#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.

View the Show Notes Page for This Episode https://peterattiamd.com/kylerbrown/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250526-pod-kylerbrown&utm_content=250526-pod-kylerbrown-podfeed Become a Member to Receive Exclusive Content https://peterattiamd.com/subscribe/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250526-pod-kylerbrown&utm_content=250526-pod-kylerbrown-podfeed Sign Up to Receive Peter's Weekly Newsletter https://peterattiamd.com/newsletter/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250526-pod-kylerbrown&utm_content=250526-pod-kylerbrown-podfeed Kyler Brown is a sports rehab chiropractor who specializes in injury recovery, pre- and post-surgical rehabilitation, and guiding clients from rehab back to peak performance. As co-founder of the private training program 10 Squared alongside Peter, Kyler shares his approach to injury prevention and performance optimization—highlighting how overlooked movement patterns can quietly lead to chronic issues over time. He outlines a practical framework for assessing and treating individuals, highlights the importance of understanding movement dynamics and asymmetries, and discusses personalized rehab strategies through real-world case studies. The conversation also explores the psychological side of recovery, including the role of fear and mental barriers in rehabilitation. Kyler shares actionable tools to evaluate movement patterns and implement training strategies that support long-term strength and health. A companion video series demonstrating exercises for common problem areas—such as the lower back, neck, shoulders, and knees—is available exclusively to subscribers on the show notes page. We discuss: The personalized rehab strategy for Peter's shoulder surgery that sparked creation of a training program called 10 Squared [3:00]; Training for the marginal decade: why precision and purpose are essential for quality of life [11:00]; The Centenarian Decathlon: how training for long-term capacity enhances both current and future quality of life [18:00]; How the shortcomings of conventional rehab and performance systems led to the creation of 10 Squared, a personalized training model focused on long-term physical capacity and individualized care [23:45]; Case study: how personalized assessment and treatment at 10 Squared helps uncover the root causes of injuries [31:00]; The role of the "core" in movement and injury prevention, and the importance of training stability before strength [40:15]; The layered assessment process used at 10 Squared to determine whether a person is ready to perform dynamic movements [47:45]; Case study: the rehab plan designed to treat a hamstring injury while preserving fitness and preventing reinjury [51:45]; Training approach for clients with minimal training history: risk reduction, habit-building, and long-term consistency [55:30]; How to train foot reactivity, tendon resilience, and explosive capacity in a safe, progressive way [1:00:00]; Peter's foot and ankle pain: how to diagnose, treat, and strengthen the lower extremities [1:04:15]; How fear and perception influence recovery, what drives back pain, and when to choose surgery vs. treatment [1:13:15]; Could AI and app technology eventually deliver an individualized rehab and training experience? [1:22:30]; Kyler's professional evolution from traditional chiropractic care to a degree-agnostic, performance-based rehab philosophy [1:25:00]; How 10 Squared provides precision rehab and training in a remote format [1:30:30]; How Peter resolved a severe back pain flare-up using DNS-guided isometric exercise instead of passive treatments [1:33:15]; How to identify and treat common joint pain (neck, back, knee, shoulder) using a rehab framework that strengthens supporting structures and helps avoid surgery [1:39:00]; and More. Connect With Peter on Twitter https://twitter.com/PeterAttiaMD, Instagram https://www.instagram.com/peterattiamd/, Facebook https://www.facebook.com/peterattiamd/ and YouTube https://www.youtube.com/channel/UC8kGsMa0LygSX9nkBcBH1Sg

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:11Dr. Peter Attia?

  Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive, member-only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription.

• 0:54Dr. Peter Attia?

  If you want to learn more about the benefits of our premium membership, head over to peterattiamd.com/subscribe.

• 1:04Dr. Peter Attia?

  My guest this week is Dr. Kyler Brown. Kyler is a sports rehab chiropractor who specializes in sports injury, pre- and post-surgical rehabilitation, and bridging the gap from rehab to performance. He is the co-founder, along with myself, of 10 Squared, an Austin-based private member training program focused on building and maintaining exceptional muscle capacities for the marginal decade. Originally, this was a conversation that we recorded just for the 10 Squared audience, but once it got out there and we saw how much the clients there appreciated it, we decided to repurpose it as a podcast for all of you. In this episode, we discuss the principles behind injury prevention, recovery, and

• 1:49Dr. Peter Attia?

  performance optimization, including how small movement dynamics can lead to chronic issues, discuss a framework for assessing and treating individuals, heightening the importance of understanding from between movement patterns, functional asymmetries, and personalized rehab approaches, talk about some specific case studies, including Kyler's work with professional athletes and others, to demonstrate the benefits of individualized strategies. The role of fear in movement and rehabilitation and how overcoming mental barriers is just as crucial as physical recovery. Actionable strategies for you to assess your own movement patterns and implement proactive training techniques to build strength and longevity. Now, in addition to this conversation, Kyler also filmed a short series of videos in the gym demonstrating exercises

• 2:32Dr. Peter Attia?

  for common issues like lower back, neck, shoulder, and knee pain. These are designed to help you put some of these concepts from today's episode into action. The videos are only available to subscribers and can be found on the show notes page for this episode. So without further delay, please enjoy my conversation with Kyler Brown.

• 2:56Dr. Peter Attia?

  Kyler, wonderful to have you. Yeah, thanks for having me. I want to kind of give folks a little bit of a sense of what you and I came up with a few years ago in the throes of my recovery from shoulder surgery and why that gave us this idea to take two things that seemed quite unrelated at the time, my recovery from an injury, coupled with this idea that I'd been marinating around this idea of a centenarian decathlon in a marginal decade, and why we decided to kind of put the best ideas or the themes of these together. So how does that sound? Sounds great. All right, so let's see, you and I met four years ago as soon as I moved to Austin. I don't even remember what we worked on because I think it was just like preventative stuff. You really wanted me to come over, I think initially just

• 3:41Dr. Peter Attia?

  doing some DNS stuff, like some routine maintenance things. And somewhere around the second or third visit, I was like, what's going on with the shoulder? And that kicked off this whole conversation because in my world, this idea of just doing one technique or providing one service isn't really a complete approach. That's right. You're right. We were probably a couple of months in, maybe, and it was clear that I was nursing this bad shoulder.

• 4:05Dr. Peter Attia?

  And I knew what was going on because I had torn the labrum before. The diagnosis, I remember, was actually made in 2009. I had my first arthrogram in 2009. For folks listening who don't know what that is, an arthrogram is an MRI where prior to you going in the scanner, the radiologist takes a needle about yay long, like four inches long, shoots the needle into the capsule and injects contrast so that it really allows the MRI to show the labrum and how much it's detached from the glenoid fossa. And so it was patently clear at that time I had a torn labrum. It was significantly torn, but not as torn as it would be 13 years later. But I had largely avoided surgery by doing as much as I could to strengthen the rotator cuff.

• 4:49Dr. Peter Attia?

  And frankly, I was afraid to have surgery. That was the bottom line is I didn't want to trade one problem for another, meaning I didn't want to trade pain and instability for immobility. And I saw that as the trade off. Folks listening probably recall that I had a podcast, I did a sit down discussion with Alton, who is the amazing surgeon, Alton Barron, who ultimately did the repair. But what I was most impressed by in that experience, which turned out to be wildly positive, was that immediately you and Alton started working as a team. And maybe you could talk a little bit about what you guys decided to do in the six, I think it was eight weeks, we knew prior to surgery. We scheduled it such that you could do something before then.

• 5:34Dr. Peter Attia?

  What was that discussion like?

• 5:36Speaker 01

  Alton did an amazing job in a lot of ways, but one of the things as a rehab professional that I really appreciated was how he didn't want to just cinch down that joint to where his liability was so covered that that shoulder would be strong, but you lost a ton of function. And I think that is one of the key things that he did for us was he did the right amount. He put the staples and the sutures in the right places to where that shoulder would be functional. And we got to your shoulder well before it became any kind of more significant structural compromise. So it's a really important window to do so. But I do remember that conversation because you had a date several months out where you're like, I'm going to have to use my arm a lot. I need to be strong.

• 6:12Dr. Peter Attia?

  Basically, I needed to be able to hunt in September. So we backed out of that, said the surgery needs to be no later than March. It was January. And then the question was, should you do the surgery right away or do you use two months to prehab?

• 6:26Speaker 01

  Yeah.

• 6:26Dr. Peter Attia?

  And so tell me how you thought about that.

• 6:28Speaker 01

  That conversation was one of my favorites because I've done this before where if we know the big picture goal as well as the near term surgical date and then we reverse engineer, okay, I want to check off a certain amount of things pre-operatively to where that joint is ready. And essentially, in the most simple terms, what you're looking for in that situation, especially with the shoulder, because it's such a mobile joint, is you want to make all the muscles around the shoulder just awesome. But we need to do so in a way that doesn't make the surgery more complicated or injure you more. And so we did a lot of things where we didn't only use technology like BFR, but we also used very aggressive approaches on your core stability, the way your scapula interacted with your ribs, and all these things have an effect on how my shoulder moves. And if my really mobile

• 7:12Speaker 01

  shoulder that has a torn labrum isn't stable and doesn't have a support infrastructure around it, you're always just going to ask for more pain. But the best thing about that is the day you got the surgery, we jumped on it really quick. Once things were healing from the surgery itself, all those other ancillary things were actually functioning really well. So now we only had to really target the shoulder itself because the rest of the human was really strong and ready.

• 7:33Dr. Peter Attia?

  So the things that I remember, which are probably fewer details than what you remember is, one, how much rotator cuff work we did ahead of time, particularly around supraspinatus. So we really got that muscle as strong as possible in eight weeks. You know, anybody who's gone through that type of rehab, which I'm sure many people listening have, it's uncomfortable. I mean, you're burning a little tiny muscle that is not used to working that hard. The second thing that I remember, and hands down the most important thing, was what you and Alton decided to do post-operatively completely shattered everyone's understanding of what we do with these patients. So the traditional view is, especially, this wasn't a slap tear. The entire labrum was hanging by a thread. And

• 8:15Dr. Peter Attia?

  normally, as you said, a surgeon's primary objective is, hey, I'm going to make sure that this is never unstable again. I'm going to cinch this down really tight and you're going to be in a sling for four to six weeks. And that's going to give it plenty of time to heal. All of that sounds great, but you'll never regain your mobility. You'll never regain the range of motion you want, the healthy range of motion you had. And frankly, you'll probably atrophy away. And so Alton said, no, we're going to have you out of a sling in 24 hours. And I was like, how is that going to be possible? And yet we did. There's no way he could have done that if you guys weren't partnering on this. How is that even possible? And why does that fly in the face of everything we would think of?

• 8:55Speaker 01

  The broader picture here is what we touched on, the liability, and it's really difficult for modern physicians and rehab pros to integrate. Professional sports tries to achieve this as well, but they have time constraints and all these other constraints with how many people they're working with. So ignoring all those layers, I think the most important thing is to know, Alton and I had these conversations in detail and he was really specific about, okay, did we get the training we talked about? Is that supraspinatus, the serratus anterior, all these other muscles that help stabilize? Are those really good? And I had some metrics I was able to discuss with him and he felt really confident in the stability of your shoulder. So if we're speaking to a general population, I would say that no sling or sling decision was based on what we knew exactly what we did. The other thing is that you followed everything to a T.

• 9:39Speaker 01

  One of the big complications in rehab, athlete or not, is are people following the rules? Are we going to take this athlete or individual out of a sling? And are they going to forget about it and all of a sudden go reach for the cereal? Or are they going to follow the rules? And you were definitely a rule follower, so he and I had a high confidence in minimizing the risk.

• 9:55Dr. Peter Attia?

  Truth be told, I learned a lot of that the hard way from my first orthopedic surgery back in 2000, when A, I'm not even convinced I received post-operative instructions. And if I did, I didn't read them and I was breaking every rule there was. The stakes were higher here in a way and I think I was very mindful. For example, people, myself included, when you have surgery, you tend to go on YouTube to learn all about it.

• 10:18Speaker 01

  Right, right.

• 10:18Dr. Peter Attia?

  And I'm like, okay, I want to see everything. I want to watch the post-operative, I want to watch the rehab process. And so one of the big milestones you see for people with labral surgery is when they basically can dangle the arm and rotate like a lightweight. And Alton was really clear, like, you're not going to be doing that for a while. We're talking about range of motion without stress on the repair.

• 10:41Speaker 01

  Right. And very early on, pre-operatively and post, we were able to do very gentle but targeted isometrics, where there wasn't complexity in the joint itself, but we were loading the tissues in a very articulate and specific way. And that's how you, again, put this support structure around it. I always kind of described as like the roll cage in a car. We want all the muscles around that to be ready to absorb force. So those joint structures that are getting the staples or whatever else in there, aren't stressed. We don't want to yank on those things while they're healing.

• 11:09Dr. Peter Attia?

  So in parallel to this, I'm continuing to sort of refine my thinking around the idea that we're all going to have this marginal decade one day. And it does come across as sort of a depressing thought. Nobody really wants to think about the idea that there will be a day when you knowingly or unknowingly enter the final decade of your life. But at the same time, to act as though it's not true, won't make it not so. So I think it occurred to me that the more deliberate we can train for that last decade as though we are athletes, the more we can enjoy it. Because as I watch people in the final decade of their lives, and I've had the both privilege

• 11:52Dr. Peter Attia?

  and curse of seeing a lot of it, I believe that the thing people complain most about is what's taken away from them physically. Now, there are lots of people in the last decade of their life that are lonely because they were miserable sons of bitches and their family, you know, they don't have family or friends.

