#58 - Creating a Pre-habilitation Program with Dr. Davis McAlister, Part 2

Hi guys, welcome to The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. In today's episode, we're wrapping up the final segment of this 2-part series with Dr. Davis McAllister on creating a prehabilitation program. In part 1, we discussed how using this proactive approach to prepare for activity can decrease the chances of serious injury and optimize performance. Today, we'll discuss the evidence-based components that every prehab program should have. We'll dive into the research surrounding ACL injury, as well as the application of force and movement as it relates to injury prevention. Our instructor is Dr. Davis McAllister. a clinic faculty doctor for the Parker University Dallas Wellness Clinic, and a chiropractor that has served as a team doctor for several sports teams from the amateurs to the pros. Prior to his career in chiropractic, Dr. McAllister served in military intelligence for the US Army. He holds a bachelor's degree in anatomy, a master's degree in educational leadership, and has certifications in adaptive rehabilitation and acupuncture, amongst others. His specialties include chiropractic treatment for sports-related injuries, rehabilitation, taping, and soft tissue. So, if you aren't currently doing any prehab programming with your patients, I would listen closely and take notes. I can guarantee this training will teach you strategies you can implement in practice right away. Let's dive in.

So functional assessment. This is by no means a comprehensive list of all the possibilities that you can do for a functional assessment. These are the things that I typically use when I go through and assess somebody for an ACL injury risk, as well as other things. That's looking for a lot of other things as well, but focusing on ACL risk, these are the main ones that I pull the information from. So there's a list here that you can see. These are possibilities. that you can do. When I go out and I go assess a team, these are the majority of the tests that I will do these on. So with back squat, back squat's a key component of functional assessments. So you have the Functional Movement Screen or FMS. You have certain elements of the squat that allow for assessment for deficiencies that lead to ACL risk. So we talked about lateral displacement. Those are some of the things. You also look for anterior drift, knee collapse. You'll typically see the knee collapse more on going up out of the squat position than you do going down. So those are things that need to be addressed. Trunk position deficits reflect inadequate core strength, which we already talked about, and that would translate to deficits in the hip mobility and asymmetrical positioning. Hip position deficits relate to asymmetrical weight shifts in both the lateral and frontal plane. Then your frontal plane knee alignment deficits may present as valgus or varus shifts of the knee due to poor neuromuscular control and function. On rare occasions, you may see people that will have a valgus shift on one side and then a varus shift on the other, which means it just looks like their knees are going like this when they bend. And so those are things that you need to go through and correct. So frontal plane knee alignment deficits may present as valgus or varus due to poor neuromuscular control and function. So it could also be a lack of strength in the lower extremity. That's probably one of the hardest things to get high school athletes to understand, especially the, the non-football. Male players and then just female players. The majority of female programs that I've seen, they're very, very lacking in their strength and conditioning programs. In particular on the strength side, they don't like to lift weights a lot. And I understand the need to be able to do more functional lifting, but at some point we've got to be able to increase the weights. I have 5 kids and I've seen the variety of programs. Both my daughters play volleyball and I've seen the program that they put them through and they lift the same weight every time they go in, whether it's in-season or off-season. And They never increase and there's no strength development at all. So another thing to look at on the back squat, knee valgus, when the medial aspect of the knee passes the medial malleolus. So decreased hip abductor and external rotation strength, increased hip adductor and ankle dorsiflexion restriction. So it could also be a compensatory mechanism from pes planus that we talked about with flat feet, the ankles roll in, but you also have to look at ankle dorsiflexion. And determine if that's being a contributing factor for the lack of mobility and poor mechanics. Also, during squat, tibial translation angle, it should be maintained and parallel to properly positioned upright trunk. Deficit will be excessive restricted translation. So if you have excessive anterior translation, increases shear forces and knee extensor torque. This can be the result of posterior chain weakness, in particular weak gastroc soleus, weak hamstrings, weak glutes. Quad dominance, all those things that we've already talked about. So restricted tibial translation results in increased anterior torso translation. So as they go down, you'll see the upper body start to drift forward more and more over the knee and ankle to the extent where it goes out front. Sometimes it's even what I refer to as the folding chair. They think they're going deeper because their upper body is going down, not the lower body, and they're not properly engaging the muscles and getting proper range of motion in their squat with the lower body. So this also can be a result of ankle restriction from posterior talus translation, decreased hip mobility, or decreased foot mobility. You'll see some of them that they get a posterior restriction in the ankles, and that will inhibit dorsiflexion. And so on the chiropractic side, just a simple adjustment of that ankle to bring that talus back into the proper midline position from a posterior restriction So it should be able to help increase that dorsiflexion. Then it's a matter of also strengthening the ankle to be able to prevent that from being a recurring problem. Foot position, entirely planted on the ground during the entire motion. So you don't want to see heels coming up. Weight should be distributed over the midfoot to the heel. And then the biomechanical foot deficiencies translate up to the knees and hips. So it just starts at the ground and works its way up. Y-balance test or star excursion balance test. These are similar tests, but they're not exactly the same. I use the Y-Balance itself. You can go through FMS as well. That's part of an SFMS FMS assessment. And we actually have the sliding blocks and so forth that we measure with. And so a composite score of less than 94% lower limb results in a 6.5 times greater increased risk for lower extremity injury in a female athlete.

