• Misbah Haque

Part 1| Bulletproof your creaky knees, wonky hips, and weak ankles w/ Dr. Sean and Dr. Jeremy

If you’ve been living with acute pain and just accepted it as “part of the game” -- this conversation is a great place to start. It won’t replace a practitioner, but you will get quite a few actionable tips and tools you can try at home. Dr. Sean and Dr. Jeremy have worked with CF athletes like Brooke Wells, Brooke Ence, Sam Briggs all the way to Olympic caliber athletes. They’ve systemized a strength program that addresses pain for ankles, knees, hips, shoulders, back, and more.

In this episode, some things we talk about:

  • Assessments, exercises, and ratios you can use to find the root of your problem

  • Do you need more flexibility and mobility work? Will couch stretching make your hip flexor tightness disappear? Or do you need to move on? And if so, to what?

  • Why and how would working on one leg or one arm helps you get more pullups or a higher squat?

Show Notes:

  • How confident are you that this will work for 10 different people with knee issues? (4:00)

  • What should you look for in a practitioner? (9:00)

  • Why do PTs and Chiros use manual therapy? When is it appropriate? (10:22)

  • The fundamental difference between PTs and Chiropractors (12:20)

  • Why do we feel the sensation of “tightness”? (15:20)

  • What is the root problem? The 3 most common areas to start looking (18:25)

  • Using the assessments (19:16)

  • What place do activation and motor control exercises like glute bridges and wall slides have? When are you ready to move onto things like suitcase deadlifts and carries? (26:00)

  • Knee pain -- where to look, what to do, why? (30:00)

  • The ratio for Deadlift to Back Squat for the general population vs elite athletes (33:30)

  • Working on one leg is going to help you get better...here’s how (34:30)

  • Ankles -- two at-home exercises to try (38:00)

  • Misaligned hips -- why are adjustments from your chiropractor not staying there? (41:20)

Resources we may have talked about:

  • Hierarchy of needs

  • Movement Screen/Assessment

  • Bulletproof Shoulders, Back, Knees, Lower Body, Ankles, Hips

  • Bulletproof Coaches Course

How you can connect with Sean and Jeremy:

  • https://performancecarerx.com

  • http://www.livetheactivelife.com

  • Instagram: @activeliferx

  • Instagram: @bulletproofrx



(00:00):


This is Dr. Jeremy and Dr. Sean, and you're listening to the airborne mind show.


(00:21):


Hey guys, Misbah Haque. Thank you for tuning in today. We are going to be talking with Dr. Sean and Dr. Jeremy from performance care RX. If you've been living with acute pain and you've simply accepted it as just a part of the game this conversation is a great place to start. It's not going to replace a practitioner, but you will get quite a few actionable tips and tools that you can start trying at home right away. Dr. Shaun and Dr. Jeremy have worked with CrossFit athletes like Brooke Wells, Brooke ants, Sam breaks all the way to Olympic caliber athletes. They've systemized a strength program that addresses pain for ankles, knees, hips, shoulders backs, and more so in this episode, we're going to talk about assessments, exercises, and ratios that you can use to find the root of your problem. Some questions that we'll answer are, do you need more flexibility and mobility work is couch stretching going to make your hip flexor tightness disappear, or do you need to move on?



(01:16):


And if that's the case, what do you move on to? Why and how would working on one leg or one arm helps you get more pull-ups or a higher squat? These are just some of the things that we talk about. This was such an enjoyable conversation. We went on for about an hour and 40 minutes, which is why this is split up into two episodes, but I guarantee you're going to walk away with tons of stuff that you can just start trying. Tomorrow, before we get started head over to the airborne mind.com and grab your movement, audit checklist, this is something I've put together, which is designed to help you figure out what am I not getting enough of in my training? And if I had 10 to 15 extra minutes to focus on these weaknesses, what would I spend that precious time on?



(01:58):


We've had Zach Greenwald, Travis mash, Julian Pinel, Dave Duran, Dr. Shawn, Dr. Jeremy, all on the show, and they've given us some valuable ratios and assessments that we can start using immediately to objectively figure out, you know, where you need to put in the work. If there's one thing that you've gotten out of any one of those episodes, it is that if you have certain deficiencies or strength, balance issues, you are much more likely to get injured. You are much more likely to experience aches and pains, and you are much more likely to plateau. So definitely go grab that. I guarantee that you will walk away with something from that. And with that being said, please enjoy the show Dr. Shawn, Dr. Jeremy, thank you for joining us.