• 12:09Speaker 01

  Yeah.

• 12:10Dr. Peter Attia?

  All of those things. There are many people whose cognition has failed them long before their body has failed them, and that can be very distressing. But if I'm really thinking about this in terms of large numbers, more than two thirds of people, I would say, in the final decade of their life, when they're really thinking about what's impacting the quality of their life, it's this. It's the physical part. That's the thing I've lost that I miss the most. And sometimes it could simply be freedom from pain, but more often, it's restriction of activity.

• 12:37Speaker 01

  Yeah, totally.

• 12:38Dr. Peter Attia?

  And that's my biased experience. You see much more of this. Tell me what you think.

• 12:41Speaker 01

  It's a really analogous to the pro athletes I've worked with as well, where it's really interesting to see these mature athletes who've been playing their sport eight or 10 years, and they're starting to kind of look this reality that their career is going to be over. And they start recalibrating how they train because they start thinking about the long term. And what's really fun for me is when they start to get that perspective of it's not just about this weekend, it's about the long game here. And I think, to your point, a lot of people out there have the best intentions, and they're maybe even working hard, but there's no precision. Nothing's accounting for their specific details, their nuances of their joints and how they move and how their body feels when they move and their trust in their body and all these variables. And a lot of people are either want to put in the effort and don't know where to start, or a lot of people are putting in the effort, but it's not calibrated.

• 13:26Dr. Peter Attia?

  Yeah, and I kind of even began to observe that in myself, which was there were a lot of activities that I was doing where I was doing them because I'd historically always done them.

• 13:38Speaker 01

  We fall in a groove.

• 13:39Dr. Peter Attia?

  This is the type of exercise I enjoy doing. This is a type of workout I enjoy doing. And then I had to kind of take an honest assessment of some of these and say, okay, for every activity, just like for every investment, there's a risk and there's a reward. And the way you might think about investing in your twenties is probably different from how you maybe should be thinking about investing in your sixties or seventies or beyond. And similarly, the risk and reward changes over time. So for example, when you're 20, the risk is just inherently lower because you have better tissue. We could go through all the reasons why inflammation, senescence, everything that changes as you age reduces tissue quality. And younger people, I'm sure you see this all the time, can just get away

• 14:23Dr. Peter Attia?

  with doing things incorrectly. In fact, would you agree that sometimes some of the most gifted athletes actually have horrible patterns of movement, but because they're so gifted, it doesn't seem to matter?

• 14:32Speaker 01

  Yeah, I mean, specialization is one. Some people are just born jumpers and then you train it and they practice it when they play and they get better and better at jumping. Absolutely. But moreover, it's almost like we're set up for failure. We're set up with this baseline norm of I could bench press 225 when I was a senior in high school, but then that individual is not accounting for the 20 years of lack of activity, lack of practice, they've atrophied, and then they jump right back into the gym and then they hurt things or they feel like they, quote, can't do it anymore. And the reality is it's all about capacity. If you don't use it, you lose it. And a lot of us aren't really thinking about what have I actually actively lost from an activity standpoint? Is it jumping? Is it mass? Is it strength? All those variables that you spoke to. But I definitely see this a ton on the injury and pain side.

• 15:13Speaker 01

  Injury doesn't show up out of nowhere. It has reasons why it shows up and it's compounded by emotional stress and all these other kind of multifactorial things. When our brain perceives threat, we feel pain. Absolutely. Sometimes that's a physical threat. Like I haven't jumped in a long time. I started jump roping. All of a sudden I wake up, my Achilles is sore. That doesn't mean I ruptured my Achilles, but it does mean I was not prepared for that movement because I've been on the shelf for a long time. And so I think a lot of- People with that investment strategy analogy is fantastic and they should really incorporate that is making sure they're accounting for all the buckets that their body needs to do, not just with what they want to do, but what we know people need. Demographics, Western society, age, all these things play a role to like, if you pull up the stats, a lot of people will have, oh, high risk for a low back or high risk for an ankle or whatever.

• 15:58Dr. Peter Attia?

  Yeah, the jumping is a great example because if I go back to when I was in my sort of training peak, so basically age 13 to 20, call it those years when I was training a lot. Jumping was an enormous part of what I did. There wasn't a day that I wasn't jumping. So for example, I was skipping rope 25 minutes every single day. You know, lots of those are doubles. So you're really up there. Absurd amounts of plyometrics. And then from basically 20 to my mid 40s, didn't jump at all. Not a single jump. That became one of the realizations was, oh, you've lost a lot of tissue pliability. As one example, now something that I do a lot of is low level jumping. You're right.

• 16:42Dr. Peter Attia?

  Sometimes I get really worried. I'm like, oh, man, I don't want to have an Achilles rupture. Like that's the middle aged man injury.

• 16:48Speaker 01

  Oh, yeah.

• 16:48Dr. Peter Attia?

  Playing soccer with my kid and I'm just waiting for it.

• 16:51Speaker 01

  Yeah, right. In my private practice, I see this all the time, but what I always tell people to do is like, look at your kids. If you go to a coffee shop with your kids, I guarantee one of them will run and jump off a rock and like do a twist and land it. When was the last time one of us did that? Right? And that's why they say maintaining play and always playing games and increasing that to where it's randomized games. You're actually reacting to things because there's the neuroplastic effects as well. But just for the tissues rehearsed load on the Achilles and the foot. If you go and get a job and you drive to work and you sit at your cubicle all day and you drive home and you didn't jump, that times five or 20 years is going to cause a lot of lack of capacity in your tissues that you don't want to learn the hard way.

• 17:30Dr. Peter Attia?

  That's right, because all I'd been doing in the intervening 25 years was swimming, cycling,

• 17:36Speaker 01

  Non-impact, non-impact.

• 17:37Dr. Peter Attia?

  hiking, which is fine, but it's still not jumping. It's not reactive. And so part of what made me start to realize this was as my kids got old enough and I was now playing sports with them. When you play basketball, soccer and baseball with kids, you realize exactly what you just said. It's not a predictable movement. It's never the same movement exactly twice.

• 17:57Speaker 01

  Yeah, three dimensional, short, long, quick, slow. Yeah, I mean, a lot of variables there.

• 18:01Dr. Peter Attia?

  Which actually gets to this idea that people listening to us are probably very familiar with, which is the centenarian decathlon. Give me some of the things on your centenarian decathlon.

• 18:10Speaker 01

  For me, wrestling with my kids, which means getting down on the floor, having the flexibility, wrestling with my grandkids.

• 18:16Dr. Peter Attia?

  Wrestling?

• 18:17Speaker 01

  Yeah.

• 18:17Dr. Peter Attia?

  That's big.

• 18:18Speaker 01

  Just like play, right?

• 18:19Dr. Peter Attia?

  Yeah, yeah, yeah. Not a pile driver.

• 18:20Speaker 01

  Depending on the kid. If they're my grandkids, maybe, but that's definitely a goal of mine is that bonding that you get when little kids wrestle around the ground. And I saw my dad recently doing that and I thought that was really cool. He's over 70 and he's on the ground messing with my three-year-old and it was just cool to see. And that's how I added that to my list. It was hard for him, right? It wasn't easy, but he got down there and he could do it and he didn't suffer from it. That's one of mine for sure. As you know, I fell in love with rucking over the last couple of years. And so I want to be able to really crank out some mileage, especially in national parks as I get older. I'm not looking to be an ultra marathoner per se, but I really want to be able to hike long distances, probably with a pack on it.

• 18:56Dr. Peter Attia?

  When you're in your marginal decade, how many pounds would be your expectation? Give me some numbers. How many miles, how many pounds?

• 19:02Speaker 01

  Yeah, I think my numbers will be a little distorted because I'm a pretty big guy. You know, I'm 6'3" over 200, so I should be able to carry at least 20 pounds without worrying about too much for four to six miles.

• 19:10Dr. Peter Attia?

  Okay, I like that goal.

• 19:12Speaker 01

  Yeah, I mean, I want to be reasonable about it.

• 19:13Dr. Peter Attia?

  And this is on what kind of terrain?

• 19:15Speaker 01

  Not too technical, like I'm not thinking boulders and rocks, but I definitely like to go hills, up and down, dirt track, all that kind of stuff without having to worry about it.

• 19:23Dr. Peter Attia?

  Okay, what else?

• 19:24Speaker 01

  Another one is, I grew up being an athlete. My youngest seems to be the more inclined to be an athlete. So as I age, I want to be able to hang with him as long as I can. So that means throwing, hitting a baseball as long as possible. Who knows how their careers will evolve from an athletic standpoint, but odds are they're not going to be pros. So I really want to keep that base where I can keep playing with them as long as I can. But to me, it's all about being able to still play with the grandkids because family is one of the most important things out there. And if your grandpa is sitting there and can do cool stuff, I think that serves as a great role model. Whereas if you're suffering from an injury, you're not healthy, then they want to hang out with you, but at the same time, kids want to go do stuff and I don't want to be left out.

• 20:00Dr. Peter Attia?

  I agree. I think as much as I think there are probably examples where the wise old grandpa or grandma can sit inside and tell stories to the kids. I mean, there's value in that, but I think there's even more value in going to their world. They typically don't want to come into your world. You typically have to go into their world. So you have to be able to go fishing, hike. And again, people listening to us who have young kids should not waste the opportunity to observe what young kids do. There'll be different technologies in 25 or 30 years, but I think the principles will be the same. Kids like to play and therefore, playing with my kids today is giving me a dry run of what I want to be able to do in 30 years.

• 20:42Speaker 01

  Yeah. And if you aren't building up these areas of need, or you're accidentally letting these certain athletic kind of movements fall by the wayside, all of a sudden you're like, oh, man, I can't do that anymore. I love coaching my kids' basketball team and one of the other kids on our team, their grandpa was out on the court with us one day. He was, I think, 74. He wasn't doing windmill dunks or anything, but he was moving and he could shoot. And every kid there, their eyes lit up. They're like, grandpa can shoot? That's crazy. That was a cool moment. That's why I put on my list of just playing with kids might be my whole CD. My wife might have something different to say about that, but I think for me, it's like, if I can play and if I can do all those things, then I'm doing pretty well.

• 21:19Dr. Peter Attia?

  When I first introduced this idea, the Centenarian Decathlon, to the first of our patients, this is before, of course, we started 10 squared. One of the bits of pushback I got a lot was especially from people who were like in their 30s and 40s. They were like, Peter, I'm not that interested in my 80s and 90s. Like, you keep talking about making me a kick-ass 80-year-old. I want to be a kick-ass 40-year-old. What's wrong with that? What's the flaw in that logic?

• 21:48Speaker 01

  To me, it's everyone's drawn to this high performance, be awesome right now. And that's like a boom-bust strategy. You might pull it off, but you're high risk and eventually you'll hit the wall for a race car. But if we're thinking long-term, then by default, if I'm going to be an awesome 70 or 80-year-old, I kind of have to be an awesome 45 or 55-year-old. We're going to be doing things now that make you crazy strong, that help your lean muscle mass, that burns your fat, all those health risk things. But you're also going to be way more prepared for whatever life throws at you. And if your buddy talks you into going skiing or going to do a volleyball game or whatever else, you're going to be way more ready for it if you're thinking long-term and building this crazy, robust foundation, rather than just chasing the newest technique or the newest technology.

• 22:30Dr. Peter Attia?

  Yeah. The analogy I used with people at the time, because archery is something I enjoy, is that what we're trying to do is train you to be exceptionally accurate at 100 yards. And you're telling me that you don't care about 100 yards, you just want to be accurate at 40 or 50 yards. And I'm telling you, trust me, if you're an ace at 100 yards, it's like shooting fish in a barrel at 40 yards. And this is where the analogy is actually, has a deeper layer of truth, which is that's a very nonlinear thing. 100 isn't just twice as difficult as 50. It's four or five times more difficult.

• 23:07Dr. Peter Attia?

  And similarly, to be really fit and healthy in your 90s is a dramatically more demanding feat than just to be a fit 50-year-old.

• 23:18Speaker 01

  Yeah, there's a lot stacked against you, plus variables that we're not prepared for, or we could roll our ankle. But give me somebody who's strong all day, and if they sprain their ankle coming out of the bar, they're actually going to sprain it less, odds are. So all this insulation and capacity we put around us with the individual goals is crucial to prevent injury. And these injuries can stack up and cause a lot of trouble, and then we get less healthy. And that's how you get these multipliers, where I was on track to be really good, but this knee arthritis or this multiple meniscus repairs I had to get because I wasn't stable caused me to actually lose my hiking ability. And then all of a sudden, I got less healthy.

• 23:53Dr. Peter Attia?

  Let's fast forward a little bit. Basically, as I'm kind of getting better from the shoulder thing and realizing how fortunate I feel to have had this experience where I've known Alton for a while, then I met you, it's this great connection. I say, hey, man, what do you think about this idea of we build this separate little business that just focuses on the training piece, that's outside of my practice, outside of your practice, but integrates it with everything that's necessary to train a person for the marginal decade? So you bring in all of the cardio training, you bring in all of the strength and conditioning, you bring in the coaches to integrate the whole thing. So, okay, we're doing that now. Of all the things we do in 10 squared, I still think that your domain is the hardest for people to wrap their heads around. I think people understand, oh, yeah,

• 24:37Dr. Peter Attia?

  you guys will help me get a high VO2 max. And you'll boost my zone two and you're going to make me stronger and blah, blah, blah. How do clients look at you? What do they figure is going on with you?