Mm-hmm.

Anterior reach asymmetry of Greater than 4 centimeters results in 2.7 times increased risk in all high school athletes. So that's pretty significant there. Another study on D3 football players showed a 3.5% higher risk of non-contact injury with a composite score of less than 89.6%. And so when you go through and do the score, there's a composite score that you develop based on a formula that incorporates limb length and distances that they can reach in multiple directions. And then you put that into a composite score and you get a percentage of efficiency within each side in the lower limb. The drop jump screening test is primarily used to measure knee valgus values by measuring knee separation during 3 separate frames of reference by recording images from 3 jumps from a box. It helps if you do have video imaging, if at all possible, to do this. You can do it visually, but it also helps if you're having to do large numbers of people. It helps to have that imaging to be able to go through and view that. Most studies were related to the use of neuromuscular training programs to improve knee alignment, particularly in basketball and volleyball players. Currently, there's no research to support using this test as a means of predicting injury risk. So, I mean, this is something that can be used, but it's going to be an additive. This is not going to be able to stand alone to be able to assess injury. You're going to have to combine it with other things. This would just be one component that you could use to help. with comparing information that you find from other tests. So the usefulness of this test is related more to asymmetry during landing and knee valgus, and it could be used in conjunction with the force plate. So your tuck jump assessment. Your tuck jump assessment is commonly used. You'll see this commonly used with PTs and athletic trainers and performance specialists. It's going to assess 10 aspects of the jump. It only takes about 10 seconds to perform, so it's pretty efficient, and you have a couple of minutes to score while visually recording the test from a frontal and sagittal plane. Does it require a box? Like the LES and the Drop Jump Test. It's highly recommended that the same clinician should administer it so that way you're not running the risk of inter-rater reliability issues if the same person's doing the assessment each time. So if you're going to do a pre and a post, it's ideal that the same person do both the pre and the post. And if you have multiple people within the team, then it should be the same person administering that particular test each time. For consistency. So your Landing Error Scoring System, this is the LESS test, similar to the Drop Jump Screening Test. The exception is that it's recorded from the front and sagittal plane. Participants jump from a 30-centimeter box to the point equivalent to 50% of their height away from the box. So you actually got to measure their height, go 50% of that, and measure that line out to the front of the box. And it's all about maximal vertical jump. Jumpers scored based on 7 technique and 10 landing errors during 4 jumps. Participants with low LESS scores demonstrate less knee and hip flexion angle, so less knee valgus and hip abduction, increased internal knee and hip internal rotation with anterior tibial shear forces. And it was established as a reliable assessment with recurrent validity. So it's a, it's a high-value test. Research shows that the optimal cut point for ACL injury predictability was 5.17 through a study of 829 youths. That's a pretty good— Number for a study to be able to support evidence. The same study showed that those that had a LESS score of 5 or more were at a 10.7 greater risk ratio for injury as compared to those who scored less than 5. The single-leg motion analysis— this is basically a sidestep cutting maneuver that you go through and assess. It's also referred to as the change of direction assessment, one of 3 primary techniques, with the others being the crossover cut and the split step. are the other 2 components to it. The sidestep generates higher degrees of knee valgus and internal rotation movements, key stressors to the ACL, with high degree of test-retest reliability. One of the main things that I'm going to look for on this test is overextension, not being able to, not having proper weight distribution, core control during the course of that movement to be able to maintain and control momentum, especially if it has to be a quick stop-start type situation. So Tests on post-ACL reconstruction athletes showed that 80% had greater than or equal to 5 degrees of knee valgus on the plant foot, with 60% showing an increased valgus on the uninvolved leg. So that's, that's something that really needs to be looked at closely. So things that you need to consider when you're doing this assessment is forces generated during non-competition are not as great as during, so it's really hard to replicate competition-level Forces. And so, but if somebody is already showing signs of lack of control, overextension, excessive knee valgus, internal rotation, that type of thing during this simple test, then it's going to be exaggerated more when they're out there actually competing. So there is some value in that. Planned versus