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

The the the the between between the 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 two part series with doctor Davis McAllister on creating a prehabilitation program. In part one, 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 this 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 doctor Davis McAllister, a clinic faculty doctor for the Parker University Dallas Wellness Clinic and a chiropractor that is served as a team doctor for several sports teams from the amateurs to the pros. Prior to his career in chiropractic, doctor McCallister 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 a 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 an assess somebody for an ac L injury risk as well as other things that's looking for a lot of other things as well, but focusing on aco 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 them. So with backsquat, back squats key component of functional assessments. So you have the functional movement screen or FMS, you have certain elements of the squat that allow for assessments 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. Trump position deficits reflecting adequate core strength, which we already talked about, and that will translate to deficits into hip mobility and asymmetrical positioning. Hip position definits relate to asymmetrical wayshifts and build the lateral and frontal plane. Then your frontal plane knee alignment deficits may present as valgus or various shifts of the need 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 various shift on the other, which means it just looks like their knees are going like this when they've 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 varius 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 non football male players, and then just female players. The majority of female programs that I've seen, they are very very lacking and their strengthened 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 five kids, and I've seen the variety of programs. Both of 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 the backspat nieve valgus when the medial aspect that knee passes the medial valuolis so decreased hip abductor and external rotation strength, increased hip adductor and ankle dorseflection restriction, So it could also be a compensatory mechanism from pest planets that we talked about with flat feet, the ankles roll in that you also have to look at ank orseflection and determine if that's being a contributing factor for the lack of mobility and poor mechanics. Also, during squat tibial translation angles, 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 sheer forces and knee extends or torque. This can be the result of post to your chain weakness in particular weak astroc solius, wee camstrings, weak blots, quad dominance, all those things that we've already talked about. So restricted t build translation results and increased anterior torso translation. So as they go down, you'll see the upper bodies start to drift forward more and more over the knee and ankle to the extent where it goes out front. Because sometimes it's even at what I referred to as the folding chair. They think they're going deeper because the arupper body is going down, not the lower body, and they're not even properly engaging the muscles and get a proper range of motion in their squad with a 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 and the ankles and that will inhibit dors deflection and so on the car practice side. Just a simple adjustment of that ankle to bring that talus back into the proper midline position from a posterior restriction should be able to help increase that dorsy flection. Then it's a matter of also strengthening the ankle to be able to prevent that from being a recurring problem. Foot position and entirely planned it on the ground during the entire emotion, 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 kneast and hips, so it just starts at the ground, it works its way up. Why balance test or star excursion balance test. There's these are similar tests, but they're not exactly the same. I use the why balance itself. You can go through FMS as well as part of an SMS assessment, and we actually have the sliding blocks and so forth that we measure with and instead, a composite score of less than ninety four percent lower limb results in a six to point five times greater increased risk for lower extreamting injury, and a female athlete anterior reach asymmetry of greater than four centimeters results in two points seven times increased risk in all high school athletes, so it's pretty significant there. Another study on D three football players showed a three point five percent higher risk of non contact injury with a composite score of less than eighty nine point six percent. And so when you go through and do the score, there's a composite score that you develop based on the formula that incorporates lend 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 and the lower limb. The drop jump screening test that's probably used to measure knee valgus values by measuring knee separation during three separate frames of reference by recording images from three jumps from a boss. It helps if you do have video imaging if at all possible to do this, you can do it individually, but 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 newer muscular training programs to improve knee alignment, particularly in basketball and volleyball players. Currently, there's no research to support using this test as it 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 the loan 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 found from other tests. So the usefulness of this test is related more to asymmetry during landing and kneevalgus, and it can be used in conjunction with a 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 ten aspects of the jump and only texts about ten 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 satical plane. Does it require a box Like the lists, the LS and the drop jump test. It's highly recommended that the same clinician should administer so that way you're not running the risk of inter rate or reliability issues of the same per doing the assessment each time. So if you're going to do a pre ni POST, this 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 into administering that particular test each time for consistency, so you're 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 sidgital plane. Testimants jump from a thirty centimeter box to the point of it equillan to fifty percent of their height away from the box, so you actually got to measure their high go fifty percent of that and measure that line out to the front of the box. And it's followed by a maximal vertibal jump. Jumpers scored based on seven technique in ten landing errors during four jumps. Diticipants with low less scores demonstrate less knee and hip fletch and angle, so less knee valgus and hip adduction, increased internal knee and hip internal rotation with interatibual sheer forces, and it was established as a reliable assessment with recurrent THELID. It's a high value test. Research shows that the optimal cut point for aco injury predictability was five point one seven through study of eight hundred and twenty nine YUS. 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 five or more were at a ten point seven greater risk ratio for injury is compared to those who scored less than five. The single leg motion analysis this is basically a sidestep cutting maneuver that you go through an assess is also referred to as the change of direction assessment. One of three primary techniques, with the others being the crossover cut and the split step or the other two components to it. The side step generates higher degrees of knee valgus and internal rotation movements key stressors to the ACL with high degree of test retest liability. One of the main things that I'm going to look for on this test is the over extension not being able to not having proper weight distribution core controlled 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 a CEO reconstruction athletes show that eighty percent had greater than are equal to five degrees of knee valgus on the plant foot, with sixty percent showing an increased augus 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 assessments. 