• 24:46Speaker 01

  It's funny you say that because the assessment takes two days and we're looking under the hood a lot in a lot of different ways. It's funny how they evolve like their perspective of it because what I was kind of forced to do in my career was I had experience working with teams and all that other stuff. But I kind of became an off season person for these athletes and by default, I had to almost become a strength coach. Not because I wanted to, that was my goal, but because these athletes needed that bridge from I'm injured to I might be injured to, hey, I've got the green light for performance. All humans are moving up and down that spectrum based on our recovery and all these variables. So what's been fun at 10 squared is I get to do all the assessment I want and it's not really a clinical assessment.

• 25:26Speaker 01

  On the one hand, we're of course, looking at things that either have pain or that individual member has had a previous injury with. And we're accounting for that and we're making sure that's on track or could be improved and we add those things. But then I also get to play around and look at what else is weak. What is this individual at risk for? So one example is we have a client who loves to surf. He's got a shoulder issue. So by default surfing and swimming on a surfboard is a different position than a traditional freestyle stroke. So we had to make his shoulder uniquely robust in certain directions. And so that's part of his strength program. One of my biggest pet peeves in the rehab world is when people give someone 30 exercises that are really tedious and boring and no human sticks to that. They might do it for a week or two, but if it's not bridging to what they love and what they want to do, it won't get there.

• 26:11Speaker 01

  So if we can bake in ensuring that all the strength training won't make them worse. And then also make sure that we're baking in their little corrective exercises or improving the gaps. That's where you make a huge difference into how someone feels, but also how they can perform.

• 26:25Dr. Peter Attia?

  What are some of the things you see? And I'm not asking this to be critical of what other rehab professionals do, but as a person listening to us who says, look, man, I've been not getting better. I've had fill in the blank injury. So I've had tennis elbow that won't get better. I've had lower back pain that's just not getting better, shoulder pain that's not getting better. How do you help that person think about whether or not there's an underlying structural problem that needs a surgical intervention? Or a more direct intervention versus you're not being instructed to do the right things and or you're being instructed and you're not doing it. Like, how do you walk somebody through that tree?

• 27:00Speaker 01

  Obviously, it's a heavy lift with a lot of details. I think the first rule is the medical community, so your orthopedic surgeon or your neurologist, and then your rehab pro have to be in sync and have a relationship.

• 27:10Dr. Peter Attia?

  And how often is that happening?

• 27:11Speaker 01

  I mean, it's very rare. What's really interesting is the philosophy and the individual just spirit of either surgeon or the rehab pro, they have to be kind of committed to the service oriented field. If they're just doing it for money, they're going to do scale and they're going to do like the PT mill that there's four clients with one therapist and that therapist is probably doing the best they can, but they're just kind of outnumbered. And they're not accounting for those four different people all at once. So first off, it has to be one-on-one. You cannot tell me that you're rehabbing you the same way you could rehab my grandma who had a shoulder issue.

• 27:43Dr. Peter Attia?

  Are you saying that, it's going to sound like an ignorant question, are you saying that in some facilities, one PT will work with multiple clients at the same time and put them through the same workouts, even if they're quite different?

• 27:53Speaker 01

  Yes. Oh, yeah. Typically, it's a very cookie cutter approach. Usually, it's an insurance model thing where they know that these certain exercises and putting ice or STEM is going to be reimbursed by the insurance company. So that PT clinic is going to do that on everybody regardless of what they need. So that's one of the biggest pitfalls is it's never one-on-one. It's not custom. I mean, in the same way, I've had pro athletes come in and we're supposed to do shoulder rehab that day and the night before they did a ton of stuff to their shoulder. So guess what? I'm not doing anything. They actually need to recover that day. It needs to be customized. To go back to your original question of how do people navigate this world? I think your rehab clinic needs to do more than just offer services. They need to offer a plan. This idea that, okay, this is what I offer. I offer cupping or dry needling or whatever it could be. One service doesn't

• 28:38Speaker 01

  ever fix anyone and it definitely doesn't increase their capacity over time. The magic word of capacity is what it's all about. Are you building me back to what I want to do? So if your rehab clinic is a bunch of passive modalities on tables and a bunch of techs doing ultrasound and stuff, that's a red flag for me because they're not going to build you to get stronger and stronger. Number two is the orthopedic needs to actually be hunting down that physical therapy. So a lot of times what I see in the orthopedic world is they have to give their clients something for rehab guidance because they're not totally sure if their client's going to go do rehab. Can they afford one-on-one and all these other factors? So they give them this handout. Well, a lot of times this handout is from 30 years ago, and it's the same five or six cookie cutter exercises. But then there's no accountability, there's no nuance.

• 29:22Speaker 01

  So there's just a lot of holes in this path to trying to get your shoulder or your back or your knee from it hurts, do I need surgery or not? Built all the way back up to I can do whatever I want.

• 29:33Dr. Peter Attia?

  Now, is this taking the extreme example at the other end, which is professional athletes? You work with a lot of them. You work with golfers, football players, basketball and baseball players typically, right? Is there any other type of athlete I'm missing?

• 29:44Speaker 01

  You know, I've had some incidental tennis people, a lot of runners too.

• 29:46Dr. Peter Attia?

  Yep. Now, some of those athletes come with deeper pockets than others and come from leagues. So when you're talking about the NFL players, for example, is that problem completely solved?

• 29:57Speaker 01

  No, not at all.

• 29:58Dr. Peter Attia?

  Still not.

• 29:59Speaker 01

  There's a lot of environmental problems. So one of the biggest issues with all these people, and I have friends that work with all these professional teams that are great, and they're handcuffed because they only have their athlete for so long. So you all of a sudden get this multiple cooks in the kitchen problem, where even if everyone has no ego and the best of intentions and they're most science-based people, they're still not sure, okay, what'd you do last week? What are we trying to do? Are you in a contract year? Like, there's so many variables for a pro athlete. So in a weird way, professional sports is wellness upside down. It's how can we get the most out of this athlete, this commodity for their contract? And that's not really a long-term play. What's been really interesting at 10 squared is we've had some pro athletes approach us with this idea of, hey, can you guys be my reliable? You're invested in me only and be my oversight. Where are my gaps?

• 30:44Speaker 01

  Is this okay? Should I play through this pain? Because there are times you play through pain, there's times you don't. But the most important thing is this idea of having one person driving the bus, who knows all your variables? Because if someone comes to us and changes their central decathlon, like they want to change one item, like, hey, I really want to start doing jump rope every day. And then we look at their testing, we're like, look, you're high risk for Achilles. Let's bake into your program some really good articulate, smart strengthening to get you there, rather than just hope it works out.

• 31:13Dr. Peter Attia?

  So how do you guys do that? I didn't ask her in advance if we could do this, so we might have to edit this out of the discussion.

• 31:19Speaker 01

  Sure.

• 31:19Dr. Peter Attia?

  Can we use my wife as an example? My wife is a client at 10 squared.

• 31:23Speaker 01

  Great example.

• 31:23Dr. Peter Attia?

  So Jill's a runner, like a little deer. Runs, runs, runs, runs.

• 31:27Speaker 01

  Built for it.

• 31:27Dr. Peter Attia?

  Yep. I'm very hands-off, anything that has to do with her, actually, by design. Can you tell us a little bit about her? And what did you learn when you did an assessment of her? And how did that impact? How she works with the other members of the team? On the cardio side, on the strength and conditioning side?

• 31:42Speaker 01

  Yeah, other than saying that she's a saint for having signed up with you. You want me to talk? Okay. Jill's a really great example because she had some pain when she showed up. So my job immediately is evaluate that pain. Is that a structural insufficiency? Are we worried about a real injury here? Or is that just an annoying nuance? Based on the testing I did, so I did my clinical exam, but way more detailed than I normally would in my private practice, because at Tensquare we have the time. And we want to remove confirmation bias. So we don't want me to just say, oh, your hamstring hurts. Let's order an MRI. Let's test it six ways and in a smart, conservative way. And if all six of those indicate that, then we're going to do an MRI. So with Jill, we saw some proximal hamstring issues. She's of course, like you mentioned, endurance athlete.

• 32:23Speaker 01

  Her profile, her demographics, her running history all pointed to there might be a tendonopathy there. And then based on my testing, it reinforced that. So I said, let's get an MRI. Let's really evaluate this tendon. Because we knew in the near term, within a year, she wanted to run Boston. And as an injury person, I saw this as, look, she's okay now, but it hurts. Once we start stacking up her mileage, that thing's going to get in the way.

• 32:46Dr. Peter Attia?

  There's another detail here that I do recall. Obviously you recall as well, but it might be worth pointing this out to the listener. So she normally only runs one marathon a year. Last year she ran two. She ran her Boston qualifying marathon, which I think was Chicago or Houston or something like that.

• 33:03Speaker 01

  Yeah.

• 33:04Dr. Peter Attia?

  And then got into the London marathon and went and ran that seven weeks later. And started to get for the first time ever, a little bit of knee pain.

• 33:14Speaker 01

  Yes, the other knee.

• 33:15Dr. Peter Attia?

  The other knee. So can you explain why you didn't think that was a coincidence?

• 33:21Speaker 01

  Very much so. So that story perked my ears up, that history. And I saw her for knee pain and brief to get her through London and that kind of stuff. But the way runners move, a lot of people don't appreciate, but running, even though I'm moving straight ahead, is technically a unilateral or single leg rotation propulsion drill.

• 33:36Dr. Peter Attia?

  Explain what that means, because it's counterintuitive.

• 33:38Speaker 01

  It really is. So golfers are actually the same. They're single legged, actually. Rotates to create that torque. So what happens is my favorite term that's out there right now is called the spinal engine, which really speaks to this reciprocal movement of the spine on top of the pelvis and then my feet through the ground. So those three domains, if you will, work in unison to propel me forward. It's a lot like with sailing, like you put the sail relative to the wind and it points me in direction. All three of those domains have to work in sync. And so when I all of a sudden see an athlete like Jill, she wasn't new to running. She definitely added her volume in a short window, which is a great recipe for injury. But that right knee flaring up told me, okay, there's something going on at either her feet or her pelvis that's not in sync.

• 34:21Speaker 01

  Because she essentially with her mileage overloaded that right knee and created a repetitive stress injury. So that's why I was saying earlier, injuries don't just show up for fun, right? The great almighty above didn't say Jill, Tia, right knee pain today. And so whenever you see a story like that, and then you do the evaluation, and the way her pelvis was rotating, the way her core and her spine were set up, and also the way that left hamstring was affecting her motion. She was basically dumping into that right knee over and over. 10 miles for someone like her, no big deal. You stack up two marathons pretty close with that much mileage, all of a sudden that right knee really flares up. And so the right knee flare up was actually an indicator of something else going on functionally. And it wasn't only about making her knee better, which is what traditional medicine does is like, okay, rest it, ice it,

• 35:04Speaker 01

  myoxcam treatment, rehab, chiro, whatever. And then the knee's better. And then traditionally, those people go run again and three or five months later, it comes back. So we need to look at these asymmetries everywhere else, not just the side of pain.

• 35:16Dr. Peter Attia?

  And so if the knee is caused by the hamstring, what do you think is the cause of the hamstring injury? And why are women, middle aged women, so susceptible to this injury?

• 35:27Speaker 01

  Yeah, great question. I think demographically, a lot of middle aged women, it's getting way better, but don't strength train, number one. So the health of their tendons and the muscle fibers and the mass of the muscles just aren't normally as high and as strong as someone else, especially if they're an endurance athlete. Runners nowadays know that they need a cross train, but how they're doing it, what it looks like is still a big gap, in my opinion. So using the word cause is always tricky in biomechanics because it's always kind of like the snake. Beats the tail like they're all kind of intertwined. But the most simple way of describing it is that tendon overuse. What we found out with her MRI is that she had a true tendinopathy, damage to that proximal hamstring tendon, as well as one of the hip rotators that inserts on the same site next to that hamstring, had a little damage and irritation.

• 36:10Speaker 01

  That area was a byproduct of the way she was rotating through her pelvis and the way that spinal counter rotation was happening. Jill has a tiny bit of scoliosis, which sets her up for that asymmetry. And so her brain, subconsciously, was basically forced with the decision of, do I jam my right low back? Or do I really try to pull with that left hamstring? And that combination over time created a little fraying in the tendon.

• 36:34Dr. Peter Attia?

  And the other thing I would add to this, which I suspect any woman listening to us who's had kids will appreciate is even though Jill is tiny, she said her body never went back to pre-pregnancy. So if she talks about how she used to run before 2008. So our first child was born in 2008 and she ran a bunch of marathons before then. And then she's run a bunch of marathons since and she weighs the same. She's been very fortunate in that regard that her body weight hasn't changed in that period of time. But she says she cannot biomechanically do what she used to be able to do. Now, when I hear that, I assume her pelvis was mechanically changed having kids and she feels it, but she can't articulate it, nor can I necessarily.

• 37:19Dr. Peter Attia?

  But she just says there's something different. She felt like she used to float and now she feels like she runs.

• 37:25Speaker 01

  Yeah, right. She's colliding. I could definitely see that and I think a lot of women feel that way. My wife had the same experience. I think one of the biggest crimes in modern medicine today is that a running back, if we blow an ACL, we know exactly what to do and there's a protocol and everyone's like, okay, in eight months, this athlete will be back. But women, everyone cares about the baby. The baby's born, even the mom cares about the baby. They sacrifice their own body to just to make sure this little creature grows up and gets everything it needs. And so this focus on what women need the first year after is very lacking, in my opinion.

• 37:56Dr. Peter Attia?