(02:43):


I am really pumped to have you guys on the show because I feel like a majority of the population who may be CrossFitters. And even if you're not a CrossFitter at some point, if you have not already, you are going to experience some discomfort and you know, you might have pain in one of the areas that we might be talking about today. So you guys are about to really drop some massive knowledge. And I really appreciate that. So to kick things off, let's kind of tell me the story about how active life RX came about. I know you guys have your own practice, you have a CrossFit gym, and then Bulletproof RX walk us through a little bit of that journey.



(03:21):


Well, I guess it started I was still living in Croatia running a gym out there and treating patients. And we kind of, my wife and I had had a child. We wanted to move back to the U and, you know, be closer to our family. And I made a trip back to go to a seminar. And Sean and I have been in school together. So I gave him a call. I knew he was running a CrossFit gym and practicing very similarly. So I gave him a call just to see what he was up to. I wanted to see what I was getting into when when I came back and, you know, I always stopped in, had some dinner, hung out a little bit and just kind of was like, all right, see you later. And then he called me, he was like, Hey, I need a partner. So so I was like, perfect. That, that makes great sense. And probably what, six months later after we moved back and we started practicing chiropractic together and started putting our minds together and coming up with the system and, and, you know, using it on people day in and day out.



(04:17):


And so where did the idea for Bulletproof RX kind of come from? Was that just over years of kind of testing what you were doing with actual patients and then eventually kind of systemizing that


(04:28):


Well, so active life RX and Bulletproof, our extra Instagram handles, you know, w our, our business is active life and Bulletproof is what we call our programs, right. So what happened was we basically looked in their situation and we were like, we're, we're doing a really good job helping people one-on-one, but there's a lot of people who either a can't afford what we're doing, or don't want to afford what we're doing or B don't have the time in their day to do that, or see aren't that serious about their competitive performance, where it makes sense for them to be paying for one-on-one programming. So we basically took a real long hard look at what we were doing, what people were having the most trouble with overall. And we developed a system that we can put those things all into a program for them. And the idea of it is that it's much less expensive to have a little bit less access to us and our staff, but eventually on those programs, they're going to get what they need, even if it's not immediately, like it would be in the one-on-one.



(05:27):


And I also feel like it's a great way to kind of make it a little more accessible, because a lot of people, even though they know they may, they should go see a practitioner they may delay that, or they just might not get around to it for a very long time until, you know, they're on the verge of breaking and it might be a little too late. So it seems like a great way to kind of you know, include this into your routine. And it's 15, 20 minute sessions are each of your workouts, right.


(05:54):


They can run 15, 20 minutes sometimes a bit longer, depending on how much you talk to your friends in between.


(05:59):


Okay. now how difficult was it to really kind of systemize all of this? Like, so, you know, if you have 10 people that are kind of having trouble with, let's say their knees how, like, how are you confident that this kind of will work for most of them without diving into each person individually?


(06:18):


Well, through, I don't know how many years of experimenting and reading and, you know, doing it in practice and doing it, the gym, you ended up you know, boiling down to these, these common denominators in knee pain or hip pain or ankle pain. And, and that's where we started. It was like, okay, you know, through, through seven, eight years of practice, we see this, this, and this in the clinic, we see this in the office or then the, in the gym. And how do we address that with, you know, with programs and that's really what, it's, how it started and saying, okay, like this is a risk factor. This is a risk factor. We're gonna, we're gonna take care of it to piggyback on that a little bit. We actually started off and we thought that we'd be able to have Bulletproof shoulders, Bulletproof legs, and be done where it was our idea for legs. But as you know, legs should be able to handle the knee, the ankle, the hips, and the low back right shoulder should be able to handle the shoulders. So, so what else really is there that would be viable to write a program for, and here we are now, like eight months after we started and we have legs, hips, knees, ankles, shoulders, and we're about to elaborate on every one of those programs and have more tracks within them



(07:29):


Right now. Do you ever get people who are maybe, you know, like, so beat up are so broken that the, you know, the Bulletproof program might not be enough, so, you know, maybe they need to go see a practitioner they need to, you know, have one-on-one coaching with you. Like, what's the approach for that?