unplanned movement. So redirecting, having a plant cut, if you're trying to avoid somebody, how do you deal with that? Let's see, fatigued versus non-fatigued. Sharper angles generate greater ground forces. Things to consider with this one: forces generated during non-competition are not as great, which we just talked about; planned versus unplanned movement; fatigue; sharper angles generate greater ground forces; approach velocity. So velocities are typically higher in competition. Visual disturbance or dual cognition, such as with a ball and interacting with other individuals, will generate higher ground forces or may slow reaction times. So when they're having multiple things like dribbling a ball, that type of stuff, that's drawing more on the brain. And it's going to affect their ability to be able to properly react, to be able to focus on proper movement mechanics. So time-based tasks may provide greater simulation of effort. So do things like a shuttle test, that type of stuff for redirection, that you can kind of get a decent idea when they're trying to do it as fast as they possibly can. You may be able to get a little bit better assessment with increased effort. So some basic components of an ACL prehab program. So after evaluation of several research papers that proved the need and validity of prevention programs for ACL risk, females have a risk reduction of 52% and males have a risk reduction of 85% for a non-contact ACL injury. So there's some high validity for having an ACL injury prevention program within an athletic program. So 6 principles that you need to consider. Age, okay. The earlier that you start working on these mechanics, the better. Studies are showing that introduction of ACL programs in younger athletes are more effective than older athletes. It's one of those things, it's better to take somebody that doesn't know any better and train them up from the get-go rather than trying to take somebody who's already developed bad mechanical habits and trying to get them to change them. It's a whole lot better if you can start with youth programs and be able to work them up that way. And while you're trying to work on the ones that are older and trying to undo their bad habits. So biomechanics, there's a need for assessing and addressing different movement patterns that involve an increased possibility for increased knee valgus. Compliance is a huge deal. So compliance rates greater than 66% have shown a rate reduction of ACL injury by 82%. So basically, if they follow the program, it's gonna work. If they don't follow the program like they're supposed to, you're gonna, it's not gonna be as effective as it needs to. Okay. So number 4, you have dosage. An average of studies has shown that a session should last between 20 to 30 minutes for 3 to 4 times per week. The program should be initiated during preseason conditioning and maintained throughout the season into offseason. So it's— this is one of those deals that people look at this, well, I don't have 20 to 30 minutes to just focus on ACL injury prevention type programs in my athletic program. It's because you need to take it and incorporate it with the other things that you're doing. You have your different phases. So you have your immediate postseason, you have your preseason workouts, and then you go into your in-season. Those are all different components, but these are things that you can incorporate and work into your program to be able to assess and to be able to work and train so that you can decrease that risk of injury. Feedback. There should be a combination of visual and verbal feedback with verbal correction cued from the coach/trainer and visual in some form of video or training film. This is where, as a practitioner, you could be able to come in and be able to make observation. Because coaches— think about basketball coaching. The basketball coach is out there watching. They're watching to see if their players are executing proper alignment, if they're going in the proper formation, if they're setting their screens properly, those types of things. They're not paying attention necessarily to the technique of what's going on. So you need to have somebody specifically assigned for that, to be able to watch techniques and be able to make those corrections. Whether it's an assistant coach or you as the trainer itself, can be able to watch and make sure that your athletes are executing proper technique. You see consistency in that, then it needs— that's something that needs to be addressed. It also helps that they're filming practices. You can go back and look at those things and be able to work on some of those mechanics, point it out to the coach, maybe have the coach point it out during film session. So exercise variety. So training should have 3 different components. You should have plyometrics built in. Neuromuscular training for balance, and then strength training with it. So your 3 components, you have plyometrics is key. The key is focusing on proper technique and mechanics. So plyometrics should be incorporated at least once a week into a training program. Depending on what texts you read, if you go through your CSCS certifications, it tells you that you can incorporate plyometrics at least twice a week if they're properly spaced out.