  I hope somebody's listening to us, by the way, and is thinking of another type of a 10 squared, which is what are we doing for women immediately post-baby? Vaginal and C-section is two totally different operations or two totally things. There should be really robust rehab paths to get them back in amazing shape immediately as opposed to, we'll come back to this in 10 years.

• 38:17Speaker 01

  The complexity of what they deal with is fascinating because not only do they just add weight by adding this human, the relaxin hormone creates areas of stress and laxity that will shorten up and tighten up over time, but it affects different women differently. Some women's feet change in that environment of more relaxed and carrying more weight. The arch in the foot gets affected. And so in a way, I always look at it as like, okay, all these areas suffered a little bit of what you might call as an injury, but let's look at it like, okay, it's a natural process, but how do we account for all these layers? Like, no one out there is telling women to do foot strengthening when they're two months pregnant, but they should be.

• 38:54Dr. Peter Attia?

  I wouldn't have thought of it until you just said it now.

• 38:55Speaker 01

  Yeah, literally, women, just like we did for your shoulder, if you find out you're pregnant, you should start doing some foot strengthening things, some core stability stuff. There's a ton of things you could do prehab. Then after, obviously, you know, God willing, see how it goes and get the baby good, but then you start trying to strengthen the right way.

• 39:10Dr. Peter Attia?

  And I think there's something about the pelvic floor that is absolutely decimated in pregnancy or delivery, more to the point. And I deep down believe, no pun intended, that that's a part of what has gone wrong in her hamstring. And I see this in many of her friends. This is a very common complaint and it doesn't present as even a hamstring injury. It presents as either knee injury, like an ischial tuberosity pain, which is like the sit bone. And they say, oh, I just not comfortable sitting. Yeah, I don't want to sit.

• 39:36Speaker 01

  Oh, yeah. One of my favorite orthopedic surgeons in town, he called me and he's a hip ortho, great guy. And he's like, hey, you gotta help me out here. My wife has the same issue and she's been doing traditional PT for like eight months and it's no better. And she's about to fire me. She's like, what are you doing? But it's a very common thing. And that's what's been really cool for me to see these pelvic floor specialists that are rising. It's really cool field, ton of expertise with it. I am not an expert in pelvic floor by any means, but you touched on the pelvic floor is very much a big player in how we pressurize our intra-abdominal stability. It's basically the flooring of that whole canister that we're supposed to create with proximal stability. And so if the diaphragm or the pelvic floor isn't doing its job, then our body's going to immediately start to compensate and create rotations and tilts around things.

• 40:20Dr. Peter Attia?

  Let's talk for a minute about the core. I hate the term because it's so misused, but the way we talk about it is probably most closely aligned with how DNS thinks about it. Dynamic neuromuscular stabilization. So maybe just say a moment about it through the lens that we think about the core as a cylinder as opposed to quote unquote abs.

• 40:39Speaker 01

  Yeah, exactly. I think that's the starting point that I wish everyone could automatically understand is that if you have a really prominent rectus abdominis, that six pack, that has nothing to do with how you stabilize your trunk, especially if I'm doing things in multi planes like tilting and rotating. So it's not just your obliques either, but it's the deep stabilization system that not only pressurizes with our diaphragm, the pelvic floor, but it's also all the small muscles up and down my spine, including like multifidai. Do all those muscles kick on and create stiffness in the right way at the right time? I think a lot of times people are accidentally over coached into thinking they only need stiffness. Cause the second step to that is, okay, now I can activate that deep stabilization system. I have that bracing, I'm pressurized, I'm using my transverse abdominis, all these other structures down there.

• 41:23Speaker 01

  Now can I do that with motion? And that's where you start looking at someone kicking or running or throwing. That needs to be a dynamic system, not just a stiff system. And I think a lot of people, they don't have the first one. So they see a ton of these exercises like the DNS three month or dead bugs, or whatever else we want to call them that create deep core stabilization. But they don't see the next step after that, which is, okay, now how do I maintain that pillar and that strength? And then I get a free shoulder blade or a free hip to move. And one of our shared clients, he had a lot of ridiculous nerve pain from a disc issue. And he was convinced he had some of that. But one of the most fascinating cases for me in recent memory, because with him, we were able to actually find a trigger point that referred pain that mimicked that ridiculous nerve pain.

• 42:08Speaker 01

  So when we literally pressed on his glute minimus, he got referral that he thought was attributed to his back. So that was a window towards, okay, that's a muscular issue. That's not your spine causing trouble. And then we gave him these stabilization drills, which helped that glute just relax for once. What we see all the time in the clinic setting is muscles are meant to be a muscle. My bicep is meant to contract and relax. It's not meant to be a shoulder stabilizer. But if my stabilization isn't doing its thing, then that bicep and the trap and all these other muscles try to help. And that's where we lose freedom of movement because your body's essentially perceiving a little threat, a little instability, and so it tightens other structures up. So then I see people coming into our office saying, will you dry needle this or work on me or do soft tissue work? They go to the stretch place. That's going

• 42:50Speaker 01

  to be a six hour benefit. But if we activate this deep stabilization system and get all the parts moving in unison and in sync, all of a sudden, those movement problems go away, and you're much more robust and strong.

• 43:01Dr. Peter Attia?

  Yeah, there's so much I want to say on this. I don't want to lose the thread, but I'll sort of say two things that seem unrelated, but they're quite related. The first is, I wish there was another word for stability that didn't imply static. We think of that as things that are not moving. So rigid, stable, etc. But the truest way to appreciate stability is kinetic stability. That's why in the book, which I know you haven't read, but if you do read it one day, no, I've been too busy. Yeah, I know. The section of the book where I write about stability, the analogy I use, much against the desire of my publisher, who hated it, was that of a race car. Because again, you're thinking like, how does a race car explain stability? But if anybody's driven a race car, or if you haven't, if you can take

• 43:44Dr. Peter Attia?

  my word for it, one of the fundamental differences between a race car and a street car is that in a race car, you're transferring much more of that horsepower to the tires than you are in a street car. In a street car, a lot of energy seeps out because the chassis is not very stable. And you might say, well, why? Well, in the case of a car, it's because it's more comfortable. Race cars are not being optimized for comfort, they're being optimized for performance. If you're optimizing for performance, you actually want more stability in the chassis and the suspension, so that you're transmitting more force to the tires and the tires to the surface. And similarly, when you think about an individual who has

• 44:26Dr. Peter Attia?

  stability, they are able to transmit force much more directly to the outside world, and they are able to receive force more safely from the outside world. And that's why, no matter how long you ever gave me, I could never throw 100 mile an hour fastball. And it's not that I don't have the strength. I'm sure that if you put a 20 year old version of me next to a pitcher, I could have outdone him in every measure of strength. But I didn't have the stability to be in motion and stabilize the capsule of my shoulder and transmit force like a whip through my arm. You wouldn't look at a pitcher and think that's stability, but it's remarkable stability.

• 45:10Speaker 01

  Dynamic stability, absolutely. And there's a ton of analogies I've heard over the years. I'm not a car expert like you, but one of the ones I've used a lot in my practice is for a while I had this really old truck that we were working on and it was like a mid eighties Chevy kind of thing. And when you turn the wheel from my hands are at, let's say nine and three, it wouldn't turn until my hands got to like 12. The steering on that thing was sluggish. So that dynamic stability, it wasn't very good. Whereas like an F1 car or go-kart, that thing moves with micro movement. So if you translate that to the human body, anybody who's listening, if I said, hey, do a skater hop where you leap laterally from one side to the other. How you land?

• 45:46Dr. Peter Attia?

  Can you stick that landing or are you falling over as you go?

• 45:50Speaker 01

  And there's a million variables involved there, but the big ones of course are your rate of force. Can you absorb that? Can all your tissues, the arch, the Achilles, the IT band, the hip, your core? Can all those tissues kick on at the same time to create stiffness? Number one. And a precursor to that is where's your balance? To generate that first force, were you organized or did you have to like throw your head and hands weird way to generate the force? But now I'm not in an optimum landing position. So what a lot of times you see in youth athletes is people rush to put strength on them. But a really good strength coach can put strength on a college athlete, you know, in eight weeks. But do they have speed? Do they have organized movement? Are they quick in all planes of motion? Is their balance really good?

• 46:33Speaker 01

  Because now my nervous system, my software is ready to absorb all these things. And then you put strength on top of that, that's a great athlete. And a lot of these genetic people that are just naturally really good, they have some of that underlying ability to where they can land and organize well. And then later they put strength on. Pick a sport and you can show me somebody who was really athletic and they weren't really big and strong, but you can put the strength on later. And that's one of my biggest personal passions is these 14 and 15 year olds who just get berated in the gym and then they tweak their back. I had one local team where it was a golf team and about 30% of their athletes had a stress fracture in their lumbar spine.

• 47:09Dr. Peter Attia?

  Oh my, what?

• 47:10Speaker 01

  Yeah, it was absurd.

• 47:11Dr. Peter Attia?

  How is the strength coach not getting fired?

• 47:13Speaker 01

  So I reached out to the head coach and the strength coach and to give all these people a little bit of a pass, they're not really equipped because they're managing 200 kids. I think it's just a bad setup. You have 200 athletes that you're supposedly managing a program for and you're not watching technique. Whether or not you know what you're talking about is a whole nother argument. But like the idea of, okay, we're going to do a high performance on a 14 year old and put strength on them. But no one's watching technique or teaching them the foundations of lifting. While at the same time they're 14, we should be making them quick, athletic and coordinated first. Cause that's a platform you want to build an athlete on. You don't want to make a kid really slow, but really strong when they're 15. It's really hard to train speed as you get older.

• 47:50Dr. Peter Attia?

  So when a client comes into 10 squared and you do an assessment, how do you gauge how far they are away from being able to do the dynamic movements? How are you gauging? What are you testing? What are you looking for to say, yeah, this person could start doing plyos? Like for example, one thing I love doing, I don't have this on my centenarian decathlon list because we're being so strict about that only having 10 things. But I have kind of a side list of things that I want to be able to do. Like I want to know how late in life I can maintain certain metrics. And one of them is how late in life can I still do a broad jump of my height? So why is that something I enjoy doing? Cause it combines two things. It combines the concentric strength and power to be able to leap.

• 48:35Dr. Peter Attia?

  But even more importantly, and at least as difficult is it requires the eccentric strength to land and decelerate really quickly. How do you know when you look at someone if they're ready to do that? For example?

• 48:46Speaker 01

  We did a ton of work. The literature and the science is out there to a degree for you stack things on top of themselves. So you start with isometrics. You progress people to more explosive or compound movements. So let's assume that I don't have any injury risks at all.

• 49:00Dr. Peter Attia?

  And you would determine that based on just my history?

• 49:03Speaker 01

  No, and testing, history, testing, demographic risk. There's a lot of variables we look into for having concern about musculoskeletal injury. That's number one. But yeah, every person is different that way. And we've had people come in who've had multiple surgeries and injuries. And then we've had other people come in who they're high risk for injury. But overall, they're a pretty good package to work with. There's not a lot of medical concern, if you will. So ignoring all the medical side of it, I really like following the principle that the exercise is the test. Because we basically look at everything about four to five different ways. But if I watch someone do, let's say a wall squat.

• 49:36Dr. Peter Attia?

  So just to be clear, people understand a wall squat is just level one, it's isometric.

• 49:40Speaker 01

  Isometric load, it's what we all used to do in like high school practices. Where it burns your quads and your patellar tendons and we can even set you up to where you're in the right position. So that's going to tell us, A, comfort with the position, number one.

• 49:52Dr. Peter Attia?

  Is failure constituted by pain or not doing it for a certain length of time?

• 49:57Speaker 01

  Every metric we have has a qualitative and a quantitative associate. So the quantitative, we have minimums, it's either time or percentages of body weights for every test. Or distances, like you mentioned on the broad jump. But then there's also like, how does it look? And then the how it looks one is the vague part of the movement world. So you're going to have your coach and myself both looking at it. But then we have other ways where we're confirming that with our motion capture machines. With our force plates, with our videos that analyze the movement. So there's a lot of ways to confirm. You can also see these things cross over. So how does someone do on the double leg versus single leg? Gives us a really nice window to, okay, where's the lack? Great example, two leg, really strong, they're solid. We put them on single leg and they're abnormally less functional and weak and don't have the range.

• 50:42Speaker 01

  So I'm immediately thinking, okay, there's a balance control issue here. Cause on two legs, I'm really stable, but on one leg, I'm significantly less stable and it's much more complex for the body. And so if their scores, even though they're strong and their quads have the capacity. But when they're on single leg, they're not strong and they can't stabilize. That gives me a window right away as saying this person has a major balance risk or things like that.

• 51:03Dr. Peter Attia?

  And in the case of that individual, do you not progress them?

• 51:07Speaker 01

  No, we find their floor and we build from there. So some people will have really cool, robust Instagram worthy exercises for one region. But another area, we're filling in gaps, we're building foundations and we're basically building them up from wherever those floors are. And the key for us is this big grid we have where we have every category movement we care about. And then we build them from their floor. So I'm really visual person, but I always say, okay, we have this baseline floor. Maybe for their upper body pull, they're on the third floor, they're badass, they're killing it. But then their core stability in one plane is like in the basement. Like I'm worried about a lumbar stenosis or a nerve issue. So that takes precedence first because I don't want this person to experience pain. And I want to build them up to where they're all on the first, second, third floor of the building.

• 51:47Dr. Peter Attia?

  Okay, so let's go back to Jill for a minute. So we have this diagnosis, which is, okay, we've sort of figured out why your knee is hurting. We now have a radiographic diagnosis that completely comports with what's being seen on the physical exam and symptoms. These are stubborn injuries. What was the next step?

