Starting Strength Podcast | Physical Therapy Done Right with John Petrizzo

[Mark Rippetoe]

She has also gone from an underweight 49kgs to a good 53kgs (so far), but the orthopedic professor warned against the weight gain given that it will load the skeleton further.

Stop for a second and think about this. These people have become so removed from the physical world -- the world they presume to rule -- that this bizarre statement has become professional advice worth paying for. But this is the norm.

I am currently in PT to rehab my shoulder. I'm 5 weeks out on decompression, Mumford and spur removal on my left shoulder. Would love to know how exactly you rehabbed.

The external rotation is taking the longest to come back.

And the reason you think that the external rotators are slow in coming back is because you are being told that they function in isolation as external rotators of the humerus. They do not. The only time they actually do this in in the PT office. Think for a second: have you ever performed this motion outside of the therapy appointment? Ever? Even once? Their actual anatomical function is as humeral stabilizers -- they maintain tension on the humeral head, keeping it seated in the glenoid. They also happen to externally rotate the humerus if you construct an artificial situation in which this can be done with a tiny weight -- that cannot make anything stronger.

Presses and chins require that the humeral head remain stable in the glenoid, and all the muscles that perform this function are involved in these movements. ALL OF THEM. So, if you press and chin/lat pull, you are working all these muscles, including the injured ones, and doing so in a more normal anatomical context than in isolation with a 3-pound dumbbell or an elastic band. In the systemic context, the injured muscles work while (whilst?) being protected by the healthy muscles adjacent to the injury. As they heal, they assume a greater share of their normal anatomically-assigned role. And this is the basis of correct rehab. Typical isolation-based PT is not.

[Gustafson]

And the reason you think that the external rotators are slow in coming back is because you are being told that they function in isolation as external rotators of the humerus. They do not. The only time they actually do this in in the PT office. Think for a second: have you ever performed this motion outside of the therapy appointment? Ever? Even once? Their actual anatomical function is as humeral stabilizers -- they maintain tension on the humeral head, keeping it seated in the glenoid. They also happen to externally rotate the humerus if you construct an artificial situation in which this can be done with a tiny weight -- that cannot make anything stronger.

Presses and chins require that the humeral head remain stable in the glenoid, and all the muscles that perform this function are involved in these movements. ALL OF THEM. So, if you press and chin/lat pull, you are working all these muscles, including the injured ones, and doing so in a more normal anatomical context than in isolation with a 3-pound dumbbell or an elastic band. In the systemic context, the injured muscles work while (whilst?) being protected by the healthy muscles adjacent to the injury. As they heal, they assume a greater share of their normal anatomically-assigned role. And this is the basis of correct rehab. Typical isolation-based PT is not.

They actually don't have me using any weight yet, just streaching. I can get my arm overhead but its well foward from the lockout position of the press. Im definitely growing impatient with rehab, as I was released with "no restrictions " from surgery.

I did purchase a 15lb. training bar to use to start pressing again, as soon as possible. Im just being told "not yet" by my PT.
I aware of your position on PT, how and when would you suggest I start pressing again?

Couple more pieces of info that might be worth while:
male, 39, 180lbs.(normally around 195). I also have osteoarthritis in my GH joint in the left shoulder, which is what led to the surgery in the first place.

[Mark Rippetoe]

I'll have to make a video.

[Joe Jaloszynski]

I discussed this podcast with my wife. She is a social services director at a medical rehab facility. When I told her of PTs not "progressing" clients, she was amazed that some therapists don't do this. The therapists at her facility don't use barbell loaded movements, but apparently they all keeps logs of the patients' work and use a basic adaptation model. I was happy to hear that.

[spacediver]

in my experience with physio, the progression has been to either increase the number of reps per set (e.g. week 1 = 15 calf raises, week 2 = 25 calf raises), or to switch to a completely different exercise (e.g. week 1 = calf raises, week 2 = skipping). The closest thing to a load progression that I was told to do was to switch from calf raises on two feet to calf raises on one foot, which effectively increases the load from 0.5 x bodyweight to 1x bodyweight.

[John Petrizzo]

I discussed this podcast with my wife. She is a social services director at a medical rehab facility. When I told her of PTs not "progressing" clients, she was amazed that some therapists don't do this. The therapists at her facility don't use barbell loaded movements, but apparently they all keeps logs of the patients' work and use a basic adaptation model. I was happy to hear that.

Generally, subacute rehab facilities generally have to keep much more detailed documentation than outpatient PT practices. Similarly, patients are often discharged based on attaining certain functional goals such as "walking 100 feet independently." In my experience, there is more pressure in these facilities to discharge patients quickly because the longer they are there, the more likely they are to have complications that the patient's insurance company will not pay for. In contrast to that, most outpatient PT facilities do not have the same incentive to push patients to do more and ultimately discharge them. It is generally the opposite scenario where the outpatient facilities try and get as many sessions paid for as possible.