Mm-hmm.

Given the amount of time, whether you're in-season or off-season, That's going to also dictate how much you can actually work in plyometrics. So probably if you're in season, you're only going to want to do it once a week. It's probably going to be a little bit less intensity than what you would do during an offseason program. So those are things that you need to think about. So your neuromuscular training— so improve the athlete's ability to generate optimal muscle firing patterns, improve overall movement patterns, increase dynamic joint mobility, improve postural control and lateral motion stability. So that's your overall objectives when you do this. So this is going to include some of your balance exercises, proprioceptive training for balance. You could do wobble boards and that type of thing. It's really best to be able to just do it on flat foot. I'm not a huge fan of unlevel surfaces to work on those types of things. It's better if you can do something simple as star pattern type movements with body weight. In order to be able to work on those mechanics. But a lot of it also is going to come back to making sure that they're doing proper core engagement and glute engagement and those things, that they're actually doing all the proper mechanics just to maintain balance. If somebody's able to do a single-leg stance and they can't stand on one leg and hold it, if you look at that, see where the instability is coming out of. Is it coming out of the knee? Is it coming out of the ankle? Is it coming out of the hip? Is it a core problem? Or is it a combination of those things? And then design your exercises to address those individual problems so that it will address the balance overall. So then you have strength training, which can include muscle-specific retraining or overall power-generating lifts. I'm not a huge fan of overhead-type lifts, power lifts, Olympic-type lifting for especially high school programs. I know that I've made some high school strength and conditioning coaches upset with me by making that statement before, but having been in multiple high school programs and the minute that they start incorporating overhead, specific lifts. Now you're going to have athletes with developing shoulder problems and those types of things because they don't execute it right. If you can't get them to execute proper mechanics on basic movement patterns that they need to do to be able to execute their sport, why would you have them do something that is going to require even more mechanics and focus and specificity in the way they lift rather than keeping general lift movement patterns? So that's just my soapbox on that. So your training progression— all training programs should be organized into tiers and progressions that range from mildly difficult to challenging. So you're going to start with a Tier 1 and should build into more complicated versions of the same mechanisms based on the target muscle group. Training progression should also reflect on ongoing assessment to determine readiness for tier transition. So you need to be able to make sure that you're assessing. So if you come up with your first tier level of exercises that you're going to do, you need to make a determination on whether they're ready to move to the Or if you have some that are ready to move on and others are not, you've got to have the flexibility in there to be able to allow the ones that are ready to progress, allow them to continue to progress. So, and in some cases you may need, you may have to have regressions. Somebody gets up to a certain level and then they can't seem to maintain proper mechanics. You go back down. It's okay to take a step back if you need to, in order to be able to retrain and continue to build back up again. And so you may know this as a remedial phase for transitioning to the full training program. If somebody needs remediation, it's better to get them down in the proper mechanics and proper strength levels to be able to execute so that they're going to be better players overall.

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So that brings me to the end.

Thank you so much, Dr. McAllister. We have a few questions that have come in. So, one of the questions was related to, you mentioned that when the ACL is replaced with a cadaver ligament, that oftentimes that makes it a little bit tighter. So, how would you suggest what type of rehab or what things would you take into consideration when you're doing rehab for a patient that has received cadaver versus those that have just had a simple repair?

So, the couple things that you have to factor into that when you're rehabbing somebody with that, Is one, you gotta make sure that you don't tear the graft. So you've gotta allow it to have time to set in. So you wanna do a lot of passive range of motion, not active, and then start building up the musculature around the knee. The musculature's gonna be weak. So I always recommend a lot of isometric type exercises to start working around that knee. And then once the orthopedist that you've worked with has, they will give you the timeframe that it usually takes for that ACL to set. So that you retear it. I can't tell you how many times that I've seen people go to their rehab and matter of fact, I had a neighbor that he had a shoulder repair, went to rehab and they tore his shoulder back. So would think that you need to go, it's better to go conservative at first. You wanna obviously instill as much motion as you can, get as much passive motion, even bike type movements, that type of thing. And then as that graft is set, Then you can be a little bit more aggressive on stretching that out, and a lot of that's just going to come from strengthening. So you want to progress from on your isometrics to your eccentric-type contraction movements, then you can progress to your concentric, which is going to allow you to be able to get more flexibility in that knee.

