E41 | Frank Alexander Talks Sports Medicine

• Frank's role with Dr. Ahmad
• The Catch-22 of pushing an athlete and feeling their resistance
• What changes have been made at Dr. Ahmad's clinic during the pandemic and will any of these changes stick around post-pandemic?
• How injury prevention is more important than seeing new patients
• The pitfalls of waiting to operate on ACL's and Tommy John surgeries
• The research behind ACL injuries and what does it all mean?

• Dr. Ahmad's website
• Frank's Instagram
• Frank's Twitter

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Episode Transcription: Greg: Welcome to the Resilient Performance Podcast. I'm pretty excited to have here, Frank Alexander, and partner, Trevor Rappa. So Frank, works with Dr. Ahmad and his team and actually just, I'm going to let you kind of run with it from here and give us a quick intro, kind of, your academic background, athletic background, how long you've been with Dr. Ahmad, kind of like, what is your normal patient that you guys see? What kind of surgical procedures are you doing? Just kind of start with that and go where you want. Frank: Awesome. Thanks guys for having me. I really appreciate it. So my background is I'm an athletic trainer and my bachelor's degree is a bachelor's of science in athletic training. I got my masters in kinesiology and for me, my athletic background, I played baseball and football in high school and then I was fortunate enough to continue my baseball career in college. So where a lot of my interest has been in baseball. A lot of it due to some of my teammates, some of my closest friends growing up that wound up with these injuries that we see very frequently in the office. So my goal in my life and my athletic and my post athletic life, my professional life has always been to stay around sports medicine and help athletes kind of stay on the field and if they're not able to, and they wind up with an injury, help them get back to playing at a level that they're happy with and hopefully help them reach whatever the next level is. So when I was working at the high school level, I wanted to help the kids get to the college level, if that was what their aspirations were. At the college level, you always want to watch those guys no matter what their sport is. If it's baseball getting called up to the next level, we actually had a couple of guys at the college level go to the... I worked at a DII school and some of them went to the Division II combine. So we always wanted to help those kids reach whatever goals that they had set for themselves. So I think that's a lot of what we do as professionals too, is making sure that one we're able to operate at a level that we want to be at, but making sure the athletes and our patients are getting back to what they want to. Whether it's an athlete who wants to play professional baseball, or if it's a grandmother who just had her rotator cuff torn and she just wants to hold her grandkid again so we treat them all the same. For us in our practice and Dr. Ahmad's office, I'm one of four of his assistants and, we have myself, our nurse practitioner, a nurse and our [00:03:00] another athletic trainer and we all function differently. A lot of what I do is coordinating the care for all of our baseball players and a lot of our patients. So for our baseball players, making sure they get in with excellent physical therapist, such like you guys and making sure that they're on track, whether it's the constant text messages that the three of us are always sharing, or if it's even some of our older patients, just making sure that with their therapist, that they're getting the care and they're on the right trajectory. Greg:  Yeah. And, I mean, for an athletic trainer, your job is very atypical. I mean, the typical athletic trainer job is out of school where you're working. I mean, the hours that athletic trainers are working are ridiculous to begin with, and then you're working with caring for the athletes yourself, whether it's hands on or through exercise or whatever it is, you're setting up a fields with coolers. Like you're doing all of this stuff, coordinating different practice times and a million [00:04:00] different things, a million different hats. And your role, I would say is like, I mean, there's got to be like a 0.5% of athletic trainers that are doing what you do. So I think that's pretty cool. It's pretty unique and it's cool to see that there are other ways that you can help people and just sort of talk about how did you even wind up in the role that you're in with Dr. Ahmad and how did you out of all of the AT's who might be interested or even non AT's, NP's or PA's, you know, people who are interested in sort of this path, how did you find your way there and how'd you find your way there with Dr. Ahmad? Frank: So a lot of what I did prior to working with Dr. Ahmad was exactly that sideline work after school. And I, like I said, I did it both at the high school and the college level. Those are two separate beasts in and of themselves. The high school, I worked at a school where they actually had a block schedule. So it was similar to a college level academic structure where you had class and it was an hour and a half. And it was only four or five blocks a day [00:05:00]. So you're only seeing those kids a very similar rotating schedule, but I would actually be in during their lunch hour. So if kids needed rehab, I can knock it out there or if they, like, if we were rehabbing an ankle sprain or something that didn't require surgical intervention or higher level rehab then I would outsource and say, all right, go to this therapist. You got to go see this doc. At the college level, we handled everything a hundred percent in house. So that was a beast in and of itself. I remember one fall, I worked, I think four or five weeks straight without a day off. 16 hour days doing double sessions. It's just a grind. Trevor: What sports did you work with in college, Frank? Frank: So, got a little taste of everything; during the fall we had football, women's soccer and volleyball, but then in the middle of the fall semester, you'd have men's and women's basketball men's and women's swimming and diving all together and then you had the non-championship sports in the spring. So men's lacrosse, baseball, practicing, but they weren't getting the same [00:06:00] level that the guys that were in their championship season, like the footballs, the volleyballs, they got the full care that they needed because they were in season and then once we got to the spring, that would flipflop. So spring football always had somebody with them just because if they were going to thud or wherever they were going football just needed help. Then for football, someone was always covering baseball games or practice, I was out there a lot. I took a lot of Florida trips down with those teams and it's tough in March when you're playing in the Northeast and guys aren't able to get the reps that they need to. And then you fly down to Florida and you get knocked around a bit. So we had, when I remember we played the university at Tampa and their number one was the number two at Nebraska the year before. He wasn't happy that he was going to be their number two again and he said, all right, I'm transferring and he left and he's the one at Tampa that year, I mean, the kid was a lefty throwing and he was pumping. This kid was [00:07:00] somewhere mid to high nineties and he wound up getting drafted. So it's two different worlds and depending upon what the needs were, that's where we had to be in. At the college level I was one of three full time athletic trainers. We would pick up per diem, in my later years