(07:47):


Absolutely. we first of all, like our programs will not replace a practitioner and there are instances where, you know, getting essentially an early intervention will prevent having to go see a practitioner, but there are certain red flags that we're going to find where it's, yes, you, you need some hands-on therapy to really get to the root of your dysfunction. It's going to be faster. You're going to feel better. It's going to unload that joint and working with the Bulletproof program, the Bulletproof program is a bridge from that, from that manual therapy back into the gym, because that's another thing that we find is, you know, maybe the PT or the chiropractor gets them back to regular life, but they want to do more than regular lives. They want to, they want to be in the CrossFit gym and they kick, but, and there's a gap in the current model there.


(08:33):


You know, you also have people who who've had chronic chronic injury and there's a certain amount of psychological overlay that goes with that. And those are the people that are going to need some more one-on-one to really start to help redefine it and talk out what's what's going on with their body and why they're experiencing pain. And we also have, we also have the forum, which is helpful for the Bulletproof, which is it's certainly not one-on-one. And like Jeremy said, we're not going to replace a practitioner, but we have people who constantly will ask us questions on the forums that we have. And when they use those, there are many, many instances in which we'll ask for a zip code and find them a responsible practitioner in their area, so that they actually go beyond just having to find someone themselves. We provide them with the support, because we understand that we're not going to replace that person on the ground.



(09:20):


That's really useful. Now, how do you guys kind of go about choosing that right practitioner? Like, what are you looking for in somebody at that point?



(09:27):


That's a good question. We start with, with where we learned, right? So we've been fortunate to have a lot of education from Dr. Bill Brady who started integrative diagnosis. And he has a website, integrative diagnosis.com, where you can go on there and look for a provider who is practicing the in-person manipulation, the same way that we would in regards to soft tissue and, and general chiropractic. That's where we start. If we are unable to find somebody on that database, we'll go to active release.com, looking for an active release doctor who is often better than the standard doctor for no other reason than they're trying to be. And sometimes we'll even call offices for people and say, you know, this is what we're looking for in this area. Is, is your office going to go provide that?


(10:19):


Very cool. Now, could you guys explain the difference between, you know, why PTs and chiropractors use manual therapy versus, you know, teaching exercises and you know, using strengthening exercises like you guys are and kind of maybe when a, when is each appropriate?



(10:38):


Well, the reason why peaches and Kairos use more manual therapies, is that what we learned in school, right? That's that's, that is the meat and potatoes of our curriculum in Cairo, physical therapy, a little bit more exercise chiropractor, a little bit more spinal manipulation. And you're seeing both fields move towards a lot more soft tissue manipulation some of it in school, but a lot of it is post-graduate work and really that's that's, that's, that's their lane. They should own that. We should own that. As, as manual therapists, whether we're PTs or chiros or whatever because that's what we can have the most profound impact on that coach can, right? They're not allowed to put their hands on people. They don't have the license to do that. And so, so that's, that's their lane. That's what they're good at. There's also physical chiropractics chiropractors.



(11:23):


Haven't expanded out into exercise as much as we have, you know, we've been immersed in CrossFit gyms for years now and really using it every day and being able to use our clinical minds on our athletes and, and starting to do it. So I just, I don't think the education is in place right now for a lot of people to, to do this stuff. But it's, it's getting there there's more and more people doing it and getting better, better and better at it. We were also both in fitness before we were in CrossFit, right. And so it's not like I stumbled a level one Monday and said, Oh, this is how I, this is how I exercise. I had been providing continuing education for personal trainers at Equinox three years prior to coming on to CrossFit. And I know you were doing some stuff with athletes as well before you started. So I think for us specifically, it's having the background of being frustrated with what our license enabled us to do based on the education that we were provided and saying, how can we stretch the scope of what we're really good at.



(12:21):


Now, I love to ask this question to kind of every chiropractor, every physical therapist I come across. And it's just interesting to hear all the, you know, everybody's version of the answer, but could you explain kind of the fundamental difference between you know, chiropractics or chiropractors and physical therapists and kind of the school of thought behind each?


