to the way I am.”

This is nothing like me, but we have met all types.

I personally thrive on change. I haven’t held a single position for more than a couple of years. One of the reasons I really enjoyed working for a larger company was that I could move through the company relatively easy and learn other jobs, without sacrificing my place in the company or benefits.

When I worked at Sam’s club, I started as a “cart boy” (man do I miss Don and Howard). I moved to cashier, where I held the title of Big Dog (only those that worked their would get it, but it was the person who scanned the most items per hour) many times. I worked at the service desk, as a cashier supervisor, overnight stocking, tire and battery center and freezer cooler.

Those that know me, know that I don’t know a damn thing about cars. Over time, I could do a set of 4 tires in less than 15 minutes from the time the car hit the lift to the time the tires hit the ground.

My first day in TMA resulted in me needing a drug test! Got to love Bill Foster for saving my job that day. I was told to drive a large older ford into the garage. What they didn’t tell me was that I had to take the turn wide using a three point turn. I took it tight (I had no clue), and I was scraping the side of the truck against the brick building for about 1/2 the bed. The truck was so loud that I couldn’t hear it.

Bill Foster comes running out giving the stop sign like a third base coach. I hopped out without a clue of what had happened.

He sold me as an incompetent idiot to the owner of the truck, as it being my first day on the job…and let me tell you that I was very grateful to be called that because the guy totally calmed down and was happy to get a new paint job. It was the first and only time that I had to be drug tested for being an imbecile.

If you live in Joliet and know Bill Foster, thank him for saving my job that day.

Don’t be afraid of change…what’s the worse that can happen?

A new paint job.

Reflections on “The Alchemist” Part XV

“The closer one gets to realizing his personal legend, the more that personal legend becomes true reason for being, thought the boy.”

Working…playing…living.

I used to go to work to collect a paycheck. It was alright, I had other passions that were more important. Some may not know, but I was previously a competitive strength athlete, having placed 2nd in IL in both powerlifting and Strongman. If you don’t believe me, check this out (https://youtu.be/Z-BXSbcpwRw).

I’ve since quit competitive lifting, but still needed that outlet of playtime. “Work” has become play. Each patient that presents to the clinic is a new puzzle that I get to piece together. There are so many facets to the puzzle. Movement is obvious…I’m a PT…there will be movement. Personality is another. Beliefs and biases. Teaching the patient and learning from the patient.

Living. I’ve heard it a couple times this week alone. A patient walks into the clinic and says either “it’s like a miracle” or “it’s like magic”. My xyz is almost gone or completely gone. Symptoms that had been present for days, weeks, months, decades seem to vanish with simple treatments that patients can perform at home.

Did I mention I love my job?

If not, I love my job. I still get goosebumps when I get this response. It’s like a kid in a candy store. I have to keep from wetting myself I get so excited to hear these phrases. Although it makes me feel good to help the patient get back to their previously lifestyle. It’s a different feeling for me.

It’s like beating Bowser. It’s up, up, down, down, left, right, left, right B, A, B, A, select start.

Yeah…it’s that feeling. It far surpasses money. It’s about the game.

Reflections on “The Alchemist” Part XVI

“When someone makes a decision, he is really diving into a strong current that will carry him to places he had never dreamed of when he first made the decision.”

A long time ago, I was unsure of what to do as a profession. I prayed and prayed between going to medical school and going into education. After much prayer, I decided to become a high school teacher. I thought I would teach biology since science always came easy to me.

After attending Joliet Junior College, my goal was sidetracked by a want. I wanted to experience the college life and the city life. I chose to go to UIC in order to experience the city. Little did I know, they didn’t offer a biology secondary education program. I was more interested in experiencing the college life than teaching biology, so I signed up to be a Spanish teacher. To me it was like a compromise. Mind you, I didn’t speak Spanish outside of what everyone learned in high school. I should’ve put a little more thought into that decision. I spent a year at UIC studying mostly Spanish and experiencing the city through tours, classes and groups. It was a very expensive year…which I’m still paying off. In the end, I came to my senses and realized that the Spanish language just isn’t why I want to spend my entire career around.

I transferred to Governors State University to finally study Biology secondary education. I made it through the program and during one of my student teaching experiences, I realized that politics never go away. This situation was enough for me to not want to be a part of the education profession.

Luckily for me, one of the courses I took was taught by a PT professor with PT students in the course. Because the body has always made sense to me, it was a blow-off course for me, but many of the PT students struggled.

The professor came up to me and noted that if I applied to PT school that I would definitely get into the program. I had no intentions of becoming a PT initially. Aside from a short bout of PT after surgery when I was younger, I didn’t even know why PTs really did aside from follow the protocol by the surgeon.