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 over extension, 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 of that. Plan 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 fatigue versus non fatigued Sharper angles generate greater own forces. Things to consider with this one force is generated during non competition are not as great, which we just talked about. Plan versus unplanned movement. Fatigue Sharper angles generate greater ground forces approach velocity, so velocities are typically higher in competition. Visual disturbance or dual cognitions such as as with a ball and interacting with other individuals, will generate higher ground forces or make 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 the time based tasks may provide greater simulation of effort, So do things like a shuttle test that type of stuff for a 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 ACO prehab program. So after a value to several research papers, they prove the need and validity of prevention programs for ACL risk. Females have a risk reduction of fifty two percent and males have a risk reduction of eighty five percent for a non contact ACL injury. So there's some high validity for having an ACO injury prevention program within an athletic program. So six principles that you need to consider. H Okay, the earlier that you start working on these mechanics, the better studies are showing that introduction of a CEO programs and younger athletes are more effective than older athletes. It's one of those things that'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 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 or trying to undo their bad habits. So biomechanics, there's a need for assessing addressing different movement patterns that involve an increased possibility for increased need. VALGUS clients is a huge deal. So compliance rates greater than sixty six percent have shown a rate reduction of a CEO A injury by eighty two percent. So basically, if they follow the program, it's going to work. If they don't follow the program like they're supposed to, you're gonna it's not going to be as effective as it needs to. Okay, So number four, you have dosage, and average of studies has shown that a session should last between twenty to thirty minutes for three to four times per week. The program should be initiated during preseason conditioning and maintain throughout the season in the off season. So it's this is one of those deals that people look at this while I don't have twenty to thirty minutes to just focus on aco 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 end 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 que from the coach trainer, and visual in some form of video or training film. This is where as a practitioner, you can be able to come in and be able to make observation because coaches, when think about a basketball coach, but basketball coaches out there watching, they're watching to see if their players are executing proper alignment, if they're going into 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 a consistency in that it needs that's something that needs to be addressed, and 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, pointing out to the coach, maybe have the coach pointed out during film session. So exercise variety, So training should have three different components. You should have pliometrics built in, neuromuscular training from balance and then strength training with it. So your three components, you have pliometrics, the keys 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, tells you that you can incorporate pliometrics at least twice a week if they're properly spaced out 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 pliometrics. 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 off season program. So those are things that you need to think about. So your neuromuscular training, so improve the athletes ability to generate optimal muscle firing patterns, improve a roll 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, appropriate acceptive training for balance. You could do wobble boards in that type of thing, it's really best to be able to just do it on flat foots. 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 angles, it coming out of the hip, It's a core problem, or is 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 and 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 one and should build into more complicated versions of the same mechanisms based on the target and 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 or whether they're ready to move to the next step or if you have some that are ready to move on and others or 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, 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 is better to get them down and the proper mechanics and proper strength levels to be able to execute so that they're going to be better players overall. If you're listening to this podcast and you've yet to attend a FACTOR Rehab live course, I have a special offer just for you. See, I realize that sometimes you need to kick the tires a bit to learn more about a course before you register, especially one that offers a certification track. So I've developed a special offer just for those of you who are interested in learning what this FACTOR thing is all about. See, We've put together a free one hour webinar to introduce the concept of having a systematic approach to rehab. In this one hour online course, our director of Education, doctor Todd Riddle, will show you how implementing a system for patient treatment can improve patient outcomes, streamline your operations, grow your profitability, and help you to build a practice that you absolutely love. You'll also hear from doctor Riddle's personal experience in using the Factor rehab system, both with elite athletes as well as the everyday patient just looking to move and feel their best. It's a great first step to learn more about FACTOR certification and how Factor could impact your patient care. And to sweeten the deal, we're offering CE credit for completing this online training absolutely free. Yes you've heard that correctly, free CE so CE credit is available in a number of US states for chiropractors, as well as for massage therapists, athletic trainers, and physical therapists. To learn more and get your free CE while learning more about how Factor can impact your patient care, visit the free Factor webinar link in our show notes. Now back to the show. 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 dabbing daver 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 in 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 got to make sure that you don't tear the graph, So you've got to allow it to have time to set in. So you want to do a lot of passive range of motion, not active, and then start building up the musculator around the knee. The musculator is going to be weak, so I always recommend a lot of isometric type exercises start working around that knee, and then once the orthopedies that you've worked with, they will give you the time frame 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 a matter of fact, I had a neighbor that he had to shoulder repair went to rehab and they tore his shoulder back. So I would think that you need to go It's better to go conservative at first. You want to obviously instill as much motion and you can get as much passive motion, even bike type movements that type of thing, and then as that that graft is set, then you could be a little bit more aggressive on stretching that out. Then 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 your concentric which is going to allow you to be able to get more flexibility in that need. 