(12:43):


Well, I think there's earliest traditional PT and chiropractic, and now there's this, this evolution that we've really seen in the last, I guess, because since I've been aware of the last 10 years, right. And what Kelly starts really pulled forward, in my opinion in traditional physical therapy, it's a lot of exercise and stretching. It's very fundamentally, you know, like let's make it longer, let's make it stronger. Traditional chiropractic is let's adjust, let's, let's manipulate joints, whether they're spinal joints or extremities. And so that's, that's the core of both of those, you know, if you go back probably 30, 40, 50 years but what we're seeing now more is this, this evolution and this best practices and people saying, well, that that's just not good enough. It's not, it's not successful enough. As far as taking care of the population that we are catering to and, and you're starting to see a lot more like a lot more PTs and chiros practicing the same way, like, you know, you know, go out on the road.



(13:40):


And I don't know if they're a physical therapist or chiropractor, unless they tell me because we're a lot of us are doing the same stuff. And I think that I think that's great though. The kind of the, the best is rising to the top. I think there's a lot of ego to chiropractors learn how to adjust really well in school. So that's what everybody needs, right. Everyone who walks into your office needs to get adjusted. Cause that's what I learned. So that's what you need and physical therapists, it's the same thing. Right. I learned how to do exercise correctly, exercise. So that's what you need. They can't both be right all the time. I think that's a big, that's the big problem that we see with the general physical therapist in general chiropractic approach. And that's why, like Jeremy said, most people we surround ourselves with, it's difficult to discern whether they're a chiropractor, a physical therapist, cause they're doing best practices.



(14:34):


So do you think that you know, if somebody, you know, is experiencing issues, like, is it more appropriate appropriate for somebody to go to a chiropractor versus a physical therapist in certain situations?


(14:47):


No. Well, it depends. Right? So, so outside of post-surgical, right? So you come out, you come to our office, you just had surgery on your shoulder. You know, good example like Jeremy was working with Samantha Briggs before the open and regionals and the Gaines. She gets shoulder surgery after the games, we're the wrong office, right? We're not here to help you get, you know, passive range of motion back and starting strength back. We're here to bridge the gap between that and getting back on the performance field. Outside of that, I think it's looked for a good practitioner.



(15:23):


Got it. Okay. now walk us through a little bit about, you know, why we feel the sensation of tightness, right? Like a common example that I notice a lot in our gym is like, okay, everybody's hip flexors are super tight. Everybody's couch stretching. Maybe one side might be more than the other, but what's really kind of going on here.


(15:45):


So where, where are their hip flexors feeling tight in which position?


(15:50):


Let's say in the bottom of a squat.


(15:52):


Okay. So the hip flexors are tight. That's the first thing you're when we're in the bottom of his squat, your hip flexors are not on tension. They're on Slack, right? They might be contracting, but they're not in an elongated position in the air. And then you stop here when you're talking. So specific examples to clarify what, what Jeremy's saying there is that you're talking about people feeling the hip flexors tight in the front of their hip crease is what we're assuming. Right? Because your hip flexors in that your psoas will be on tension in the bottom of a squat, but that's not what you're describing in the sensation you're talking about now.



(16:25):


So yeah, as well, I'm just talking about that instance. All you talk about the tennis later, but in that instance, we hear this all the time and that's why I wanted to bring this up is when you're, when you're at the bottom of the squat and you feel that sensation at the front, it has nothing to do with your hip flexors being tightened or shortened right there. They're not at maximum allegation. At that point when you're feeling is actually an impingement, right? It's, it's your, it's your, your, your femur running into your pelvis. And typically that's because of some sort of posterior hip restriction that's actually changed the axis of rotation. And now, now those kinds of you're getting that almost it's not bone on bone, but your bones are starting to pinch those soft tissue in between. So then what, so that's, it's a good error.


(17:04):


A good example of an error is all, I feel my hip flexor tight on the squat. I'm going to do a go to couch stretch. It's not going to help. It's just not going to help. So I just, I'm off the soapbox on that to kind of hedge on the soapbox. It's the idea of how often do these people do this couch stretch all day, every day, they're getting better right. Week to week. Are they improving? Or they're like, yeah. You know, I've noticed that there's less string in the front of my hip when I squat. No, they don't. So what are they doing? But if I said to you, I want you to dead lift really, really, really heavy every day. And your back started to hurt. And I was like, you need to tell this really heavy every day, I'm not going to how much weight you've left. And in the end of two months, we looked at it and you're lifting the same amount of weight that you were lifting the first day. Would you keep doing it? No. No. So why would you sit against the wall and just stretch your, your quad and your, your hip flexors, if they're not making any kind of a measurable change.