Most of the discussion of PT on this board relates to the typical outpatient experience as it is currently practiced.

[Gustafson]

In contrast to that, most outpatient PT facilities do not have the same incentive to push patients to do more and ultimately discharge them. It is generally the opposite scenario where the outpatient facilities try and get as many sessions paid for as possible.

Most of the discussion of PT on this board relates to the typical outpatient experience as it is currently practiced.

This was bothersome to me because my surgeon told me "wouldn't really have much recovery" after surgery. But then the PT tells me my recovery period is similar to a broken bone. So go to PT 2x a week for 1.5 hours each trip doing all the static stretching, pulling my arm over head w/ a pully, external rotation w/ stick ect... When really the only thing that seems to be of use is when the PT stretches my shoulder out which takes maybe 15 min.

It dose make me wonder if the PT was necessary for recovery. Or is it just a waste of time and money?

[Frayedknot]

The 3-lb dumbbell story made me laugh. John's general description of outpatient PT was spot on in my experience. When I started PT for my cervical disc issues, I warmed up on the hand bike. I then got a massage. Usually I then started e-stem after that. Then I did some rows/face pulls with a light band followed by bent-over rows with a 3-lb dumbbell. I finished with cervical traction (only useful thing in the place).

The bulging discs caused me to lose ~80% of my strength on my right side. The 3-lb rows were beastly. However, on my second visit the PTA hands me the same 3-lb dumbbell. I tell him that I used it the first time and I needed to go up. I might as well have questioned his mom's character. He and the PT consulted for much longer than needed. He came back with some story about how they don't usually increase the weight........."...but if you want too, go ahead."

I went back to get the correct diagnostic codes so that my insurance would pay for my own cervical traction device. I rehabbed myself using face pulls, chins...and SS. My PT told me to never do any overhead barbell movements. Since then I've pressed 225 for a single...10 lbs over body weight.

My wife claims I'm hostile towards the PT profession. I prefer "dismissive".

[JasonJones]

RE: Mumford Procedure

I had a mumford and bursectomy two years ago, age 30. I began pressing with a wooden dowel within 48 hours of the procedure, and began using one of those gimmicky body blast bars with cement weights (1kg increments) within a week. Performed my first chin after 5 days, IIRC (might have been within 5 days of having my sutures removed, which would be approximately 12 days post). By my six week check up I was pressing 75% of my pre-surgery weight. By three months I had set a new PR in both the press and the clean.

To this day I have not performed an "external rotation" or used a band for anything other than slapping the ass of an attractive co-worker.

[John Petrizzo]

This was bothersome to me because my surgeon told me "wouldn't really have much recovery" after surgery. But then the PT tells me my recovery period is similar to a broken bone. So go to PT 2x a week for 1.5 hours each trip doing all the static stretching, pulling my arm over head w/ a pully, external rotation w/ stick ect... When really the only thing that seems to be of use is when the PT stretches my shoulder out which takes maybe 15 min.

It dose make me wonder if the PT was necessary for recovery. Or is it just a waste of time and money?

It is hard for me to say without knowing more about your surgery, but my general experience has been that a lot of the orthopedic surgeons I deal with greatly downplay the recovery after most surgical procedures. Most of my post-op patients are genuinely surprised at how much pain they are in post-op and how long full recovery often takes. That doesn't mean that your time in PT could not have been better spent, it just means that just because the surgeon said there wouldn't be "much recovery" doesn't mean that is always the case.

The 3-lb dumbbell story made me laugh. John's general description of outpatient PT was spot on in my experience. When I started PT for my cervical disc issues, I warmed up on the hand bike. I then got a massage. Usually I then started e-stem after that. Then I did some rows/face pulls with a light band followed by bent-over rows with a 3-lb dumbbell. I finished with cervical traction (only useful thing in the place).

The bulging discs caused me to lose ~80% of my strength on my right side. The 3-lb rows were beastly. However, on my second visit the PTA hands me the same 3-lb dumbbell. I tell him that I used it the first time and I needed to go up. I might as well have questioned his mom's character. He and the PT consulted for much longer than needed. He came back with some story about how they don't usually increase the weight........."...but if you want too, go ahead."

I went back to get the correct diagnostic codes so that my insurance would pay for my own cervical traction device. I rehabbed myself using face pulls, chins...and SS. My PT told me to never do any overhead barbell movements. Since then I've pressed 225 for a single...10 lbs over body weight.

My wife claims I'm hostile towards the PT profession. I prefer "dismissive".

As you have observed and Rip has spoken about many times, the typical outpatient PT model is generally a waste of time for anyone who has any serious training history. Most PTs have no educational or practical experience in dealing with the population that frequents this board.