I had my plans of becoming a teacher squashed. I had nothing better to do at the time, so I applied to PT school. I didn’t realize how hard it was to get into a PT program because I was essentially recruited into the profession.

I still think about that day at Loyola University kneeling at the statue of Jesus by the lake. It’s one of those things in which the best laid plan is laughable by God. I had no clue that my life would go into this direction.

Now that I’m here, I feel I should make the most of it. These past two years have really pushed my comfort level and people have noticed. UpDoc Media tanked me in the top 40 in the country, as an influencer in 2017. The local newspaper, that I read growing up, ran a two page article about my journey. I’ve impacted many kids in our community both through my story and volunteering.

I’m not at the place I want to be financially, but I think that after 12 years in this profession that I am starting to find my place.

Reflections on “The Alchemist” Part XIII

“People need not fear the unknown if they are capable of achieving what they need and want.”

This is something that it took me time to figure out. I was afraid of making the jump back to private practice physical therapy because of the lifestyle that I had grown accustomed to living.

When making this jump, I wasn’t thinking about the sacrifices we would have to make, such as no vacations for awhile, making dinner at home instead of Chiptle, brewing our own coffee instead of going to Dublin (because Starbucks is too expensive even when doing well).

Essentially, what I had to decide is…is the sacrifice worth it? Do I think I’m too good that I can’t go back to living the same way I grew up in order to achieve a long term goal?

Have I gotten so used to living easy that I’m above making sacrifices?

The answer is no. I made a jump and failed. It’s okay. We still have the basics and a roof over our head.

This simply means that we lived to take another risk. I landed back on my feet, but have to work longer hours than previously.

My wife is the true hero of this story. She is the one that (wo)mans the fort while I’m off trying to save the world. Without her as the cornerstone, I wouldn’t be able to attempt any of the goals that I have succeeded and failed while attempting.

For all, take a risk, when you are ready and able. Don’t make the leap if you can’t afford to fail. Don’t stay in a failing business if the end result is a major impact on your or your family’s health.

As long as a failure is not a figurative death blow, nothing ventured nothing lost or gained.

Reflections on “The Alchemist” Part X

“Now, I’m beginning what I could have started 10 years ago. But I’m happy at least that I didn’t wait 20 years.”

It’s the adage: “the best time to plant a tree was 20 years ago. The second best time is now.”

This is very fitting in my life. I seem to have a 3-8 year itch regarding my profession.

It’s hard to believe that after 38+ years, the longest job I held was Sam’s Club 8298. That job was perfect for me. I get bored relatively quickly and try to do more or challenge myself in a different fashion. I could bounce from one section to another without ever having to quit.

In the PT world, it rarely works that way. I may be able to switch locations, but it’s essentially the same job. There’s rarely additional challenge.

I can honestly say that every job, but one, which is a different story for a different day, I left to do better, be better or work harder.

If there is a dream that you have and the opportunity presents itself, what’s stopping you?!

Don’t regret the decision you didn’t make!

Always think of the worst case scenario. How would that worst case scenario affect you and your family?

If it’s not a death blow, why not make the jump? Sink or swim, but do your due diligence before making the jump.

Research what you have to do to be successful. Spend some time that you would’ve slept to figure out how to stick the landing on the jump and not fall flat on your face.

I landed flat on my face and you know what?…

It wasn’t a death blow. We lived to fight again.

Reflections on “The Alchemist” Part XII

“Once you get into the desert, there’s no going back. And when you can’t go back, you have to worry only about the best way of moving forward.”

In 2017, I made the decision to leave a good paying job, with good benefits and it was only an 15 minute commute.

I walked away to take a chance on a better position. It started at less pay, worse benefits, and a 45-60 minute commute each way.

I never looked back. I poured 100% of my efforts into this new position because…there was no going back. I made the decision to better myself and my family’s lot in life. This means that I am working way more than I ever had in the previous job, but it has a much higher upside than the last job would’ve been able to afford my family. There were some growing pains, as now I get paid when we make money and if there is no money being paid, I don’t make as much. It’s the life of an employee vs an employer.

Never take for granted the position of employee. It comes with perks, such as low cost of entry (for the most part just sitting through interviews and hoping to get paid), it comes with a salary (unless you are commission based), it gives benefits such as vacation and sick time.

The role of employer is not as predictable. It has a higher cost of entry. The employer has to purchase equipment , pay employee taxes, doesn’t come with a standard salary (employees get paid first) and it’s is much harder to take a day off when there is no one else that will give the business the same care that the employer does.

This quote applies to any decision in life. Gary Vaynerchuk is famous for saying “don’t do anything half pregnant”. In other words, go all in.

When you have a family depending on you, this is much easier. When you’re younger, you have the ability to taste a bunch of different aspects of life to determine what direction you want to go all in.

But once you make your decision, you go all In and don’t look back!