Absolutely, thank you.

Do you have any advice or guidance on specific prehab that you would do with winter sports athletes? Such as downhill skiers and those that are on the slopes a lot. So you get a lot of ACL injuries obviously when it comes to skis and snowboards where your feet are kind of locked into position. Is there anything that you would suggest, specific things to look for and to assess in the preseason before they get started?

Yeah, that's the thing with, with a lot of your snow skiing because there is more of a predisposition for the knees to go into a valgus position. So that's going to take a little bit of retraining that's going to have to be done to get them to where they can still be able to ski, be able to execute their maneuvers, and not allow that knee to collapse. Because if you watch a lot of your downhill skiers, especially during the Olympics, as soon as they hit that redirection, look at that extent, the outside leg on their turn. If you start seeing that knee drop in, they've got to work on their lateral strength development. So really a lot of that where that would be concerned is more focused on your strength development. And more concentration on keeping those knees pushed out more so that they don't allow that. Snow skiing is one of those. I've done it. Fortunately, I managed to do it without— I actually had to learn how to do it when I was in the military, which was interesting enough. But just the level of force that's actually applied, because you're going at much faster speeds, strength development is going to be a whole lot more focused for me if I'm going to work with somebody on that. To be able to push and keeping that lateral strength. Also making sure that you are looking at their glute and glute med. So they may need to do more monster walk type things, keep the piriformis loose. Because what tends to happen after time is that as the glute, you get that quad dominance and then the glute, I mean, because you think about it, they're constantly got those quads contracted. They're in a bent over position, bent over exaggerated athletic position. Eventually those glutes continue to weaken. Well, what happens then is your intrinsic muscles that are up underneath, like your piriformis, And then you'll get glute med weakness on top of it. So they're going to have to really focus on keeping those strong during their strength development to be able to help with that.

Wonderful. We've talked a lot about in the past, and it's kind of made a lot of headlines, especially with the healthcare community, about fear avoidance behaviors. Fear avoidance behaviors. So essentially athlete tears one ACL, and then as you mentioned, the research supports that they're reports going to be more likely to that they are more susceptible to tearing the other ACL, but yet you as a practitioner are faced in a situation where you want to try to help them rehab post-surgery, but then also strengthen the other ACL. How would you combat some of that fear avoidance behavior in an athlete that's already had that tear once? So that's the first part of the question. The second part is, do you feel that fear avoidance can be a contributing factor to reinjury?

Yes, it will. Just because they tend to be more timid, they're going to exaggerate. They're going to tend to put— that's where you're going to see a lot more of that lateral displacement that we talked about, just even something as simple as a squat pattern. That's what I refer to as the neuromuscular rehabilitation. You've got to get them, make them aware that they're doing that shift. There's always that tendency that they have to gain confidence in it. So you want to build them up. You have to kind of assess where they're at. Sometimes when I coach powerlifting, when I'm working with an athlete, it's not always necessarily looking at where they're at, but where their potential is. And so you have to allow them to be able to build the confidence up by slowly working them back up and letting them be able to feel it and know that it's going to stay— be stable and it's not going to give out on them. So there's a progression that has to be— has to take place and allow them to build that confidence. And as they continue to build that confidence and realize that Okay, I'm not necessarily going to hurt this now. They're going to build confidence just by knowing that their, their movements are stronger if they are aware of what the mechanics were that caused it to happen the first time so that they can be able to focus and not do those patterns again and work out of that. So it can develop, but you're going to have to really educate them along the way and allow them to be able to develop that confidence and work up and not necessarily rush them. I feel like sometimes athletes are rushed way too fast before they even have a chance to even get the proper strength and mechanics down trying to get back into play. So it can be done, but you're going to have— it's going to require a lot more patience and it's going to require a lot more analysis on your part, seeing when they're ready to go, but also being able to just show them what they're doing in those patterns and get them focused on correcting that. And then once they get more confident in that, then their confidence overall will increase.