(18:00):


Right.


(18:01):


So, so, so, so to, to get to a direct answer to your question, the reason why people feel tight is that muscles are either short or stiff, short being that they've changed length, stiff being that they're living in a state of shortened length, but only functionally. And when they go through range of motion, they feel the impacts of that. Through compensation, either the joints are getting closer together or other joints are being forced to move too much. And that's where they're feeling stiff and tight.



(18:32):


So what would you say is kind of the solution to that? Like what is the root problem that people should be attacking versus simply couch stretching? And


(18:44):


You just saw that yourself, they have to find the root problem. Right? So, so, so it's not there, isn't a problem. It's I feel this because of this. And I feel the same thing. Cause I mean, I had the same thing you do now. Right? We both have a fever. Do we both have the same sickness? Not necessarily, but we both have a fever. So just because you're feeling something in front of the head doesn't mean that there is a single solvable solution for you. The place that we say to start looking, you say attic nerves your external rotators of your hips, your post, your hip capsule. Those are the three most common areas that we see, but there's also some bony anomalies where it can just be that your bones are not able to go that way. There's too much bone in your joints.


(19:27):


Got it. Okay. And you guys have a pretty you know, comprehensive list of assessments that you guys put people through, right. Upper body and lower body. What does that kind of look like? What do we achieve out of that? Like how many are there, could you give us some details on that?


(19:43):


Well, it all relates back to our kind of our athlete's hierarchy of needs and shoulder. Oh, shoot. I shoot over a, a, a picture of that after this, so people can look at it. And, and so we really start both in the office and with our online, you know assessments with flexibility and mobility, right? Do you have adequate ranges of motion, you know, both passively and actively? And if you do great, you don't need to do more flexibility and mobility work. You need to move on and figure out what else is going on. If there are some sort of limitations in there. Well, great. That's a good place to start and they need to be specific. It's not just me saying, Oh, you're, you know, your, your hips are tight. Well, in what direction are they missing? Extension, are they missing fluxion or they're missing X internal-external rotation?



(20:25):


Well, knowing that is very powerful because once you know it, then you can address it either with a practitioner or, or by yourself. So, so from there then we start to look into strength, balance, work, restructural balance work. And now we're starting to say, okay, you have the ability to elongate your tissues passively. You have the ability to elongate your tissues actively and then create some torque. Now, how well are you? Are you really, you know, transmitting force? How well are you producing force in different angles and with different movements? And there should be a certain relationship with all these movements, right? If I'm really good at pressing down and pulling down and not so good at pulling up or pressing up, I'm going to have a little bit more impingement in my shoulder because, you know, every time I move my shoulder, there's going to be more downward scapular rotation then upward.



(21:12):


And that's going to start to, you know, overpressure my tendency. This is one example. So that's, that's where we go. So I think we have, we have six six tests that we look at the, the lower body for flexibility mobility. We have, you know, five or six for the upper body. And then as far as the strength goes I think there's the, the baseline that we do is about 12 tests. Just to get an idea as to how you're producing for us, you know, globally, but that goes, the tall tasks become any more tests as we start to figure out what's going on. We want to dive deeper into certain factors and to kind of jump in real quick and talk about something that kind of over time when I listened to podcasts, leaves me wanting more. Is that what Dr.



(21:53):


Jeremy just talked about what was actionable. It's the most actionable thing that people can listen to and say, Oh, a light bulb is turning on and off and says, I can do something about this right now. And I know we're going to talk more about actionable stuff later on, but if you're walking into the gym and you're super flexible, and we have a movement assessment out there that again, we can send that to you. You can make it available to everybody. There's no cost of taking a movement assessment. If you can move, you should stop working on being able to move. Right. And I mean that in a very specific way, I don't mean stop working on your movement. I mean, you don't need to be stretching your quads, your hamstrings, you don't need to be rolling out in a lacrosse ball before you squat. These are things you already do. Well, there's lower hanging fruit that you can be working on. So hopefully someone listening to this heard that will save themselves 45 minutes a day,