there, we would outsource a little bit more. But at the high school I was by myself. So I was fortunate that the school wasn't a big, it wasn't a AA school in New York, everything is a AABCD, I'm not sure how it is in New Jersey, what the structure is like. But I had about 400 kids in the school and about 200, 250 student athletes throughout the entire year. Very rare these days and you guys see it too, there are not too many, two sport athletes anymore. A lot of them are specializing too young and we'll get into that I'm sure much later on, but the demands weren't as much as the college kids; the college kids, just the way that they were a lot more soreness, a lot more treatment [00:08:00] sessions, a lot more real injuries that we had to manage. So that all set me up for what I'm doing today and I'm very fortunate to be able to work alongside Dr. Ahmad and take care of athletes from the lowest levels of play to the most elite levels of play and it's really cool to be able to be in this position and see the differences not only in the level of play, but in the level of commitment from the kids too. Because that can really dictate how much effort that you need to put into them, because the way that it works, I can't care more than that athlete cares because if I care too much, then either I'm going to get pushed away or somebody's going to wound up getting frustrated with it and that's just the reality of athletics in general. Greg: We can talk about that for sure, you can only care as much as they do and just lead the horse to water, so to speak and hope that they take the advice. Frank: Yeah, definitely. And it's tricky [00:09:00] in, because sometimes it is that catch 22 where you're trying to push them a little bit and you can feel that resistance too, where they're just like, you know what, today's not that day, but maybe tomorrow it will be. The professional guys they want to be out there and that's why they're playing at that high of a level is because they're able to grind and they're able to push through, look 162 game season is a long year spending half of it on the road. Obviously this year in the middle of a pandemic is going to be a different story, but still it's going to be a lot in a very short period of time. So it'll be interesting to see where this leads us. Greg: Yeah. And that was something I wanted to bring up too, is the whole pandemic that we're all in right now and we've all been dealing with and, sort of, we won't talk about that probably for too long, but what are you seeing first, clinically in the office? What are some things, well, maybe not in the office more remotely, but like, what are some things that you guys are doing to continue [00:10:00] providing care for all of your patients that you've previously seen. I know you guys have stopped or at a certain point you stopped doing surgical procedures that were elective of course and then just recently, I think you've sort of started back up with some procedures potentially. Just kind of talk about in general, how the pandemic kind of changed things for you and then what I'm interested in, we've talked about Trevor and I have talked about this and Doug, what are the things that are probably going to stick? What are things that you see as like, oh, this could be useful outside of having a global pandemic to deal with that we might want to continue doing just because it's going to be helpful for our patients? Frank: We've all learned a lot during this whole situation from you guys and what the capabilities are of a physical therapist, whether it is reducing the hours of in person, contact time, working a little bit one on one with patients more versus how we're able to see a lot of patients and make sure that all of our patients are still being cared for. So a lot of what [00:11:00] we're doing and we shut down everything the day before Saint Patty's day. So all surgery, all in person visits with the exception of a couple of different types of injuries or pathology. So anybody that had an infection, anybody that had an acute fracture or dislocation, those were all still being seen in person, just because of the nature of the injury itself. The follow-ups for surgery, if they were seeing a physical therapist, I know Trevor and I have been sharing videos with some of our ACL patients, making sure that they're still doing all right, which has been awesome and making sure that they are on track. A lot of our therapists at Columbia have been doing virtual appointments as well, just because the facilities, we can open them, but we want to maintain social distancing. We want to follow their parameters as well. It's tough to have and you guys are seeing it I'm sure as well, have a high [00:12:00] volume and maintain it while you guys have a huge space that you can work with. You still want to make sure that we're all doing right by our patients. It's one thing to be business oriented, but everybody's patient oriented. So I think what we're going to continue to see is tele-health for follow-ups because some of that stuff is, you can use a physical exam and for a lot of our players, our athletes, even non-athletes, it's good. Even if they're doing a one on one session that we video chat during that session, I know Trevor did it with one of our other patients. Dr. Ahmad did it yesterday as well with another professional athlete. So to be one-on-one and do manual strength testing in the middle of it, being able to show off the work that you've done with that patient is really key. I think it's really cool to highlight what you've been doing with them and say, hey look, this athlete's eight, nine months status post an ACL reconstruction. Let's build it up a little bit more and you can say, hey, look, this is what we've achieved in such a short [00:13:00] period of time and this is what our next goals are to make sure that she's running at the 12 week mark, make sure that she is going to get ready for that. Greg: That's a good point, actually, just talking about the little bit, that was awesome that you just mentioned how like, you can have the doctor appreciate what we're doing and like, almost see, have us put on display the things that we've been doing with your patient, Dr. Ahmad's patient because I think a lot of times with doctors or assistants who aren't like you, or we have a texting relationship, we can easily contact you. If it's a doctor, maybe we haven't worked with too much. We might not speak the same language necessarily and we might not know the nuances of how different things are working clinically versus yeou know and the expectations might not be aligned. I think that's a really interesting point and I really hope that we do a lot more video followups. Especially with doctors who don't sort of know what we do, because they might say one thing and we're actually saying the same thing, but we call it something [00:14:00] different or just the terminology and language that we use might be a little bit different. But if we're showing them this is the thing that we're doing and they see it and they're like, oh yeah, that's what I was talking about but I was calling it this or whatever. That's just one crude example. Trevor: I think it's such a great way like even just examples, you're bringing up Frank, of us to be able to be on the same page and for the client to understand that they are really getting the best care, truly coordinated care. I would say one of the main, you guys are obviously the exception and we have a couple other doctors that are in that same realm or they're so easy to get in contact with and if we have a question or we want to ask them just something about the patient or the patient said something, just knowing