Yeah, absolutely. Another question here was regarding assessing kind of return to play. In this situation where you have a patient who has gone through surgery or repair, how do you assess them in terms of their readiness and their ability to return to play?

So as based on where they need to be for the level that they're at, so Obviously, like I said, when you start them off and you start somebody off, it's going to be more passive isometric. And so you have to determine, okay, they seem to be responding well, there's no pain, we're not having problems with isometric movement patterns anymore, we've been able to progress to full range of motion at this point. Now we've got to start doing some more eccentric type movement patterns. Once they get stronger with that, there's no knee pain associated with that, then you can progress up to your concentric patterns. Start off with lighter weights and then start building up and strengthening from there. Once you get it stronger, then I would start progressing into more sport-specific type movement patterns to start working on movement mechanics. Start them slow. Allow them to be able to get the— because they're having to get a feel for— their legs are not going to feel the same like they did before. And so, and then you're also having to— what was referenced in the last question, you're going to have to work through some of that hesitancy and some of that. subconsciousness that they have a fear of reinjuring. And so it's just, it was going to require a constant assessment throughout the process to be able to determine that they're really ready to go. A lot of times people try to focus more on readiness based on time rather than performance. So I would shift your focus to more performance, not, and less on time to determine whether somebody is ready or not.

Wonderful.

Thank you.

Is repair or reconstruction good, better for ACL injury to receive better outcomes? What does the research say in regards to a repair versus a reconstruction? And I know that might be subjective based upon each individual, you know, case or circumstance.

Yeah, it depends on what they're wanting to do. I mean, if they're in a sport that requires them to do a lot of cutting maneuvers, they need an ACL to be able to do that. And you can brace. There's certain sports that allow you to be able to brace, especially if somebody does have that fear. You're going to allow them to brace and it may not necessarily be necessary for them to have a brace on that knee. But if it gives them that extra confidence, then allow them to do that. You'll see most orthopedists will recommend though, if you're not going to play anymore, if you're retiring from your sport but you still want to stay active, you can still be active so long as you're not trying to cut and do those hard type redirecting type movements. If you're going to do those types of things, then it's better to get it, get it redone so that you can continue to do that. You're just, you're just going to have to know that once you get cut, that you're going to be dealing with other issues later on down the road. Eventually, you're going to have plaque that builds up, scar tissue that builds up in that knee, and that may have to be dealt with later. There's no easy solution there, but it really kind of depends on what the goal of the athlete is.

Absolutely.

Would you suggest any type of Sports psychology or some adjunctive therapy that deals with addressing pain and fear, kind of like pain psychology?

Yeah, absolutely. Any good sport program from the college level up is going to have a sports psychologist. You definitely need to co-manage with that. Talk to the psychologist, collaborate, let them know what you're seeing, let them know what you're seeing, what their tendencies are. And then they can talk to the athlete and figure out what their concerns are and their fears are. Yeah, that's absolutely a necessity. I mean, especially when you're dealing with athletes that need to be able to perform at a high level consistency, there's a lot of stress that goes along with that mentally. And you'll see it in the way some athletes end up in the news. They handle their success or they handle the stress of their role better than others. And so, yeah, absolutely. You need a psychologist to be able to help with that.

Absolutely. So we've talked in the past about how hormone fluctuations at different times of the month can affect things like ligament laxity. How do you take that into consideration when it comes to the prehab or the rehab work that you do with female athletes that are dealing with ACL issues?

So, and it's funny because I actually, the majority of the athletes that I coach right now are female. I've kind of transitioned over that, and in all honesty, it's, I've actually enjoyed coaching female athletes More than I have males at this point because they tend to listen better. But there's always that ongoing issue there. You'll see when they have those times that you're also gonna see that they're gonna be weaker. So during those hormone fluctuations, they're also gonna be at increased risk. And so that's when it's really gonna be imperative for those athletes to be more focused on technique and their strength development and being able to rely on those things. To be able to execute. Because with the joint laxity, they're going to have to get more comfortable with that dynamic and know that they may have to be a little bit more reserved in their movement patterns to be able to compensate for that because of the joint laxity that can exist. So, and a lot of that's also coaches don't want to hear about that stuff. They really should, but they don't want to hear about that. All they care about is if their player can get in there and play or not. So that's unfortunately, that's kind of a no-win situation. with that because I would recommend that certain athletes, if they're going, you would have to kind of gauge how they react during their, and how their bodies process during that time. And if somebody has severe reaction and their joints seem to have a lot more laxity, you can get in there and assess during that time to be able to see where their level of laxity is. And some of them, it's just, it may just be better that they don't play during that time.