(22:43):


Right? Yeah, definitely. Well, dude, I've talked about this actually in previous episodes I've done. And I did a little experiment on myself a few years ago where every night I did one hour of mobility work for my hips. And it was, you know, it was a long time, but I was like, all right, I'm going to stay committed to this. I'm going to see what happens. And I think in reality, it was much longer than three months that I stuck to that. And I mean, I felt great, right. I felt like a million bucks afterward, but after training, when I would come back at you know, come home at night and kind of do it again, I'd be right back to square one. And that's when, you know, obviously after three months, the light bulb kind of goes off and you're like, all right, why has this not made any change yet? So I do think, yeah, that's, that's extremely valuable.



(23:26):


Well, I think it should be said too, that that's you, the, the, the intervention didn't meet the dysfunction, right? The treatment didn't fit the diagnosis for you, for somebody else who's who isn't is failing, or is limited, I should say. And mobility or flexibility exams, that stuff could be impacted in a profound way. And that's what some, you know, many people have felt that, but other people haven't. So the intervention is to meet the dysfunction.


(23:51):


Right. Okay. Now do you guys put people like everybody who comes through the door at your CrossFit gym, are they going through these same exact assessments?


(24:01):


Yes and no. So our coaches to our, our CrossFit gym is run where someone comes in for elements, they get one-on-one elements. So you're getting one-on-one personal training for three sessions, and then a fourth session you're kind of acclimating into class unless you feel like you need more of that coach feels like you need more scattered throughout those three sessions before they do the movements that are associated with the test that we would be giving them, they get the tests. If somebody comes in and is moving very well, then there's no need to go any further. They're not strength testing people in an element, but they're going to look at very, very basic stuff. Can you touch the floor standing up? Can you sit down on your heels so that when they have somebody squat, they know what their range of motion is before they injured that person? So it's, it's some proactive, some reactive based on the way the person was when they come in, but our coaches understand how to use these tests to make changes in someone's program.



(24:56):


How do you feel like you know, people respond to that who, you know me or somebody who may have been doing CrossFit for even a couple months would totally see the value in coming in day one getting assessed. But just for the average individual walking in through the door how do they kind of respond to that? Are they super grateful that you're putting them through that? Or are they kind of like, Oh, well, why do I need to do this? I just kind of want to jump right in.


(25:19):


So really, really good question. And one of the things that we talked about in our in our coaches workshop is that if you do this with every athlete every day, it's a great way to close your gym, right? People, people don't want to be tested and, you know, modified for every day. There's, there's a mental barrier to being modified in anything. And at the same time in that same breath, I'll tell you, we're not looking for the average person to walk through our door. Right. So if someone who doesn't value this kind of stuff there's a place for them in our gym for sure. But the thing that they're going to get, whether they want it or not, or realize it or not, is these fundamental concepts built into their program every single day. Awesome. And the assessments take 30 seconds to a minute at the beginning of an almonds class.



(26:12):


Right. Okay. Very cool. Now let's talk about, so when you're in that initial phase of, you know, visiting your practitioner, and obviously it depends on your problem you know, you might get things like glute bridges scapular attractions, wall slides, and all that good stuff. But at some point, you know, maybe once you've been doing that for a little while, and you're ready to kind of transition back into moving, like dead lifting, squatting, all that good stuff maybe, you know, you might get injured again or you didn't, you know, figure out a way to kind of connect the two. So what places, what place do these exercises kind of have in addressing pain? Like when should we be moving on to doing things like a suitcase, deadlifts carries and all that stuff. And when should those smaller activation type of exercises have a place in the program?



(26:59):


Well for me, again, it comes down to the treatment fitting the diagnosis, right? Then when you look at a lot of those exercises that you just talked about, those are the, the top of our pyramid. Those are motor control. And if you're starting to, if you try and build motor control on top of a joint that doesn't have full flexibility or full mobility, and doesn't have proper strength balance across it, you're going to, you're going to end up in the same problem. Right? So to me, it's, it's, it's people are jumping at a higher order that when they really, they really need to be more reductionist in their values. And, and another point is a lot of people will feel better, right? They're going to physical therapy, they're doing these exercises, but they don't realize at the same time they've stopped loading their systems as much as they were before.



(27:43):