when follow ups are just being able to have a truly continuous plan of care the entire time between us, the therapist, and you guys on the real medical side makes such a big difference. And we definitely have had frustrations where patients are like, did you talk to my doctor? He said he was going to call you. And it's like, sorry, I know they're busy, but you know, patients feel like they're kind of stuck in the middle [00:15:00] and they don't really know what's going on and I think this tele-health world that we're kind of all living in right now really has made a difference in terms of the communication that we're able to have continually. Frank: Yeah, and being able to explain it, we're able to speak a completely different language with medical jargon. Personally, I see it at home because my wife's a teacher. I'm an athletic trainer, my sister-in-law is an NP, my sister in law, and I can speak medical terminology in and out, but to have somebody that can put it into more digestible terminology and explain it on another level that I think is really the, the more important thing. So where we can disseminate information to our patients, but then on the back end of that, share text messages or hop on a phone call or these days zoom meeting, where you're able to really kind of iron everything out and my job with our office and our athletes has really been to set it up to a point where, I [00:16:00] say, look, guys, I'll talk to your therapist, I'll shoot Greg, I'll shoot Trevor a text message and leave it at that. I don't have to worry about trying to find, and like you guys, we have it the other way around. I work with therapists where I'm like, you send them a text message and then the patient goes, did you talk to him? A week, two weeks go by and you're just complete radio silence on them. So that's the tricky part, it's really the name of the game. Greg: Definitely and then, so kind of going off of that, Trevor and I were talking about how after some of these surgeries we'll have patients who will, a lot of times it's very, a lot of the similar sort of aches and pains and complaints after a UCL surgery that you guys do on elbows, but at UCLs, we'll have these normal aches and pains that we see with everybody and they're like, yeah, they're normal. They're okay. They're not red flags. They're not even yellow flags. Trevor: It's just [00:17:00] part of the process. Greg: Yeah a part of the process, and you had a major surgery, this is okay to feel. So that's always something that when I hear something new from people, I'm always thinking in the back of my head, okay. In my mind, I'm thinking, do you feel it repeatedly? Does it go away? Do you feel it only with certain movements, sort of things like that. Like, could you just speak a little bit to that side of things post op when you have followups with people, you can use UCLs as an example, you can use ACL as an example. Maybe it might be easier to also say like, what are things that you don't want to hear versus what's okay to hear because it could be so many different things, but, yeah, just kind of take that and run with it. Frank: Yeah. So I actually had a phone call earlier this afternoon with a lacrosse player who plays on the US men's national team. He had surgery with us a couple of weeks ago. He's a little over two months out. So a lot of what I'm looking for in that postoperative course is how long, if [00:18:00] you are having soreness, how quickly does it resolve? So let's use a UCL, a baseball player gets back to throwing in about four and a half months afterwards. So the first time out, we're expecting some level of soreness in there just because you haven't done it in not only four months. How long was it when you got your injury and how long was your injury before surgery? So it's not necessarily, you get injured today and then tomorrow you're having surgery. It could be a week, two weeks. It could be two months before you get injured, have the MRI scan. You try to return to play progression with a non-op UCL, and then you know what your elbow pain comes back and now you already have two months wasted or behind you, I don't want to say wasted everybody's timelines are different. But then next thing you know, it's six months before you last threw a ball again. So it's like riding a bike where you're going to be able to do it again. But the rehab process, at least the way that we explain with our patient it's [00:19:00] like flying in an airplane. You expect a little bit of turbulence, but if it gets a little bit choppier and you have to make an unexpected landing, that's why the communication between our office, you guys, and we have these spot checks every six, every eight weeks and it might be annoying for a patient to come into Manhattan for these spot checks. But it's just to make sure it's like a train on the tracks. If you get a little bit off course, you're right back on. So that's the more important part. But I think the biggest thing with any type of surgery, whether it's Tommy, John, whether it's an ACL reconstruction, my biggest analogy is it's like the stock market, there are ups and downs along the way but as long as the trajectory is still going in the right way and it's up until the right, that's the most important part. Greg: Yeah, that's a good way to put it and I think that makes a lot of sense with patients too. I think that that kind of resonates to kind of boil it down like that. That's a good way to do it. So yeah, I mean, you guys do a lot of surgeries, you're seeing a lot of injured people. What [00:20:00] kind of things are you doing besides, I mean, you've written a children's book you've co-authored with Dr. Manuel. What sort of things are you guys doing to prevent injury because I know you're doing a lot of stuff with that and you're spending a lot of time going through MLB data and just kind of talk a little bit about what you're doing to prevent injury. Frank: The injury prevention part is actually more important than the seeing the patient part. Obviously every day brings a new patient into the office with a new type of injury, but trying to keep the kids healthy to me is more important than getting them into our office. While you want to make sure that the kids are getting good and the right treatment that is paramount at that point in time. But if we can save more arms than we're fixing that to me is more important than the fixing them, because then you know, that you've reached a broader scale. The children's book we wrote is called understanding Tommy John surgery and how to avoid it and the real purpose of writing that is to open the dialogue between our youth athletes and their [00:21:00] parents. You hear, and it's always so sad to hear a kid saying, oh, my elbow hurts, but my coach kept me in the game because I was still throwing hard. That to me is heartbreaking and it's not fair to the athlete, no matter how old he is, whether he's an 18 year old where the high school coaches just riding him because he could potentially have a draft in his near future or if it's a 12 or 13 year old kid that they're playing in a four game weekend showcase of two double headers and they just need an extra arm and they're running thin. They just need to keep them out there. So our goal is to really open the dialogue. Between the kids and their parents, whether it's in the car, ride home, or even just sitting at home on the couch, watching the Yankee game, just say, hey, these are some of the warning signs are you experiencing any of them? We know that a large majority of kids are playing through elbow pain, so around 75% or higher and that's why we're seeing the Tommy [00:22:00] John rates that we are. They're not a