Absolutely.

So someone was asking essentially, Given your experience kind of working as part of a healthcare team with these athletes, how are coaches responsive to some of your advice that you give? How have you found that some of them more resistant than others? How do you usually broach these topics with coaches that, as you mentioned, sometimes they're not concerned with certain things that, you know, are very much a priority for the athlete's well-being?

With coaches, and I've been on both sides of that. Both sides of that table. And it's tough. I mean, when you've got coaches that absolutely just don't want to listen, they're actually putting themselves at risk and liability by not. And that would be— it also depends on if you're the trainer or are you the medical provider for the team? Or are you part of the overall medical team, depending on what level you're at? Because with the high school, I work in conjunction with the trainer there. With the pro teams that I've worked with, you have the trainer that kind of acts as a filter, but I've always been successful in developing a good working relationship with the medical team as a whole. As far as the coaches are concerned, they've got to have the confidence that you know what you're doing and that— because they just look at it as, you're keeping my player, keeping me from winning games because you're keeping my player off the court. They have to understand the liability, and sometimes it requires a little bit of extra education for the coach, especially if they're a young coach and don't, don't know any better. Your older coaches, I tend to find that they don't resist it as much because they know the benefit that if they allow their player to heal up, they're going to be a better, more benefit to them a little bit later on if they'll just be patient. It's your younger coaches that tend to be more impatient and they don't, they don't want to listen. They just want their player out there. And so they require a little bit more education, a little bit more patience on your part, and also just talking to the athlete. Because really it's the athlete that gets caught in the middle of that. They know that they need to be able to get in there and play. They're concerned about keeping their position. And sometimes it may require the athlete being able to tell the coach, say, look, I'm almost there, but please, I've got to get healed up so I can get out there and play better. And sometimes it may take a joint effort of the player, the coach, and the trainer to get in there and have that conversation so that they can get that player ready to go. That's one of those— I haven't had that much of a problem too, too much with getting coaches to listen. I think— I feel like they've gotten better about it, but it depends also what level. High school coaches, they tend to not listen as well as your college or your pro coaches. And so, yeah, again, if you want coaches that are going to listen better, you probably need to move up the chain a little bit and get out of high school or middle school.

So, Dr. McAllister, thank you so much for joining us today and for presenting such great information.

Thank you for having me. I really appreciate it.

All right guys, that is it for today. Be sure to tune in for episode 59 where we kick off a new 2-part series titled Supercharge Your Clinical Skillset with Dr. Benjamin Fergus. This training is one of my favorites because we get to talk about the business side of developing and managing a successful team. In your practice. You won't wanna miss it. Episode 59 drops in 2 weeks. Now, before we end today's episode, I have a quick favor to ask. I want you to visit the top of the show notes and click the link for our 60-second Factor survey and fill that out for me. It's only a few questions and it literally will take you no more than 60 seconds to complete. See, we're working on some exciting new things at Factor. And while I can't yet announce everything, what I can say is that I wanna be sure we're delivering on all of the things that you most want to see from us. See, we've already received a ton of responses, but I want to leave this survey open a little bit longer to make sure we're reaching as many of you guys as possible. For those of you that have already filled it out, thank you! I've read each response personally, and I am prioritizing the most popular requests so that they're a big part of our strategic plan moving forward. And as a little thank you gift for filling out our survey, I'll send you a cultivated playlist of our most popular Factor podcast episodes from the past year, custom tailored to your submissions. So to give you a few quick updates, we have 2 new Factor websites currently in process, one of which will be dedicated solely to our Factor podcast, which I'm super excited about. We're also doing a complete facelift and overhaul for our online store. So a lot of really great things are rolling out in the months ahead. I can't wait to tell you all about them in a future episode. So be sure to hit that subscribe button so you'll get new content from Factor right here every 2 weeks. And shameless plug here, please do give us a 5-star rating. It means more than you know. That's all for today. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.