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 feed 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 started. Yeah, that's the the thing with a lot of your snow skiing, because there is more of a predisposition for the needs to go into a bogus 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 need to collapse. Because if you watch a lot of your downhill skiers, especially during the Olympics, as soon as they hit that reduration, 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. I'm 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 actually had to learn how to do it when I was in the military, which was interesting enough. But this is the level of force that's actually applied. Because you're going to much faster speeds. Strength development is going to be a whole lot more focus for me if I'm going to work with somebody on that to be able to pushed and keeping that lateral strength, also making sure that you are looking at their glute and glue mead so they may need to do more monster walk type of things. Keep the pureiformists loose, because what tends to happen after time is that as the glue, you get that quat dominance and then the glute I mean, because you think better constantly got those quas contracted, they're in a been over position, been over exaggerated athletic position. Eventually those glutes continue to weaken. Well, what happens in is your entrance that muscles it up underneath, like your puiformists, and all those start to take the brunt and then you'll get glue mead 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 in the public community about fear avoidance behaviors. Fear avoidance behaviors. So essentially, athlete tears one acel, and as you mentioned, the research supports that they are more susceptible to tearing the other acel. But yeah, you as aquatitioner are faced in a situation where you want to try to help them rehab post surgery, but then also strengthen the other aco, how would you come back to some of that fear avoidance behavior and an athlete that's already had that tear once. That's the first part of the question. The second part is do you feel that fear avoidance can be a contributing factor to re injury? 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 to that lateral displacement that we talked about, just even something as simple as a squad 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 and by slowly working them back up and letting them be able to feel it and know that it's going to be stable and it's not going to give out on them. So there's a progression that 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 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 of 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 of mechanics. Now I'm 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 patient 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 and 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 to repair, how do you assess them in terms of their readiness and their ability to return the point so as based on where they need to be for the level that they're at. So obviously you know, 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 a problems with isometric movement patterns anymore. We've been able to progress the full range of motion at this point. Now where you going to start doing some more eccentric type movement patterns once they it stronger with that and there's no knee pain associated with that, and then you can progress it to your concentric pattern. Start off with the lighter weights and then start building up and strengthening from there. Once you get it stronger, then I would start progressing into more sports 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 reference 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 will try to focus more on readiness based on time rather than performance. So I would shift your focus to more performance and less on time to determine whether somebody's ready or not. Wonderful, thank you. Is repair or reconstruction good better for acl injury to receive better outcomes? And what does the research say in regards to repair versus a reconstruction? And I know that might be subjective based upon each individual 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 that 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 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 both of orsopetas 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 as 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 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 progressing pain and pain psychology. Yeah, absolutely, Any good sport program from the college level up is going to have a sports psychologist, and you definitely need to co manage with that. Talk to the psychologists, 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 what their concerns are, and their fears are. Yeah, that's 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 on all 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 the psychologists 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 precab or the recab work and do it female athletes that are dealing with eclog us. So, and it's funny because I actually the majority of the athletes that I coach right now or female, I've kind of transitioned over that. 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 you'll see when they have those times that you're also going to see that they're going to be weaker during those hormone fluctuations. They're also going to be at increased risk. And so that's when it's really going to 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 then a lot of that. It'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 that 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 there and how their bodies processed 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 acts that he 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 helping your team with these athletes, how are coaches responsive to some of your advice that you How have you found that some of them were resistant than others. How do you usually broke swoose topics with coaches that, as you mentioned, sometimes they're not concerned with certain things that you know are very much a priority for that with coaches, and I've been on both sides of that, both sides of that table, and it's tough. I mean mean, 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 will 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 Modican team as a whole. As far as the coaches are concerned, they've got to have a confidence that you know what you're doing that because they just look at it as is 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 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 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 their 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 lovel high school coaches they're ten to tend to not listen as well as your college or your pro coaches. And so you know, again, if you want coaches that are gonna listen better, you probably need to move up the chain a little bit and get out of high school or middle school. So doctor McAllister, thank you so much for joining us today and 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 fifty nine, where we kick off a new two part series titled Supercharge your Clinical skill Set with doctor Benjamin Fergus. 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