pandemic level, it's an epidemic level, but it's still unsettling to see; the youngest kid I've ever seen that needed a UCL repair he had surgery on his 12th birthday. That's what we're trying to avoid. Keep those kids on the field and out of the operating room. Trevor: Yeah. I think that your point of opening up a dialogue between the parent and the kid is so huge. Because I think, Greg, you've work with a lot more of them in the office than I do, but we see that all the time where the kids hurt, but he wants to keep playing and the parent wants to let them keep playing because the kid wants to keep playing or vice versa where the kids like maybe he doesn't really want to play it, but they have a showcase coming up soon and their parents trying to get them back on the field. And it was just some sort of barrier between each of them that nobody's really getting to getting to this point and the athlete is always kind of the one that typically ends up paying a big price for it. Greg: Yeah, definitely. And I know like for me, growing up, playing baseball just as much as you did Frank all the way through college and [00:23:00] like, I had pain all the time. I didn't do it the right way and I just thought it was like anything else it's like, oh, you have to just deal with it and it's okay if your shoulder hurts here or your elbows somewhere there every single time you throw and now I'm sure if I go have a catch, I'd be sore for two months, but just maybe speak to that. I would assume that pretty much everybody that you guys are getting in your office has probably had pain for a long time, can you sorta, I don't know, can you almost put numbers to it or can you figure out any way to kind of put that into perspective for people and what we're dealing with when we have all these injuries. Because it's happening more and more with younger athletes that we're seeing more and more of these injuries and you just said seeing a 12-year-old having Tommy John surgery, how does this stop? And I think the children's book is obviously that's an awesome place to start because I've never [00:24:00] seen anybody else do that before. I don't think and maybe you guys have other examples, but I've never seen a doctor and his team be able to talk in that language and make it something relatable and that's going to be huge, but can you, I mean, is it pretty much everybody you say you're expecting is like, yeah, they've had pain for a long time. They've had soft tissue injury for a long time or are there people who are healthy who are just like, oh one throw and I'm showing up in your office. Frank: We run the spectrum. So there are, we just saw a kid from a local school in New Jersey who had, this would have been his freshman year spring. He's a division one pitcher. He's had left shoulder pain since his senior year in high school. So he went to school, had a cortisone injections and it was very short lived. So now we're seeing him a year following his injury. So that is one of the, and everybody's different. Some people are quicker to pull the [00:25:00] trigger. A lot of what we'll see is second opinions. If the first one, if the initial injury is taking a little bit longer than they were anticipating Dr. Ahmad being what we call baseball, sports, medicine, physician, taking care of a lot of youth athletes and even professional athletes. That is really a lot of what we're seeing is because initially some kids may not go to, they might just go to a local general orthopedist rather than seeing a doctor who specializes in elbow injuries. So that's a big learning curve. Even for me, when I first joined Columbia, I was in the same kind of boat. Like, hey, go see an orthopedist not realizing that, hey, if this is a baseball injury, you should go see somebody that takes care of a lot of baseball athletes. In New York you have the guys that take care of the Yankees. So you have the Mets across town, of course too. But my big thing is go see, for baseball players, go see a baseball specialist. [00:26:00] And in Trevor's world of ACL reconstructions, you want to see somebody that does a lot of ACL reconstructions. You want to see somebody that takes care of a lot of knees. You don't want to go to a shoulder replacement doctor to have him fix your ACL while he may be skilled in doing it. But if 90% of his practice is shoulder reconstruction, maybe you go to the guy who does a lot more knee stuff. So there's a fine line in there too and like I said to a lot of our baseball kids that come in; had a kid coming from long Island, 15 or 16 years old mom said, oh, do I really need to see the Yankees team doctor? And there's some needed Tommy John surgery. I was like, think of it this way. Do you want to see the guy that does probably the most in the country? He's definitely in the top three or do you want to see somebody that does one a year that's closer to home and convenient? If that's me, I want to see the guy that does five on a Friday, not five in his career. and at the same thing again [00:27:00] for ACL, do you want to see the guy that's doing a lot of them and it being in New York City, we were in close proximity to a lot of different places and we even have kids flying in. We had a UCL fly in from Utah high school kid. So we're going coast to coast. We have international players that will fly in for opinions. That is really what it is to me an important factor in that kind of thing. But back to your question about the timelines, you have some kids, we just did another pitcher probably about six weeks ago, right before this whole, coronavirus broke out. He had a pop on Sunday, saw his team doc on Monday, had the MRI Tuesday wound up with the phone call results Tuesday after the MRI scan, we had him on for surgery on Friday. Greg: Which is atypical, right? Frank: Yeah. That's very, Greg: Very fast. Frank: Yeah. That was super fast for a collegiate athlete. It just worked out where he's also a higher drop draft prospect, so they wanted to make sure that they were [00:28:00] getting things in line so that if his number was called come June, the reality was this was all behind him and he was already on the road to recovery. Greg: Yeah, and I think sometimes we'll see some patients come from local orthos like, you're talking about maybe they're not as experienced with a baseball athlete or a specific type of injury or surgery. And I almost, I don't want to, you can't blame them too because with insurance policies that timeline that you just mentioned is not happening with somebody who just shows up to a general ortho who has medial elbow pain and is showing signs of a UCL. I'll often see a kid where it's like, yeah, I saw my doctor a month ago and it's not really getting better and they told me it was tendonitis and it's like, I don't blame the doctor for not just jumping to, like you tore your UCL, go immediately have an MRI because oftentimes insurance companies aren't even going to approve your MRI unless you've gone through rehab for a month. So it's like, there's so many [00:29:00] obstacles to it. It's such a layered system that I wish the timeline that you just described was sort of the norm. In certain situations, it can be with a collegiate athlete or a pro athlete. But, it's unfortunate that the people who are injuring themselves a lot with these young kids who are getting it more often are oftentimes being delayed in their timeline because they have just sort of red tape and some bureaucratic things. Trevor: What's like your guys turn around and Frank, in terms of somebody coming into the office, you guys determined that it definitely needs Tommy John, what's their typical time to surgery after that? Frank: We try to keep it under two weeks, if