• 52:03Speaker 01

  The next step was immediately, you have to have a parts approach first. If I have a damaged part, we got to make sure, does that need intervention or not? How are we going to address that? So with Jill, we knew her foundational, like, underlying movement patterns or dysfunctions, if you will, that were contributing to that. So we put a package together for her program that was all of those underlying structural, functional issues that didn't make the hamstring worse. We started building those right away. While we considered platelet-rich plasma, and she actually ended up going for it to create essentially regeneration of that tendon at the damaged site, which she did perfect with. We had to have a lot of come-to-Jesus conversations about, you cannot run too soon. If we're going to go through all this trouble and financial costs, we want to make sure that

• 52:47Speaker 01

  that can heal as much as it can. So everything we did in her programming was to ensure we didn't flare that up. And then conversely, we really communicated with not just the strength team at 10 squared, but also her physical therapist off-site and her running coach. And all of us had to put together this six-month plan where her running coach didn't accidentally flare it up, because he does have a window to everything we're doing. He definitely needs to talk to the PT, as did we, to where she could, quote, "get medically cleared."

• 53:13Dr. Peter Attia?

  I should know this because I live with her, but I don't remember exactly how long she actually had to stop running. I know that it was right after the first and second PRP injections, but does eight weeks sound about right?

• 53:24Speaker 01

  Yeah, so because of her timing for the race, and she wants to run Boston, we had a little extra runway. So the more healing time you can get, the better. We have a lot of people who are like really impatient, dying to get back to run.

• 53:35Dr. Peter Attia?

  If you're a pro athlete, you might not have that luxury.

• 53:37Speaker 01

  You don't have that luxury, right? But that's what's been fun for me about 10 squared, is I don't have all these environmental constraints. I could just get to look at people.

• 53:43Dr. Peter Attia?

  Right. When you're training for an event that's 30 years from now, you don't have to take shortcuts.

• 53:47Speaker 01

  Yeah, let's take a breath and be really detailed. And so with Jill, the PM and our docs and the physiatrist will always kind of give you different amounts, but usually two rounds for her issue. So you do one... One round of PRP, basically do nothing. And then you do another round about two weeks later. And then you slowly let that heal and you start to add physical therapy. So with Jill, total time, we were doing a ton of stuff around the area of the injection. Right away, that's imperative. You don't stop everything. You just protect the area and you train everything else. So that is going to be one of the reasons why we get a lot of success with her. And then back that up with, we really did targeted physical therapy for that site to promote the healing. So the physical therapy side, they're using a ton of things like BFR, dry kneeling where necessary.

• 54:29Speaker 01

  Everything you can to just help those parts heal, foster that growth hormone, foster that protein synthesis, build that muscle up without a lot of force in the tendon. All those things that a traditional physical therapist that knows what they're doing, they can crush that.

• 54:41Dr. Peter Attia?

  Yeah. And she for eight weeks had to swim.

• 54:43Speaker 01

  She was pleasantly open minded. It's hard for every athlete to not do their sport. I get that. But I've delivered that medicine over and over for a long time. And so she swam, so she didn't lose any true cardio, right? She lost a little bit of running strength, but someone with her background and her base, and then keeping everything else really strong, she's going to hit the ground running and she's running now and doing really well. And so I always say I have two athletes. I have the athlete that I have to encourage, like it's okay. Those tend to be more your traumatic acute, like ACL type people, where you got to show them in the lab and show them in the gym that it is okay. Keep pushing, you're good. And then I have the other athletes where you have to hold them back. And so Jill's going to be that one, like, let me go, let me go. And we have to play bad cop just enough where science supports that.

• 55:25Speaker 01

  So where she doesn't flare it up again, because we need her to have a nice, smooth progression. I'd rather her be really balanced and athletic and strong and feeling good on race day, not like a bunch of junk miles and that tendon and the knee starting to hurt her again and stuff like that.

• 55:37Dr. Peter Attia?

  All right. So let's pick another type of client that you'd see at 10 squared, which is maybe somebody who comes in who doesn't have a great training history. They've never really been an athlete, but the thesis really resonates. They sort of go, you know what? I get it. Like, I feel fine now, even though I'm not particularly athletic and I'm not training a lot. But I'm young enough that it hasn't caught up with me yet. You know, I'm in my 40s or whatever. But I now accept that when I do my test, because those people don't typically do very well on the assessment. You can't hide from not having done the work. So how do you think about where to start when there is so much work to do? So you talked earlier about this is on the second floor, this is on the first floor, this is on the penthouse, this is in the basement.

• 56:20Dr. Peter Attia?

  We're going to focus on the basement. Well, what do you do when everything is first floor basement?

• 56:23Speaker 01

  Number one, we gotta build the habit. That's a big part of this is when your coach is basically in contact with you every day as much as you want to help bend and twist and develop that formula. So where that person's actually encouraged to do it, they enjoy it, they like it. I've had people tell me, yeah, this core stuff makes sense, but I just hate getting on the floor. Okay, we gotta pivot and change the program. If I just try to convince you to do an exercise that you hate doing, it's not gonna last. That's number one. Number two is we want to really mitigate the risks of injury. You get some momentum going on the psychological habit side and then, ugh, I pulled my hamstring. I'm devastated. So we gotta get those foundations going. But then usually we look at the medical risk side. So some people, the CPAD test was terrible. Their VO2 numbers are bad.

• 57:07Speaker 01

  In our society, you gotta have a good heart. We want to get that off the table from a risk factor. So we'll probably really put that routine cardio in, in a manner in which we don't flare up the things that could create an injury. So one client we had recently, he didn't know it. He didn't bring it up. He's never had leg or foot issues at all, but his testing, his calves, he's a big fall risk. His calves are crazy weak. His balance wasn't good because he didn't have strength and he's definitely a high risk for an Achilles.

• 57:34Dr. Peter Attia?

  How old is this person?

• 57:35Speaker 01

  52.

• 57:37Dr. Peter Attia?

  You wouldn't expect to see that in somebody so young.

• 57:38Speaker 01

  Yeah, but he's just poured himself into his career and really successful, really smart, cool guy, but he just hasn't trained a lot of stuff. And he had kind of a health scare, which is what motivated him to like get organized. Let's get this stuff right. It was interesting to see his really successful analytical brain use that scare to be like, okay, I gotta get sorted out. You can see he operates his business the same way. Problem identification, what's the solution? Problem, solution, problem, solution. So with him, he didn't know he had any of these risk factors, but he is a textbook for having a fall or blowing out his Achilles because of the weakness and the lack of capacity and strength he had.

• 58:13Dr. Peter Attia?

  And if you were to handicap that, how many years away would he have been from something like that being quite likely? Is this something that's gonna happen before he was 60?

• 58:21Speaker 01

  Yeah, he's definitely in that bucket of he could have been, it's a little fear mongery, but like, he wasn't set up to like, having to change direction quickly, or maybe trips off a curb after dinner in New York. He could have had something like that easily. Big guy too, so top heavy, just like me. Big tree fall hard. So with him, he wasn't even aware of that weakness, but the last thing we're gonna do is give him a running program. We gotta design his CPET stuff and his VO2 max training and his zone two training around these inefficiencies with his body. And so the workout in the gym needs to link up perfectly with those risks and also what is the most important thing for him right now.

• 58:56Dr. Peter Attia?

  Is that difficult to communicate to clients? Because do they ever feel like, hey, I'm not doing enough?

• 59:00Speaker 01

  Oh yeah, a lot of people are overwhelmed, but what's been really nice is the data, but then the calibration. And so what's been really cool with some of our clients we've had for several months now is consistency is always the name of the game, especially when we're playing the long game like we are. And if someone's going on a two week vacation, we want to know, where are you staying? What does the gym look like? We will change your workout so that you can keep doing it while you're on vacation. And if you tell us, look, guys, I'm gonna be really active in the day. I kinda wanna decompress. I've been working in my basement garage really hard for three months. Great. Let's take care of the total human. Let's give him a 30 minute small thing to where he can almost have that lightning of the mental load just decompressed, but he's still making gains and he's still building that up. That's what's been fun for me that I almost never got

• 59:44Speaker 01

  the chance to do, even though I wanted to with some of my athletes, because there would be so many variables in the way. With this, if we get a video of your gym and we know, okay, they don't have a bench that goes to incline, but we do have TRX, and they have a treadmill that goes to incline, but they don't have a bike, we can change their workout to where they keep marching along, and it's an agreeable way for them. And it's not just like, oh, I was on vacation, I didn't work out for two weeks. Because you get muscle atrophy if you don't work out for two weeks. We go backwards. That's a bummer.

• 1:00:09Dr. Peter Attia?

  Yeah, this idea about foot reactivity is so important. I've been much more attentive to it in the past couple of years, and I've noticed the number of times when I've lost my footing and regained it. So I've never had a fall. It's never resulted in anything because it's been caught. But I keep thinking to myself, this is the type of slip that can Be devastating because these are really type two fibers that are doing it. And the type two fibers atrophying as we age are the types of jumping things that we do sufficient to preserve it. If you're someone like me and you, who part of our CD involves probably walking on uneven surfaces one day, whether for you it's rucking, for me, it's maybe going out and hunting or something like that, you're not walking on pavement and you're not even just walking

• 1:00:53Dr. Peter Attia?

  on like beautifully manicured grass.

• 1:00:55Speaker 01

  Yeah, slant it to the side. It's like pebble gravel.

• 1:00:58Dr. Peter Attia?

  You're always going to lose your footing somehow and you have to be able to regain it. What are the most important exercises that you need to be doing to maintain all of the characteristics of tissue and nervous system to preserve?

• 1:01:12Speaker 01

  Yeah, I think the best way to answer that is more principle based. So I think number one is we behave in a three dimensional space. So this idea of only doing calf raises, my toes pointed straight ahead insufficient because to your point, there's going to be moments where my toes are out or one toe is out. So we want to do all these strength exercises in multi planes of motion. And that doesn't mean even in a static position, but that's like a lunge, lunging to the side, lunging backwards. You want to train in a three dimensional space, number one. So all of your training should account for that. If we're just doing bicep curls and calf raises, it's like I'm on these railroad tracks, but the minute you make me go sideways or rotate, it's trouble. So three dimensional, number one. Number two would be to get motor unit recruitment, to really make sure that those muscles are

• 1:01:55Speaker 01

  firing, you need to do really heavy loads or things that are really fast to get that nervous system to like wake up and respond. The problem with that is not a lot of us are ready for that. So what you usually start with is really long hold isometrics. So we put you in these different positions and find ways to resist that and pull and create stiffness and remodel those tendons. So we're essentially making those parts ready to start going into the danger zone that is explosive, powerful movement. I shouldn't say danger zone as much as I should say like a higher ask.

• 1:02:27Dr. Peter Attia?

  Yeah, risk zone.

• 1:02:27Speaker 01

  So heavy overcoming isometrics, they call them. One of my favorites is that mid thigh pull. It's kind of a standard in the sports science world where you have a bar and you basically calibrate the machine to where the bar is about the mid thigh and it's almost like the very Top of a deadlift and you just pull, but the bar doesn't get to move. And the sensory input is like the force decks and they're measuring your balance, your force and all these other cool metrics. But holding that over time, we're now isometric loading the heck out of my grip. We're loading the heck out of my shoulders. We're getting into my feet, my quads, my hips, and I'm just holding that for time. That sets all these tendons up.

• 1:03:02Dr. Peter Attia?

  And you just do this with a super, super heavy loaded bar that's too big for you to lift?

• 1:03:05Speaker 01

  Not necessarily. You can actually do an empty bar, but you pull it up against the safety bars of the rack or something like that. Isometric thy pole is the thing to look up, but there's a lot of ways to load these heavy isometrics. Because that gets your tissues ready and you build that up over several weeks and that tendon adapts and now it's ready to resist force. And then the way you bridge that is you start doing deloaded plyometrics. So now maybe we do some sort of like a band assisted pogo where I'm actually pulling on a band overhead. Pulling down on that band essentially lightens me because the band's going to pull me back up. And now I get to train that speed and that quickness through the ground, but it's not my full body weight. And so that's a great way to bridge from, okay, now I've got the parts ready. Now can I deload the amount of force and train the speed?

• 1:03:48Speaker 01

  Once I've got the speed going and the parts, now I just get to become an athlete and do body weight and beyond. And so that's where you see these really high level athletes, even at early ages, their trainers know how to build that paradigm up. And bridge it across to where you don't get any injuries along the way, but you get a really springy, force resistant person. So many of us, like we touched on initially, don't train pogos. We don't train plyometrics. If you go out to the local men's or women's soccer league, how many people there are over 40? Not very many. Now, there's a lot of reasons why that is, but we're not playing games and we're not reacting to stuff. And so we need to make the gym a safe space where we can recreate these things and essentially test out these movements. So I don't lose it.

• 1:04:27Dr. Peter Attia?

  And maybe just to even things out. So Jill doesn't think I'm picking on her injury. Let's talk a little bit about my limitations. So the thing that's probably been my biggest source of nag in the past 12 months. Has been foot ankle. Like let's talk a little bit about those injuries, why they're occurring. And again, they're not debilitating. They don't actually prevent me from doing a single thing. But because I'm sensitive, I just want to know, is this a harbinger of something? What's your assessment of what's going on? And how would you even describe it? Would you describe it as my ankle? Would you describe it as my navicular Taylor joint? Where's the actual issue in me?