possible, obviously right now, extenuating circumstances, but in a perfect world, if we saw a kid today's Tuesday, if we saw a kid on a Tuesday, then we operate twice a week. So we operate Wednesdays and we operate Fridays. Of course, insurance plays a factor into all of that as to where [00:30:00] they could have surgery because we have the hospital and then we also operate in New Jersey and then in Englewood, which is actually our office is on the first floor of our building and then our surgery centers on the second floor, which is awesome for us to have everything in one building too. But if in a perfect world, we saw somebody in the middle of the week. I should be able to get them on for surgery by the end of next week, especially for our athletes, that is the more important thing. So whether you tear your UCL, your ACL, if you're a football player that dislocates their shoulder and needs a Librium fixed there is a very finite window of time that we have to get you ready for the next season. So we know that Tommy John takes a year. So the sooner you have surgery, we don't want to compromise longer. Like if we're sitting in May now, we don't want to wait until August because now you've lost all of Spring 2021 and you're going to miss all up until August of [00:31:00] 2021 and if that's your junior summer, you just lost your junior summer to get recruited. Same thing for a soccer player or football player that tears their ACL, trying to be able to get that clock ticking anywhere from the nine months to the year mark. Again, it's a very defined period of time, but using the analogy of the stock market, everybody's kind of up and down. We want to make sure that they're ready and again, our biggest thing, and I think anybody who works in sports medicine will tell you that the last thing you want to do is jeopardize two seasons for the same injury. So if you need Tommy John surgery, like I said, you want to get it done now rather than wait longer and even have some kind of put next year in some form of jeopardy. Greg: For sure, definitely. Are you seeing more, what would you say if you had to pick one age where you see the most Tommy John surgeries that you guys are required [00:32:00] to do, what would be the age that you you'd pick? What's your average age? Frank: I would say somewhere between junior year in high school and senior year in college. That's the, so if you want to pick an age, what is that 16 to 21? Greg: Yeah. Frank: If you read the research, it'll tell you, I think 17 to 19. So somewhere between again, junior year to junior year, maybe, but hopefully by the time that they; say it again? Greg: Which makes sense. It makes sense when those are the times when puberty's ending, they're getting stronger. They're almost throwing too hard for their body oftentimes, they don't have the lower level of capabilities to do things physically, but they can throw a baseball as hard as anyone else on their team. So you'll find those things kind of catch up to them with that age when they're strong enough to hurt themselves, essentially. Frank: Yeah. Sometimes these kids are growing at such a rapid rate that their bones ligaments, they're not able to adapt as quickly as they're growing. So you have that end of it. But [00:33:00] then once you have these big strong bones and you still have other things that are developing. It could be, maybe they're a little bit more fragile than they're expecting them to be. Greg: Yeah. Like they're trying to, it's almost like they're skipping the evolutionary process and just kind of skipping out of station and it's just like, I'm just going to throw a hundred miles an hour. And I don't care, I don't have the strength to support that sort of thing. We lost Trevor for a second. He was on his phone. He'll probably plug it in and come back on. It doesn't matter. We could do this without him, but something that, I wanted to bring up with you, there was a quote from Dr. Ahmad that I found, I think Trevor actually forwarded it to me on social media and then I kind of sent it over to you the other day. I just want to read one of these quotes, it was from a social media account that Dr. Ahmad had sort of consulted with the MLB in regards to opening the season back up and the potential for injury risk. So he was quoted as saying the corona virus pandemic may greatly compound and exaggerate the risk factors [00:34:00] associated with the spring Tommy John surgery spike. So that's something that we'll see with statistics that May, I think it's May, is usually the worst month for Tommy John surgeries and obviously this year is extremely different and it's interesting because I could agree with exactly what he's saying, that you should see this big spike and you should be able to worry about this sort of a reintroduction of baseball, but at the same time, I can actually almost imagine the flip side of the coin and actually think there'd be less. So I wanted to just talk a little bit about sort of your interpretation of the quote, if you've spoken to him about that topic specifically, and kind of just unravel that. I also, I'm not even aware of myself right now, today's the 12th of May. I'm not aware of what plans MLB has right now, if any, about opening up the season, first, do you know anything about that and then open everything else? Frank: All I know is what the media knows and from what I've heard, I think yesterday they came out and said, they're talking [00:35:00] about a July 4th opening day and spring training being in June. The article of Dr. Ahmad that you're referring to is actually Dr. Ahmad wrote a blog about COVID-19 and reinitiation of sports following. So he didn't directly speak to, he didn't have a phone call with Rob Manfred and say, hey, you got to be careful. I think it was, George King in the New York post that said that Yankees team doctor, warns MLB will see spike in ACL surgery. Greg: So that was my interpretation of how the media put it. So sorry. He did not consult with MLB, he just put his information out there and it was grasped and turned into... Frank: I've actually talked to Dr. Ahmad a lot about this over the last couple of days and even as we're seeing that from the beginning of this, we didn't know how long this was all going to last and what the post COVID world was going to look like. Now, as we're getting closer, we have a little bit of a better understanding as to how long guys are going to be able to ramp up for and stuff like that. So I think as [00:36:00] we're nearing the, again, with social distancing, no fans in the stadiums, the truncated schedule, we're still going to see injuries. Look, no matter what sport you're playing, no matter what level you're playing, it is not without risk of injury. So for guys that, and again, for whatever level they're playing at, whether you're a New York Yankee or on your hometown little leagues, Yankee team, the important part is you need to still have that ramp up to your season. So a lot of what I've been talking to a lot of people about recently is you have to be opening day ready, even though it's going to be in June or July. You're not mid-season ready. Yeah, you've had a lot of time, but what I think we'll see a lot of is that maybe you guys don't break down as quickly because they've had a longer off season. So maybe that world series hangover for teams isn't as prominent as it has been in the past. Greg: Right. Yeah, that was something that I was thinking about too with my initial thought is like, okay, so [00:37:00] all these people who are having Tommy John surgery, they're having injuries in May, what is the archetype type of that athlete? I'm thinking of that athlete as somebody who probably didn't prepare themselves, obviously it's preparation aside, you could prepare perfectly or not at all and still be injured regardless. So we're not talking about that, but I would think that the athletes that are probably getting injured in that May time-frame were ones that probably didn't do what they were supposed to do potentially, leading up to the season. Maybe they didn't throw enough. Maybe they threw too much. Maybe they lifted too much. Maybe they didn't lift enough or didn't run enough. Didn't fan too much. So there's all these different variables, lots of factors here, but I would think that if you then give that same athlete a few extra months, and hopefully they weren't just here talking on zoom to other people, they were actually doing things with the strength coach or independently throwing with somebody, doing their bullpens, [00:38:00] getting their bullpen session work in at a high intensity and if you're going to do let's say a once a week bullpen is sort of what I've been recommending for a lot of these athletes so that they stay fresh and sort of ready to go when the time comes. I feel like if you were to do that once a week bullpen at a high intensity and you have all these other factors sort of in a controlled environment, I feel like you can also potentially reduce the risk of injury when it does sort of get to the point when we're talking about July 4th, starting by then you would have had all of June, all of May, all of April to essentially prepare yourself as opposed to potentially showing up for spring training in February, end of February, whatever it is, and then only having March to kind of ramp yourself up for April. So I don't know. It's just an interesting thing in general to think about and makes you think about just athlete preparation in the big context of how we like to prepare athletes and just wanted to kind of hear your take on that. But, yeah. Do you [00:39:00] have anything else on that topic at all? Or what do you think about what I would, my thought processes, I'm an idiot. I don't know. Frank: Not at all. I think you have a lot of the good principles and a lot of; we're on the same wavelength in that regard. I think some of what I've been talking to our athletes similar to you with the one bullpen session a week is what I've been telling kids. I've been saying, look, throw your regularly scheduled bullpen at your regular effort but then if you want to have a mechanics day or another, a second bullpen session, maybe make it less. Or instead of throwing a 35 pitch pen, throw a 20 pitch pen and work in and out to hitters or make it a little bit more fine tuning, but don't make it a full effort all out battle. So you're throwing two bullpen sessions. You and I have talked about this multiple times over various off seasons. You're not just going to shut down, throwing completely, marathoners don't just stop training. Well for baseball players they don't get to stop training. They [00:40:00] just have to lower the intensity and the frequency that they're doing it. You have to be smart about it. They have to have good resources to do it and not just say, oh, I'm going to throw every day, Monday through Friday from November to February, it's not going to happen because then that's where you're going to see the biceps tendonitis and all the other lingering things that could have been avoided. So it'll definitely be interesting to see what happens this season with a shortened schedule with longer off season too technically, even though they did play a few games back in March. Greg: Yeah. I guess Trevor's still [41:09inaudible]. Trevor: Yeah, I'm back. Sorry about that.  My phone was plugged in charging and it's still died on me. Greg: Oh, well, Frank and I were just talking about baseball coming back, the potential for injury rescue either being higher or lower and how you can kind of argue it either way, just depending on, yeah like Frank just mentioned, you can have a longer off season, which potentially could help you out and make you less likely to be injured or [00:41:00] you could not be ready if you're having this sort of abrupt okay, we're starting July 4th and then it's like, you know, you're not either mentally prepared for it or you don't have the things in place to get ready for it. But, I know, Dr. Ahmad we mentioned also does a lot of ACL surgeries, which was one reason I wanted to have Trevor on here for sure because Trevor with what we do with resilient, Trevor is doing a lot of work with a change of direction, sports court, field court sports, basketball players, soccer players, all sorts of change of direction-ish type sports. That's sort of like his expertise for us. So we're always asking him questions and he's diving deep into that. So I wanted to talk, just bring up ACLs a little bit, have you guys talk a little bit about that and you can even talk about the patient you guys are currently sharing most recently, if you want to, I know you were sending videos yesterday about some stuff, so I don't know, just kind of take it and run with it, Trevor, if you have any questions or whatever. Trevor: Yeah. I think it's interesting because ACL research has kind of all over the place in terms of, [00:42:00] what causes it, it can be a lack of hip rotation, too much hip rotation, knee valgus. There's so many different things that you can kind of, whatever point you want to find as this is a big risk factor for an ACL injury. You can find some sort of research article that seems to prove that from what you guys see and your ops in general, what do you think are a couple of the big predictors for ACL injuries? Frank: So actually to your point about the research, I read something, I think, back in college, that said limited ankle dorsiflection could potentially be in that realm of predisposition. So for us, what we see the mechanism of injury is typically the same. It's that internal rotation deceleration, you get that twist, pop, done. The athlete goes down or maybe they walk off the field going this just doesn't feel right. In terms of like the makeup of the athlete. It's the hip, excuse me, not the hip, the quad hamstring ratio is one of the bigger [00:43:00] things you got either; somewhere, there's a deficit, 90% quad, 10% hamstring and vice versa. Wherever the athlete falls into, but usually when we're seeing them their knee has a huge effusion. It's a couple of days after the injury and sometimes it's hard to tell, just based off of that guarded exam, what they're actually looking like. So as a physical therapist, you're able to see them in the pre-hab phase, get them down to some level of baseline, get rid of that inflammation, get that huge diffusion gone and then range them, make sure that they have the functional movement to have surgery. So similar to the patient that we're sharing now, she had knee diffusion following. We needed to get her into pre-hab beforehand and then kind of build her up back to baseline, essentially. So, she's a little bit more quad dominant, I think in general. So again, it's the imbalances that is unique to each [00:44:00] patient. So I'm not going to take out a goniometer to measure ankle dorsiflection, every patient that walks in, they're all, well, maybe this is maybe this isn't, but I think just a quick visual examination of somebody for, for my purposes can be sufficient. Although I won't be able to put my finger a hundred percent on it. Greg: Yeah and you shouldn't necessarily have to be able to tease out the cause because if somebody is lacking ankle dorsiflexion as an example, which could put them in a bad position to load their knee. That's something that we should be working on regardless. It's a limitation that they