• 1:05:03Speaker 01

  So with you, without getting your foot out, you have a very mobile foot. You're swimming background. Swimmers have really great mobile feet. Show me a soccer player who had their foot strapped in cleats for 10, 20 years versus a swimmer. Very different setups. So it really speaks to how tissues adapt over time. So your feet have a ton of motion in them. They are not restricted. You also do a lot of barefoot work in the gym, which is helpful for you. Your feet are actually pretty strong, too. If we test your big toe and your smaller toes, you don't test outside the normal limits for strength requirements. But your biggest gap is that multi-positional stiffness and that ability to create force absorption through your tissues. And you're actually set up for that because you can move so much. You don't find those in ranges, either the bony in ranges or those tendons can't grab because there's so much play in that pattern.

• 1:05:48Speaker 01

  So what you accidentally do all the time is you'll go on a ruck or you'll go on a hunt where you're off-road and you're getting all these angles, you'll slowly flare up a tendon and tendons are notorious for not hurting.

• 1:05:57Dr. Peter Attia?

  And thank you for not telling everybody the last cause of injury.

• 1:06:01Speaker 01

  I would never.

• 1:06:03Dr. Peter Attia?

  Just for the listener, I don't know why, but I somehow decided two months ago to pick up a pogo stick. Never done it in my life, somehow decided.

• 1:06:13Speaker 01

  Hey, is that in the bonus Cincinnati Decathlon for you?

• 1:06:16Dr. Peter Attia?

  Yeah, I was like, I'm gonna add another activity. Pogo sticking up and down the driveway.

• 1:06:20Speaker 01

  Yeah, that goes in the bucket of you should have called me first.

• 1:06:23Dr. Peter Attia?

  Like what a, I mean, the second I started, I was like, oh, not a good idea.

• 1:06:28Speaker 01

  I'm just gonna touch your feet, not the other end. So because your feet are so mobile, tendons are notorious for, they don't really hurt at the time, but they hurt like crazy the next morning. And what you always routinely say, which is really common if you're plantar fasciitis or patellar tendonitis is when I first get up, it's really stiff and creaky and sore and hurts. And that's because tendons love blood flow. They love movement and they love motion. And so all those chemicals that come with inflammation, if we're just sitting around or sleeping, that's the opportunity to get stiff and really sore and achy. With that kind of symptom pattern, you're not really lost on what it is because that's classic tendon. You can walk, we can load it, there's no failure. So we're not worried about a muscular strain or any other damage.

• 1:07:08Speaker 01

  But that tendon gets really hot and spicy, especially in the mornings, if you're not creating that stiffness.

• 1:07:14Dr. Peter Attia?

  Just to be clear, we are nine or 10 weeks ago since my pogo sticking debacle. It's no longer as bad, but every single morning when I get up. There is still incredible and sharp pain right at that tendon. Why is this taking so long?

• 1:07:29Speaker 01

  Well, tendons are one of the slowest things to heal. And I guarantee if we really zoomed in and looked at all of it, you probably have a little tendonopathy in those tendons, a little damage here and there that could be contributing to that irritation. But the most important thing is understanding that tendons take months to regenerate. You and I've had a pretty consistent attack with it, but we finally got you on a really good rehab program you're doing yourself where we're loading the heck out of it with these isometrics and we're building the load more and more. And we're loading those isometrics in different positions. So one of the ones we do with you a lot is that front foot hover, but you're actually plantar flexing. So where you're driving, you're doing as much of a calf raise as you can in that split squat position. And then we make you hold that while you do that split squat. So it changes the whole angle and the relationship.

• 1:08:13Dr. Peter Attia?

  We'll make a series of videos, of course, to go along with this. But explain that exercise because it looks ridiculous. Nobody's doing that on Instagram.

• 1:08:20Speaker 01

  They are, but they're drinking the Kool-Aid.

• 1:08:22Dr. Peter Attia?

  Yeah, all right. But it's a complex movement. So we've got a plate in front of me.

• 1:08:25Speaker 01

  Yep.

• 1:08:26Dr. Peter Attia?

  Like a 45 bumper plate. So we're two and a half, three inches up.

• 1:08:30Speaker 01

  Yep.

• 1:08:30Dr. Peter Attia?

  That my front foot, just ball of foot and toes are on there. I'm in a split squat.

• 1:08:35Speaker 01

  Yep.

• 1:08:36Dr. Peter Attia?

  What am I doing with that front foot? I'm lifting it into plantar flexion.

• 1:08:39Speaker 01

  Yeah, for you, the goal was your toe off was one of the problems. So what happens with you is when your foot, your heel lands, you're driving your body forward and your foot's behind you, you would do like a little bit of a rotation out and create like a little bit of a whip through where it wasn't nice and pure rotation rolling through the foot and the toe. It was complex and putting extra stress at the ankle. That times 10,000 steps a day will really pick at that tendon, make it sore, which is why you wake up the next day hurting. So what we're trying to do is put these tendons at different lengths and then putting a lot of load through them. And then the complexity we're adding isn't necessarily at that joint, but we're actually adding motion and complexity above with the lunge.

• 1:09:18Speaker 01

  And also the requirement of you having to stabilize centrally in that mid part of your body while that foot is locked in. So someone with a really mobile foot, you tend to really use that foot for everything. And that's how you spice up those tendons. And I'm essentially putting that foot in a position where that tendon has to heal and it has to get stronger. But then I'm making the other parts of your body reach that complexity and meet the demand.

• 1:09:40Dr. Peter Attia?

  So this is the second time I've had this flare up. The first time I had it was probably a year and a half ago when I really started increasing rucking volume. This was caused by kind of an acute incident, which was the pogo sticking where I clearly overplanter flexed or dorsiflexed, I guess, was probably the, yeah, extreme dorsiflexion that did it. What do you think was driving it on the rucking side? And more importantly, what does this mean for me?

• 1:10:03Speaker 01

  Long term?

• 1:10:03Dr. Peter Attia?

  Yeah, because right now it doesn't matter. If this keeps happening and I'm in my 80s, this is the difference between reacting and not reacting and being able to get around and not. So how do I prevent this from being a lifelong problem?

• 1:10:15Speaker 01

  That dorsiflexion or bring your toes up, the pogo, when it's a sudden, like acute force like that, you probably also just create a little bit of a joint irritation. It's analogous to jamming your finger. If you move those two joint structures together really hard quickly and your body can't absorb that force, that'll get a lot more sore than if it's just kind of a slow repetitive stress like the rucking. The pathway is, and you've noticed the relief, like when we do the manual therapy and things like that, that's a nice short term, like, ah, feels a little better, a little less pain, great. But the bigger picture and the ask of your body is teaching it, how can it respond to this? And how do I build that force in those tendons to where not only is that tendon start to regenerate and heal, but then it's also ready to react to all the things you do. So knowing for you specifically that you love to use those feet and the more barefoot

• 1:10:59Speaker 01

  you are, like you're more likely to do that, we need to do a ton more quick work with you that's deloaded to train all those tendons. I mean, there are so many tendons in the lower leg and the ankle. We need to train all those tendons to get quick and stiff in different positions so you don't jam the joint or create a stress in the tendon.

• 1:11:16Dr. Peter Attia?

  Should I be doing less barefoot activity?

• 1:11:19Speaker 01

  No, I don't think so at all. I think that's a pathway to frailty. You want to stimulate the receptors in the bottom of your foot. Do I want you running on like a river barefoot with the sharp rocks? No, because that's going to cause other problems. But I think having you barefoot makes your foot mobile and strong. But then if we piggyback that with this specific type of training for where your gaps are, it's a huge payoff. Let's look at the other side. Most people don't have your situation. More often than not, people have a really rigid foot that's weak and stiff. So we're actually going with a whole nother direction where we're trying to get motion in the foot. We're teaching that foot to separate rear foot and forefoot.

• 1:11:51Dr. Peter Attia?

  How do those people present? What's the pain or what's the injury they present with?

• 1:11:55Speaker 01

  Interestingly, they actually get a lot of symptoms up the chain. Our foot has so many bones and all these articulations where we're supposed to comply to the ground. If that shock absorption goes away, like let's say I'm wearing these big goofy running shoes that they sell now. They have the rocker where it's all just like patching holes in the boat rather than optimizing movement. If we have a foot that is stiff, those force factors go up through the body. So now my knees, my hips and my spine have to figure out that force distribution. Because one of my best shock absorbers is the foot and the ankle. If that's not doing its job, everything else pays the price. So I see a lot of people, let's say the soleus is weak, their lower part of their calf. So that control of their tibia as either walk or lunge isn't there. So that ankle just walks up and then they send all that force to their knee.

• 1:12:39Speaker 01

  That's why one of my favorites is anyone with a chronic knee issue, I'm going right at that foot and ankle first. Because if the foot and ankle isn't up to the task, then my knee is going to take a beating.

• 1:12:49Dr. Peter Attia?

  So I don't want to jinx myself and I hope I'm not doing it by saying this. Is this why despite all the crazy stuff I've done, all the miles I ran growing up? Never really had a knee issue, but boy, do I get these feet issues?

• 1:13:01Speaker 01

  I mean, it's a good theory, but absolutely, yeah. You're really good, wide, mobile feet, your knee gets to be a knee. If that rotation, that pivot joint that's supposed to happen at the ankle isn't pronounced to the amount you want. And it isn't mobile enough, then that knee and that force factor is going to happen at the upper tibia and the femur. Where now you start to get these little meniscus things that showed up out of nowhere. That torsion has to happen somewhere.

• 1:13:24Dr. Peter Attia?

  Yeah. Let's talk about something that you touched on a few minutes ago, which is around fear. We see this a lot. We see this in the medical practice where we have patients where we're overseeing all their training. Sounds like you see this at 10 squared as well, where you have clients that are just coming in for obviously the training piece of this. So is there any common thread to this or does it come in all walks of life? I've seen it in former athletes who were injured, but the injury is so bad that they just never quite want to go back down my path. Especially if they've had multiple re-injuries. I assume you see this in people who are not necessarily athletes. So what do you think is going on there and how do you work up the confidence to accept? That the pathway back isn't necessarily pain free or injury free. But it's more of a trajectory that's going to get better.

• 1:14:05Speaker 01

  I love what you just showed there. The graph is always going to have peaks and valleys. When your brain perceives threat, whatever that could be, maybe your dad hurt himself playing football. So you're scared to play football, but when your brain perceives threat, not only is your heightened awareness up, your nervous system is kicked up, but we're more sensitive to pain. So certain things hurt more when we're ill or when we're stressed than if we're not. And if we stick to just movement themselves, a lot of people are afraid of certain movements because it hurt me in the past, or they heard it could hurt them, or maybe they just haven't done it a long time. So they're nervous about it. So you can actually empower people if you show them there's a rational reason why that fear could be there or why that pain is there. Pain does not always mean injury.

• 1:14:50Speaker 01

  Pain is your brain telling you, hey, I don't like what's happening here, but it doesn't always mean you're broken or busted. Another thing to think about is your image isn't always a death sentence. If we MRI 100,000 low backs, there's going to be wear and tear, especially if you're over 30 years old. Same goes for every other joint in the body. Does that mean we design your whole clinical plan around that? No, we really need to think about, okay, how much is there? What do they want to do? What are their strengths? What are their weaknesses? All those things we already spoke to. So when there's fear involved, you really have to address that because the individual needs to know that A, you have a plan for them, that you understand their fears. And then B, we got to account for those fears in one way or another. So this is not data, but in my private practice,

• 1:15:32Speaker 01

  the amount of low back flare ups, just your traditional back spasm, not a surgical candidate, just high back pain, but no damage. The amount of those people that have come in when their wife's about to go into labor, or they're worried about getting fired from their job, where they have like an emotional, mental stress in their life. The amount of those people is infinite. I've had thousands of people come in and go, my back flared up out of nowhere. And then you start to dive in like, what else is going on? And they're really worried or stressed about something. The goal there is you can't always fix those external, cultural, psychological, emotional things, but we can address them and identify them. And sometimes they need therapy. They need other things to address those. But more importantly, we need to empower that individual and give them rational reasons why you're like, hey, this might be why you flared up in that glute.

• 1:16:15Speaker 01

  Or in that mid back and this is what we're going to do about it. And if you outline those plans for people and give them the tools, now you've equipped them to actually help themselves. This whole game of I'm going to take an x ray of you and look, oh, there's one little bone spur. But now I'm going to scare you into like a 40 visit package to my chiropractic clinic or something. That game needs to go away fast because the only thing you're doing is making people feel more frail, more afraid, and you're actually only helping the bottom line of your business. You're not helping that individual. So it's really about empowerment with education.

• 1:16:45Dr. Peter Attia?

  What is it that you would see when somebody comes in that would make you say, actually, we need to immobilize you? Is that something that's only going to be on an exam where you see a motor weakness? For example?

• 1:16:55Speaker 01

  Immobilize how like put them in a boot?

• 1:16:56Dr. Peter Attia?

  Let's look at the lower back. So if somebody shows up with a lower back complaint to you, what's going to make you say, no, actually, the answer is seeing a surgeon or complete and total rest? What is kind of your algorithm on people presenting with lower back pain?

• 1:17:10Speaker 01

  Yeah, I mean, low backs are great. So number one is for the neuros out there, if there's weakness or you don't have bowel or bladder function and things like that, right away, get evaluated, right? Because the way nerves work, if there's pressure on nerves, it could over time create permanent damage. Now, a lot of nerve pain is sensory. It's that electrical sciatica type stuff. It's that tingling and that weird thing like that. But the real number one that you look at is, do they have weakness or do they have loss of some sort of foundational control? That's when you got to get integrated with neuro and orthos right away. If we don't have that, now you're in the like decision making domain.

• 1:17:47Dr. Peter Attia?

  So this means you're going to do the rectal exam, make sure sphincter tone is there?

• 1:17:50Speaker 01

  Yeah, exactly. That's definitely on the long list of things I refer out for, for sure. So if you're in that kind of mechanical low back pain or even some disc nerve issues, but no weakness, now there's a ton of strategies we can do almost as a first diagnostic step to see how your body responds. Now, what I mean by that is we're not going to do some crazy aggressive therapy or treatment or manipulation of the spine, but we're going to do some sort of intervention like muscle work or McKenzie exercises for discs, which are highly researched and really effective to see how the body responds to those things. If your body responds in a positive way, even for two hours. That's a great indicator. Like, let's keep going down this road. Because even the best surgeons that you and I have both talked with about mutual clients, they'll say, let's give this a little time and see what your body does. Things can heal.

• 1:18:35Speaker 01

  The natural processes of the body can take care of themselves. So one of my favorite examples actually is a disc herniation. She confirmed on MRI. She was doing McKenzie protocol, which again is fantastic.

• 1:18:45Dr. Peter Attia?

  Describe for people what that is.

• 1:18:46Speaker 01

  So McKenzie protocol is a really great system that you essentially put the patient in various positions. And you do this gentle arching or pumping. And you're basically trying to take pressure off that disc to where slowly over time, that bulge can re-center and balance out.

• 1:19:01Dr. Peter Attia?

  Can people do these by themselves or do they need to be?

• 1:19:04Speaker 01

  Yeah, very easy.

• 1:19:04Dr. Peter Attia?

  We can link to where people can go and look.

• 1:19:06Speaker 01

  Oh, yeah. McKenzie protocol is fantastic. Their website has a database where people can find people in their town. So if they have nerve pain, it's a great place to start because all those McKenzie practitioners know what I just outlined too. Like, this is a McKenzie thing, this is not. But what's fascinating about McKenzie, sometimes even in the room, they'll get a reduction of nerve symptoms while they're in that position. Nerves provide very productive information. You can trust symptoms of a nerve really well. So if I get what they call a centralization, meaning I had sciatic pain all the way down the leg, and then you put me in this one McKenzie position, and now it centralizes to the hamstring.

• 1:19:39Dr. Peter Attia?

  That's a great diagnostic indicator.

• 1:19:40Speaker 01

  Exactly. And so just because that individual might have an MRI with a disc herniation, that doesn't mean it's an injection or surgery right away. Obviously, part of the decision making is what are they having to deal with in their life? What is their timeline? All those other factors? But if you can encourage a hot disc patient to wait and make sure that they're actually letting things heal and run their course, they could be much better off in four to 10 weeks.

• 1:20:03Dr. Peter Attia?

  It's almost always the sign of a great spine surgeon, which is once you rule out the acute weakness, the thing that is a surgical necessity, the ones that want to wait are generally the better surgeons.

• 1:20:16Speaker 01

  Yeah, we've chosen the better side for sure. But this case I was going to talk about earlier, she was a fascinating one. So confirmed disc herniation. And then she had an annular tear, which basically the annulus is a part of the disc. Best analogy to describe it is she had like a little thing that was equivalent of like a cuticle. They're just kind of peeling off. So traditional protocol, we started her on McKenzie's. Great lady. We're actually still friends, but she was really hurting. So we worked with her for like two, three weeks. And every time we put her in that McKenzie position, it hurt her worse. And it was local pain, but the ridiculous symptoms reduced. So long story short, what we learned over time, she went back over to another place, tried that for a while, didn't work. The disc herniation was actually taking care of itself, but that annular tear was still sticking

• 1:20:57Speaker 01

  out, creating extension based pain. So after about a year of rehab, her body was able to scar up and that healed and it was fine. But what was really interesting to me was she needed McKenzie's early, but then we actually had to cease the McKenzie's because we were jamming that annular tear. And so then we restored just more pillar strengthening, dynamic, neuromuscular stabilization, all those other things. So it's like different things at different times played a big role.

• 1:21:20Dr. Peter Attia?

  It must be amazing how often we all encounter, hopefully not personally, but professionally, people with lower back pain. The statistics are, can't imagine there's too many people listening to us who don't have personal or indirect experience with it, either obviously through themselves or through somebody they know closely. There is something about it that I can really relate to being nerve wracking. It can be terrifying and also demoralizing, I think is how I would describe it, just demoralizing when your lower back hurts in a way that's not the same as if your shoulder, elbow, knee, or hip hurt.

• 1:21:50Speaker 01

  No, it's different. I mean, the best analogy is I sprained my wrist, might have to wear a brace or something, but I can generally function. I can go to a movie. But when your ribs or your back is hurting, not only are those muscles much more big and powerful. So when they react in spasm, they're really good at it. These small muscles in my wrist, when they react in spasm, like, oh, that's kind of sore. But the low back, I mean, that group of muscles is really good at freaking out. The type one fibers, postural stuff, a lot of detail. The other thing is you can't do anything without affecting you. Sitting in a movie hurts, walking hurts, affects them constantly. And that's a big part of the rehab story is finding these little wins where they can actually do something and it either does get worse or heaven forbid, makes them feel a little bit better.

• 1:22:31Dr. Peter Attia?

  Do you think this is scalable? I feel fortunate that we're able to take care of people where we have the luxury of doing this very bespoke approach. You can integrate your strength and conditioning with your cardio, with your PT rehab and all that stuff. And it's all great. But do you see a day when this could all be app and AI driven where any person out there with any set of lower back symptoms could be provided with the feedback that they would need to take care of themselves?

• 1:22:57Speaker 01

  If they execute, absolutely.

• 1:22:59Dr. Peter Attia?

  How would you get the feedback? If you have good enough image recognition software, would that be a necessary step that if you were using such a device, like an app, you would have to be able to set up your phone on a tripod to be at least able to capture you doing it? Cause the advantage of being able to do this the first few times with an actual person like you is the queuing is so important. A lot of these exercises are not natural.

• 1:23:25Speaker 01

  Yeah, well, especially if you're that person who's suffering from that injury, then odds are you didn't perform these exercises well, subconsciously. So that's what set you up for it. What is interesting is the video recognition software is getting fantastic. I've demoed a few now where the AI is actually watching someone do movements and saying, hey, you know, this was too far out that way or whatever. But that also goes in the bucket of everyone moves differently. My femur length is different than yours. So the angles with which I'm going to lunge are going to be a little different. This idea that if you take principles and you know the symptoms, and then most importantly, you know how people react to really conservative loads? That almost tells you more than did their tibia rotate three degrees or not? I could care way less about three degrees of tibial rotation based on AI software and care way more about, you know what?

• 1:24:09Speaker 01

  I did these lunges in this setup and we activated some neuromuscular reaction to where my glute fired a little bit better. My knee felt way better. And then when people give us that good qualitative feedback, now you know how to trim up that program. So I think the AI part of it's going to be more that it's going to be less about, oh, what degree did it move? But more about how did you respond to each drill? That's safe and then we go from there.

• 1:24:33Dr. Peter Attia?

  And that's where training the AI is much more nuanced and complicated.

• 1:24:37Speaker 01

  A hundred percent, a hundred percent.

• 1:24:38Dr. Peter Attia?

  Yeah, image recognition is one thing, but it's knowing what to do with that information.

• 1:24:41Speaker 01

  Yeah, knowing, am I going to do an overhead dumbbell in a DNS three month? And all these other nuances versus the legs? There's certain cases that I'll do that one for one and the other for another. And it's really a matter of knowing what you got to start with. And then we test it a little bit and then we test it a little bit more. And then the outcomes are dictated by how do they respond to that exercise?

• 1:25:00Dr. Peter Attia?

  And why did you gravitate towards this? I mean, we didn't really get into telling people your story, but you went to chiro school, but then you immediately went out and did a sports medicine thing. You worked with the New York Giants. Why did you just opt into the role you're doing now, which is much more in the PT rehab space than it is what people I think assume of traditional chiropractic, which is here's a 40 adjustment schedule. I don't have a point of view on that, but what drew you more towards the side of things you're on now?

• 1:25:29Speaker 01

  It speaks to a bigger thing, which I'm really degree agnostic in the sense that I hope someday in the future, there's like a more clear certification or degree where there are chiro's and PT's and frankly, strength coaches. All three of those people I would trust way more to do a rehab and get someone better. Who would I send my mom to? I would send my mom to all three of those people if they have certain skill sets and like approaches.

• 1:25:51Dr. Peter Attia?

  Independent of degree or credential?

• 1:25:53Speaker 01

  Totally, because the chiro degree was my baseline training. That's where my license is and all that. But the traditional view of what chiro is with the manipulations and the adjustments, that's 5% of our week at my practice. Our practice, we have chiro's and PT's, but you can't really tell who's who because everybody's doing what we call is active rehab. So one of the things I always tell people, I don't care what their degree is, but if you're going to a rehab clinic and it's one-to-one relationships, so it's not group, but it's one-to-one, and they've got a bunch of weights in there as well as their traditional bands and stuff, now that's an indicator, okay, these guys are going to build me back up to something actually strong, not just make me come in here forever and do rehab purgatory, where I do the same micro drill over and over. We gotta build over time. So I'm really agnostic to a degree, but that said, my story, I basically tried to create

• 1:26:36Speaker 01

  a residency for myself right out of chiro school. And back then, it was really manual therapy based. I learned a ton. I was by far the lowest guy in the totem pole, which we all know how that works. Lot of time, lot of learning, but I was there to soak it up. Everyone always thinks pro sports is the top, and it is in a lot of ways, but it wasn't really for me in terms of an official team relationship, because I just didn't like that personal schedule. And it was pure chaos. Like you'd spend a week fixing somebody up and then they go out there and get blasted again. You're like, oh, that's a bummer. It's kind of like when my son builds his tower magnet tiles and then his sister knocks it over. The look on his face was me every Sunday.

• 1:27:09Speaker 01

  So I really Enjoy the off season side. I really enjoy more of the project. And I realized early on that when you're only doing pain relief, manual therapy work, there's a lot missing. We're not building people up.

• 1:27:19Dr. Peter Attia?

  Right. It's not active.

• 1:27:20Speaker 01

  Strengthening them. Yeah.

• 1:27:20Dr. Peter Attia?

  Yeah.

• 1:27:21Speaker 01

  So that's when I just started doing this deep dive as much as I could, learning from as many people as I could about the foot and balance and neuromuscular training and all these other things to where it's a compliment at my private clinic when people are like, what are you? We actually have people come in our office now where like, I need to go see my chiropractor later. And one of my other docs will be like, well, I'm a chiropractor. Like what? I had no idea. And they've seen us for years. So we're probably supposed to identify ourselves better, but regardless, we're solving problems.

• 1:27:43Dr. Peter Attia?

  What is the role for what most people think of when they hear chiropractic? The adjustments.

• 1:27:48Speaker 01

  What does it do?

• 1:27:49Dr. Peter Attia?

  I don't want to ask you to sort of be critical, if that's the word of a profession that you remember of it. But the fact that you aren't out there doing it 24/7 suggests either you think it's really, really valuable, but it's just not something you want to do, or you don't think that it's valuable enough. How would you advise somebody that came to you and said, hey, Kyler, I have injury X, my neck, my back, whatever. I got this awesome package of 40 visits for X number of dollars with my local chiropractor. I see him for eight minutes a week, twice a week. Actually, it's really special. Do you think that's a great plan?

• 1:28:22Speaker 01

  No, the way I would describe it is I've benefited from getting adjusted myself. Things get out of whack. Things get stiff. You sleep on a plane where like, that's a real thing, but it's a tool in the tool belt. And the really good practitioners have a bunch of tools. I could say the same thing about chiro adjustments is like a dry needling or active release or McConnell taping, like a million tools out there. The really good practitioners have a huge tool belt and they know when to use which one at what time. So just throwing cupping at somebody and hoping their muscles get better. It's insufficient. In the same way, I would say just adjusting someone over and over, it's not enough. There's more that could be done. And so what I get asked a lot, especially now that I'm older, like all my friends I've accumulated over the years.

• 1:29:05Speaker 01

  I didn't account for as I got older, there'd be more questions exponentially because they're all getting sore and hurting. But what I always tell them is I need someone who's got a bunch of tools in their tool belt. I need someone who's going to literally treat your case as something unique every time. It's not just like every Everybody here signs up for twice a month. That's a big red flag for me. And I really want everyone always building towards more strength. You have to be adding strength. That's what makes things stick. That's what optimizes movement. That's what makes people feel empowered and less frail. And it frankly builds more of like a moat around themselves to where if they do step off a curb weird or they sleep weird on a plane, they're less of a triage patient. They're more of just like, I'm a little sore today, but they still work out and the workout helps it.

• 1:29:46Dr. Peter Attia?

  So is it safe to say then that whatever the suite of underlying modalities are from adjustments to taping to cupping to needling to active release to manual, you name it. The goal of all of these, and the more of them you can utilize, the better, is to create a window in which the individual is safe and out of pain so that they may do the work to retrain a movement pattern and increase strength.

• 1:30:14Speaker 01

  The most simple terms, absolutely. We say that sometimes about even corzone injection. Like, I don't like people racing to get a corzone injection. But if you tell someone to strengthen a knee that really hurts when they do a lunge, they're gonna look at you like you're a jerk. So at some point, we need to do something to get that pain down. So then we can open that door and run through it. And running through it with strengthening and making them stronger.

• 1:30:34Dr. Peter Attia?