have and as a human before they're even an athlete. So if you want to walk, you need some dorsiflection. So there are things there that we should be addressing regardless and that's where we need to be looking at everything. So it almost, doesn't, almost like doesn't even necessarily matter. It does obviously, but it's just a matter of we have to be looking at everything and addressing limitations that we're finding no matter what. So just one. Frank: And that's a lot of where it comes into in the postoperative phase. Like, hey, these are [00:45:00] your balances. There are so many different movement screens out there these days, whether you're the FMS or some type of maybe a sensor movement screen, or even a markerless motion analysis. There are so many tools out there. I don't know what the lay population or the everyday the high school, college athletes. Obviously, I'm not talking about division one. A lot of them are doing movement screens at school, but some of the other, maybe the D2T3s they may have the resources it's so scattered, no matter where you go, it could be a regional thing too. I know in New York, there's only one markerless movement screen. It's out on Long Island, I don't know of anybody else between here and Baltimore that has one. So, for that is one thing, but a lot of what I rely on, if I was on the sidelines, different story, I would want to assess with the athletes, see what they're doing, especially high risk ACL patients. I want to know what my football wide receivers are doing my cornerbacks. I want to see what my volleyball players are doing because when they're coming down from a jump, our female basketball [00:46:00] players, I would tear it based off of the seasonal needs. Based off of the gender really does play a role in that. We obviously see more in female athletes than male athletes. So a lot of that is where I would start. But for my purposes in the office, I leave that to you guys and really let you kind of filter in or out what you need. I think that's the more important thing and seeing what they need in the rehab, because then you can make a comprehensive rehab program for them. It's not just a paper script and that's the difference between a good physical therapist and somebody that maybe is a little bit weaker. Is you guys are able to fill in the gray and make sure that, hey, if it's not on the script, it doesn't mean you can't do it. I just have to integrate it in the right point in time. I don't have to spell out everything for you guys, but you know what guidelines need to met and where. Trevor: Yeah, that's something I think Greg and I talked about with just all of the post-op people that we see, it's like, we want to know what is completely counter not indicated at this point in time, for whatever reason, whether it's tissue [00:47:00] healing or if it's some kind of going in going on like that, like the running thing, for example, don't talking about, it's like, you know, structurally, like they may look ready, but; or physically, but from a structural healing standpoint is the graph not ready at this point in time for just a higher level of stress and then that's when we have to be playing a little bit more of a waiting game and building up other qualities during that time. Greg: It's like, we'd rather know exactly what we're not allowed to do; tell me what I can't do, because then everything else I'm going to do based on what a normal progression would be like, anything. Frank: Yeah. A lot of with the, in the rehab process, the return to play or return to whatever process that looks like, just because you hit three months after an ACL doesn't mean that you're ready to run. Trevor: Totally. Frank: You might be able to, but are you functionally able to do it? Is your strength there? Do you have an effusion still? Little things that maybe just float off the top of your head that you're like, oh, maybe it's a little swollen today, but it's been going back and forth like that for the last month. It doesn't necessarily mean [00:48:00] that you're ready. It doesn't necessarily mean that you're not ready. What's your stress? There's so many different permutations that go into that, that it's tricky and it is so individualized. We can use the nine month mark for return to sport for a soccer player, following an ACL but you look at Adrian Peterson a couple years ago and, put my foot in my mouth. Trevor: Yeah, exactly. Frank: And I know that, but it's not that easy to get back to football in seven months, that's unheard of. Greg: And he, I mean, he was a freak to begin with. So if you take somebody who's a freak before surgery, it's going to be easier for them regardless and that's what you're talking about earlier with the pre-hab stuff. Frank: Yeah, look at the professional level. What a lot of kids don't see and even at the college level, the high school level, the college level college kids are able to put in a lot of time into their rehab, the high school kids, maybe not so much, but the higher you go in your athletic career the more resources there are [00:49:00] for you and the more time you have specifically to dedicate to your rehab. So the more you put into it, no matter what you're talking about in life, the more you're going to get out of it. Trevor: Definitely. Yeah, that's a great point. I think that the time resource is such a huge thing, it's like, why do some people progress faster than others? It's like, if you have the resources and you have the time, and that is literally your job is getting ready for your sport, you're going to be back a lot quicker than if you're a high school kid in classroom eight to three, Monday through Friday, and then you got to go to church and all of a sudden stuff on with the parents on the weekends, you can go to PT for. 30 minutes, two to three times a week. It's like, yeah, it's going to take you a lot longer to get back to your sport rather than the Asian patient example, where he has everybody at his disposal, 24 hours a day, seven days a week for seven months to get ready to go play in the NFL. Frank: It could be something as simple as making sure you have an ice compression machine at home. Trevor: Yeah. Absolutely. Frank: Game readies are becoming more and more available to people. No matter where they're having surgery [00:50:00] nowadays, it's there for you. You can have it at home, but if you're not going to use it. It's a wasted resource and maybe it's not going to shave three months off of your return to play timeline, but maybe it shaves a couple of days off of your getting your strength back or something as, something that I'll say is my new comparatively, but it is important in the long run. Trevor: Definitely. I think knowing what to emphasize when is such a huge part of that process for sure. Any Greg: Any other questions for Frank here or Frank any other questions for us? Frank: Oh, man. Greg: Put you on the spot there. Frank: Yeah. Seriously. In terms of your progressions for whether it's a UCL or an ACL, obviously you guys have the; no matter who gives you the parameters to go by you guys. [00:51:00] are you able to, you know who to push harder, who to kind of pull the reigns on, but how do you keep those two kids? This kid you can push hard. This one you can't, and they had surgery near the same time. How do you kind of keep them competitive while rehabbing and how do you kind of not, I don't want to, you're going to keep not, you have to be mindful of like how hard you're pushing again, but able to challenge them in the same way so that they're both on the same timeline and they're not pissed off that somebody is ahead of the other? Trevor: I think our situation in Chatham is awesome because we're