  Okay, so let's kind of put this now all back together, right? We've kind of gone really deep down one of the three pillars. You now have basically two things you're trying to do. You're trying to do everything you're doing in concert with a broader agenda of creating a precision training program, not an exercise program, not a workout program, a training program for an athlete whose sport happens to be life. And you have to be able to do it with the strength and conditioning coaches, the cardio coaches. And then the other thing you have to be able to do is you have to be able to do this remote because most of the 10 squared clients are remote. They come to Austin for two days. They do a whole bunch of assessments. They go away for six months, then they come back.

• 1:31:17Dr. Peter Attia?

  Some of them go away for less, but a lot of them, they go away for a year. It's because they're out of the country and it's just not easy for them to be here. So how are you able to do this remotely? What are the challenges and what enables it to make sense? What do they need when they're back home?

• 1:31:31Speaker 01

  We get that question a lot because before 10 squared, some of the athletes I would manage who travel a lot, like a couple of my golfers, they would call me and say, my back hurts from the hotel room. And I had the luxury of knowing so much about them and how they moved and what their body looked like. I could take all that and then be like, well, what are the symptoms? We rule out the scary medical stuff and then we try some exercise. And we were able to get a lot of results for these athletes and they were about to tee off in two hours and compete. So we've taken that model and when we were designing the assessments at 10 squared, one of the biggest themes was we need enough time to know as much as we can. A lot of people want it to be faster, but we're like, that initial step needs to be so in-depth that we are certain about all the factors of how you move and where you're strong and things like that. When I have that certainty and I'm not flying blind and someone calls me and says, you know what?

• 1:32:15Speaker 01

  My knee is really sore after doing these exercises. We either hop on a zoom and just talk real quick and I can actually test them on zoom because the exercise is the test. So many people think they need a doctor to do like a Lockman's test and pull on their leg. The story, their profile, and then how they respond to the exercise, that is the test. And so we can program exercises really effectively in a remote way to probe the fence or test it. And if it responds the right way, we definitely can fix it quickly. I had a client this week, his shoulder was bugging him. We did a zoom call, took about 20 minutes. We have our library at 10 squared. I fired him off a few exercises. He messaged me, he's like, feels a lot better. He didn't have to go to the doctor, he didn't have to go anywhere. Now, obviously if the story was different and I was worried medically, I'd concierge that in the sense of I'd find him someone local and refer out.

• 1:32:59Speaker 01

  But if I'm not worried medically and we think it can respond to load, we're going to load it. And a lot of times people are shocked that we can make their neck tension go away with an exercise in the same way that if they traditionally got a massage or something, they'd get that relief. It has to do with what your body does when things are off. And if you load it, it'll actually respond more because your nervous system is involved as well.

• 1:33:20Dr. Peter Attia?

  I want to tell a story on that vein that is one of the most incredible experiences I ever had. This would have been in 2018 or 2019. And I had the first flare up I'd ever had of my lower back since 2000, when I had my botched surgery and all that nonsense. So I'd gone 18, maybe 19 years, maybe it was early 2019, without a single flare up. And then it happened. I get the flare up. At the time I was working with this guy, it was my first person I'd ever met who did DNS. I had already learned about intra-abdominal pressure. We were doing all stuff. In fact, when I went to see him, my back was totally fine. I had tennis elbow.

• 1:34:02Dr. Peter Attia?

  So I had this tennis elbow and he figured out pretty quickly that my tennis elbow was completely due to my scapular instability. And my chief complaint was when I do a lot of pull-ups, my elbow hurts. I don't even play tennis. So we had fixed all that, but I kind of was like, this is amazing. I want to know what else is going on. And then independent of that, I get this lower back flare up. And so I'm in there seeing him on one day when I'm in, honestly, like about the worst pain I'd been in in years. His training, by the way, is also a chiro. So he's chiro by training, who probably hasn't done an adjustment in 20 years, just doing DNS. And I'll never forget the exercise he had me do. Cause I was like, I don't know how this is going to work, dude. So he laid me on my back and he had me get into like an imaginary leg press position.

• 1:34:47Dr. Peter Attia?

  You know those old school leg press machines where you're pressing up?

• 1:34:50Speaker 01

  Yeah, yeah.

• 1:34:50Dr. Peter Attia?

  Not the one where it's on a slope, but the rack moves vertically.

• 1:34:53Speaker 01

  Super old school.

• 1:34:54Dr. Peter Attia?

  Yep. So I'm on my back, I'm in that position and he is now laying on top of me. So he's got his pecs basically on my feet and he's cueing me through really good intra-abdominal pressure and isometric contraction, pushing. And low and behold, my back is getting better and better. And we're doing sets, 10 second, 20 second, 30 second. At some point, I'm getting so strong, we need more resistance. So now we go and build a makeshift thing under the squat rack where, I forget if I was on a Smith machine or a squat rack, where basically now I have infinite resistance, kind of like how you described it with the partial deadlift. I am getting to the point where when I walked in there, I wouldn't have been able to push 10 pounds away from me.

• 1:35:39Dr. Peter Attia?

  That's how much pain I was in. And now I'm convinced I was pushing 600 pounds of force against that immovable bar.

• 1:35:47Speaker 01

  Yep.

• 1:35:47Dr. Peter Attia?

  And I've never felt better and I couldn't understand how that could happen. How is it that I could not walk but limp into that guy's gym in so much pain and spasm? And an hour later, I feel like a million bucks. How could that happen?

• 1:36:05Speaker 01

  Two things. One thing in your story, it really speaks how pain is inhibitory. When your brain is perceiving that threat and that pain, it goes into preservation mode where it's like, look, I'm not going to have you run the fastest four of your life because I don't trust all these movements. I'm trying to figure this out. My analogy is like that hand on the buzzer with Family Feud where the brain, like whenever it feels threat, it's like, I'm going to hit this buzzer and I'm going to send you a pain signal. Doesn't mean you're damaged. It's just like, I'm hovering. And if you're really stressed or it's a really high level pain, it's like, I'm going to do it at first sign of trouble. So number one, it just really explains your story is that effect. But then it's like, okay, how do we get the brain to take the hand off the buzzer? What loads can we introduce to make these muscles? One term in the musculoskeletal world is reciprocal inhibition.

• 1:36:47Speaker 01

  So if I'm going to contract my bicep like crazy, my tricep almost has to eventually get enough signals where it can't fire. Your brain might be trying to fire it and it's got this co contraction going on and there's that protection going on. But the more stimulus you give that bicep, eventually that tricep has to let go. So what he was doing is he was putting you in very specific positions to where you had to load something where neurologically your brain says, I'm going to turn this other thing off. And I got to actually meet the demand of this force because force is how your nervous system responds. And so he was loading one direction so much that eventually that QL or whatever else could have been spasming with you had to eventually kind of melt and let go. Not only were you now activated and stable and feeling stronger, but that muscle was in this inhibitory contracted state and then it let go.

• 1:37:29Speaker 01

  One of the things I say in my private practice all the time, my first five years out of school, I was working on the QL. My thumb has got scars from it. I don't touch the QL anymore. 10 years ago, I realized you don't even have to beat someone up so much. In a weird way, these kinds of exercises are more gentle, they're more therapeutic and they're more long term. They're active, so it's long term. You're tapping into that nervous system. Demoing an exercise or having someone do a very specific exercise based on their profile and their symptoms is actually a great way to make someone feel better. And you just got to give them the right stuff.

• 1:37:59Dr. Peter Attia?

  Yeah, I consider that one of the most profound experiences of my life from a physical perspective and also in how much it changed my point of view about what back pain is and isn't. I don't want to suggest for a moment that if you're sitting here listening and you have back pain, that's the answer. Go and find a guy to do that. But I'm saying that there's so much more going on than we realize and so much of back pain is not surgical and so much of back pain can be healed with retraining a movement patter and getting our nervous system to kind of get out of the way.

• 1:38:28Speaker 01

  I mean, one of the exercises I think we're going to cover in the gym, I have a lot of clients that come in and they're like, look, I'm nervous about the Cairo thing, or they have some fear around it. They heard stories, whatever. They're like, can you help my neck though? Absolutely. Cause there's a million other ways to cook this recipe to where we normalize the motion of your joints. We make the muscles strong again. We reestablish the relationships of your shoulders and your scapula and your neck. There's a million ways to make someone feel better with exercise where you don't have to do aggressive therapies. I don't care if it's stem cell or PRP or Prollo or dry needling or Cairo. It doesn't really matter. Exercise needs to always be the answer and you can do therapeutic exercise that actually does a lot for people that drops the pain too.

• 1:39:03Dr. Peter Attia?

  So speaking of that, I think what we'll do is we'll now pivot over to the gym and kind of work on a few issues. So we identified four areas that we want to highlight for folks. We're going to do neck, lower back, knee and shoulder. I guess you picked those because that's 80% of what people complain about.

• 1:39:21Speaker 01

  Yeah, it's really common for one. I tend to see that one of the things we want to highlight in this next session is really highlight to people, oh wow, this doesn't look like any exercise, but it could help my knee. This idea of working around a structure that has pain to help that structure feel better. I think that's what we're going to go for. And I think the regions we selected are just really common, really debilitating. And frankly, generally people whiff on these a lot. We get so many of these cases in our practice that it's like, what were they doing? They didn't do this. They should have done. So we're going to try to go that way.

• 1:39:49Dr. Peter Attia?

  So walk us through the framework. I love your framework for how you approach these. So what's the framework?

• 1:39:54Speaker 01

  First off, that bifurcation we talked about earlier, where do we need a consultant orthopedic or neurosurgeon? That's number one.

• 1:40:00Dr. Peter Attia?

  How do you make that decision?

• 1:40:02Speaker 01

  The story, the incident, what it looks like. If we're talking knee, if they're a soccer player, they twisted it really weird yesterday. It's all swollen on the joint line. I'm more worried about the joint. Conversely, if it's a runner where it's been kind of off and on for a long time, no acute incident, no joint line swelling, the pain is kind of vague. Those are two very different presentations. So one's going to be more like ortho consult. One's going to be like, let's tinker around as a rehab pro and see what we can do. So that's the first bifurcation is basically playing doctor and being like, what's the right path? The other thing I really want to encourage is that the best orthopedic surgeons in the world, like you spoke to earlier, they don't want to do surgery or inject everyone right away. They're referring out all the time. And a lot of clinics nowadays have like a physical therapy clinic in-house and there's all kinds of constraints with that.

• 1:40:47Speaker 01

  The best orthos don't just give someone a list of every PT clinic in town. They're actually referring to different clinics based on that clinic's strengths and experience. Some clinics specialize in running, some specialize in strength training. If you're orthos specifically searching out different PT clinics, that's a huge win. It's a great sign they know what they're doing. If they just give you a handout and they're like, go call somebody, that means they think all PT is the same and all rehab's the same, and it's not. So that's number one. Once we've got past that bifurcation of knowing that it's a rehab case, then the protocol really turns into what is the safest and smartest way to create a change? Maybe it's a manual therapy, maybe it's dry needling, maybe it's one of those treatments we spoke to earlier, or maybe it's a strategic load. That decision is a lot of times based on the patient's comfort. Read the room.

• 1:41:30Speaker 01

  Are they cattle rancher dude who wants to push through pain and they're going to go back to work tomorrow? Or are they someone who's really scared because the pain is high? We got to build trust. We got to get them some sort of pain relief to show that we're medically being responsible and making sure we're going the right direction. But then, once we've created that change, then we start to load it. A lot of times, if I have a joint that I know is permanently compromised, let's say someone with total knee replacement, I'm not going to actually beat up the knee a lot. Traditional insurance-based rehab is going to go after that joint because that's the code that's associated with it, and they know they're going to do that really well. What I'm going to go for first is the foot, the ankle, the hip, and their pelvis in general. Because if there's a lot of low fruit there, I can enhance the pelvis strength or the foot strength, and I can actually buffer that knee to where it doesn't have to work nearly

• 1:42:15Speaker 01

  as hard, and those people get a reduction of symptoms overnight.

• 1:42:18Dr. Peter Attia?

  Yeah, so that makes sense. That's basically the thought algorithm on how we do this. What can we show people? We're gonna go to the gym and we'll give people a few examples. I'd love people to have some takeaways on, hey, what can we do here? How could I put this into practice on my own?

• 1:42:31Speaker 01

  Yeah, well, I really want to focus on what people could do themselves right away. Like, they don't have to make an appointment somewhere. And so if you're looking at the three things that can go wrong in musculoskeletal, it's the tissues, it's the joints, and then it's that motor controller exercise window. So we're gonna dive into some of these exercises that might not be expected to be helpful for your neck or your shoulder, but actually indirectly can load those structures to try to get that relief, just like you experienced with your low back.

• 1:42:55Dr. Peter Attia?

  I see. So we're gonna just show people a set of exercises around each of those three pillars per joint?

• 1:43:00Speaker 01

  Yeah, per joint. We're gonna dive in and show like, this is what you can do for the tissue. This is what you can do for the joint. And then, most importantly, these are some loads you could do that actually help reprogram that software to where you actually stop overloading the area that hurts and get everybody else back on track.

• 1:43:14Dr. Peter Attia?

  Okay, excellent. Kyler, this was really a ton of fun. Enjoyed sitting down with you. It's not normal that I sit this far from you, but at a distance, you look just as great as ever.

• 1:43:23Speaker 01

  Devastating as always. Thanks a lot.

• 1:43:26Dr. Peter Attia?

  Thank you for listening to this week's episode of The Drive. Head over to peterattiamd.com/shownotes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAtiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice,

• 1:44:11Dr. Peter Attia?

  diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peterattiamd.com/About, where I keep an up-to-date and active list of all disclosures.