at a sports performance facility. So when we're working with injured athletes, there's 30 healthy athletes, all running around training outside. So I think just being in that environment really makes people want to work harder. like with your example, what just comes to my mind is just like, it's more of. [00:52:00] people that are afraid of certain things and they're kind of afraid of being injured and just really doing whatever we can to build up the trust and explain to them I'm not going to let you do anything that I'm genuinely afraid of you hurting yourself. We're going to take things as slow as you feel comfortable with and as long as you feel confident, we're going to keep progressing and we're building qualities that are going to help you get back to your sport. So we have to get strong before we're running. We have to be able to do some plyometrics before we start sprinting and all that kind of stuff. So I think regardless of the age and you talk different to a junior high kid versus a college kid, but just trying to make sure they feel comfortable and are confident in the process and understand why we're kind of doing what we're doing. I think that really makes just a huge difference and like telling them like, dude, it's okay to be a little bit hesitant as we start to move your feet in this way again, just a little quicker than you have and you're so used to having two feet on the ground all the time. Now I'm going to take one of those feet away. We're going to do some single leg stuff. It's definitely scary at first, but the more you practice it more, the more you're  going to be [00:53:00] comfortable with that and then things start taking off from there. Greg: Yeah. And then there's definitely sometimes where like a patient, maybe they had an expectation of what they were going to be like by a certain time-frame and in their mind, they're almost worried that they're not there yet. Then it kind of goes back to them being afraid too because if they're afraid and they're not at that point in their sort of progression that they expect to be, then I think they're oftentimes it's like a perpetuating cycle of being afraid. So I find that I have patients that are like coming in and out of my mind right now, as we're talking about this and, yeah, I mean, it's like some patients, I feel I can talk more with and kind of explain more about why we're doing certain things and they should make sense. It should be logical. I've had patients say like, oh, well my, I was told I should be running now but we haven't squatted anything close to half of your body weight yet. That's probably not a good idea. We need [00:54:00] to bring things up and kind of meet your functional sort of like timeline and milestones so that you can run and doesn't that make sense? If you expect to run, you should probably also be able to squat. That's a pretty straightforward thing and then usually it's like, oh yeah, that does make sense. Definitely and, you know, it's been so long and we've done all of these other things already that are similar to squatting, so you're definitely ready and it's just building like a confidence with them and then I oftentimes find the patients that are asking a lot of questions where they're very, they're worried and their questions are coming from a worried place or afraid sort of a place in their mind. I try to almost say less and just say like, yes. Yep. You're good. Yup. That's awesome. Keep doing that and it might not be perfect, but it's okay as long as they're exposing themselves to things in a safe way, and I'm not there correcting them and being so picky because that's going to then perpetuate this thing of like, oh, well I'm doing my exercises at home and Greg said this and this very [00:55:00] specific thing, it's like, I'd rather they did it, you know, 75% perfect and didn't have me in their ear and felt more confident, less afraid and then they're going to run with it and they're going to just build that confidence as they go. So I think that kind of answers your question. Frank: And you guys brought up to two really good key words there are expectations and afraid the psychological aspect of this, no matter what your goals are, can really be debilitating and for those kids using two kids that are the same age, it can be a mountain out of a molehill for another kid. And the other kid might wake up the next day and say, all right, I'm ready to get back to doing anything and they are kind of unfazed by it. Trevor: We definitely see that. Frank: What's that? Greg: You guys are doing some research on this stuff right now aren't you? Frank: We are. Greg: In the midst of it so nicely to plug that and if you don't have anything [00:56:00] more to talk about, it's already been over an hour. We won't take too much of your time up. It's been great talking to you, but, anything else first before we kind of sign off? Frank: I got nothing, thanks guys. I really appreciate that. This is awesome. Greg: One more question you got to show us your favorite piece of memorabilia in the room. I would think it's probably what's right behind you, like showcased with all those signatures on it. Frank: This thing is one of definitely my more favorite pieces. I got so much stuff down here. Actually, I think the most sentimental piece down here that I have is my college Jersey that I have hanging up over there but this thing, if I want to show you the coolest thing, this is probably just because it's bigger than murder asa well and, it's a lot of MLB grades that, we're fortunate to have their signatures on there too. Greg: Yeah. And that's yeah, that's pretty cool. So yeah. Frank gave us a nice little tour of his little man cave here with all of his memorabilia. He's a Big Yankee fan. Trevor: There is many baseball hall of fame that he has. Greg: It is a little baseball fan for sure. Frank: It's not a [00:57:00] bad place to be quarantine when you're a baseball guy Greg: And you've got a TV over on the side of the room over there. So you're set. Frank: Yeah, it's sitting over here. It hasn't been done that much today, but a lot more work today than play. Greg: There you go. yeah, but, this was great. I think, we'll have some good questions potentially that come out of this. We're trying to sort of solicit questions from people as we do these things because we're doing sort of like little round table discussions between Trevor Doug and myself and think it's just cool because we're we want to talk about a lot of things that are applicable and how we actually do things and we're calling it our, keep it real round table, try not to over-complicate things. So it's great to talk to someone who's doing just that. You're keeping things simple and doing things, you're mastering the basics and doing a good job with your patients and it's been great working with you and it makes our lives a lot easier working with someone like you and all the other trainers at the gym and Chatham as well. Frank: Definitely guys working with you guys is awesome as well. The biggest thing for all of our [00:58:00] patients, no matter or just patients in general is you just got to make sure that they have good communication between the offices. I can't overstate that enough and that is really patients love that there is over-communication then other patients don't like that there's over communication, but then everybody needs to be on the same page and make sure that we're all doing what's best for the patient. Trevor: Absolutely. Yeah, that was the goal. Greg: Awesome. Well, keep on keeping it real. Thank you. Trevor: Thank you, Frank. Frank: Definitely guys. Thanks for having me. I'll talk to you guys soon. Greg: Alright. Take it easy. Frank: Bye.