Ep 138: Don’t Wait Six Weeks: Prehab, Post-Op Rehab, and Return to Sport

Two people have the same ACL reconstruction, from the same surgeon, on the same day. One is back at 7 months, and the other is still working on it at 13. The surgery was identical, so what actually accounts for the difference?

In this episode, Garrett sits down with Julia Grace Gillen, PT, DPT, better known as JG the PT, who runs a sports physical therapy practice in Jackson, Wyoming. In a town where people’s identity is tied to being able to ski, run, climb, and get outside, the pressure to return someone to sport is different, and so is the standard. JG walks through the entire arc of post-op care, from the weeks before surgery through the day someone clicks back into their skis, and makes a very clear case that some of the most important work happens in the windows most patients are told to sit still through.

In this episode, we get into:

– Why muscles begin to atrophy in about two weeks, and what effective prehab does for an outcome months later
– Why rehab should start within 24 to 48 hours after surgery, and what that first session actually looks like – even with restrictions from the surgeon
– The middle phase of rehab, where recovery is quietly won or lost, and the specific targets JG uses to get patients through it
– Why range of motion and strength have to be built in parallel rather than one after the other
– The piece missing from most return-to-sport programs, and why sixty seconds of side-to-side testing says nothing about a six-hour day on the mountain
– What runners consistently neglect: the foot, the big toe, and the soleus, and why a jump rope may be the most underrated training tool

Whether you are a clinician building post-op protocols, an athlete staring down a surgery date, or someone who has been told to wait six weeks and do nothing, this conversation lays out what the research and a decade of mountain-town practice say about how recovery actually gets faster.

 

TRANSCRIPT

 

Garrett Salpeter, NeuFit (00:00.954)
Hello, New Fit Nation. Welcome to this episode of the Undercurrent Podcast. I’m joined today by a wonderful friend and physical therapist, Julia Grace Gillen, also known as JG the PT. So you’ll probably hear me refer to her as JG throughout this. She has her own practice in Jackson, Wyoming, working with a lot of mountain athletes. She herself is a fairly exceptional athlete and ski instructor. I say that because she taught me how to ski when we were together at a at a conference in Big Sky, Montana.

And JG, in addition to having her own practice, also does some consulting work for us at Newfit, supporting and educating other professionals who are onboarding the neubie device. And she has a a breadth of experience and perspective. And I’m excited to have her on. So JG, welcome to the podcast.

Julia Grace Gillen (00:48.888)
Thanks, G. Thanks for having me. I’m excited to be here.

Garrett Salpeter, NeuFit (00:52.676)
Heck yeah. So yeah, in order to give people a chance to get a sense of you and who you are, can you give us a a bit of your origin story as a P T and how you got from Birmingham, Alabama to Jackson, Wyoming?

Julia Grace Gillen (01:06.262)
Yeah, absolutely. It’s a it’s a strange pipeline coming hailing from the south. in the heat and humidity and ending up in a a cool mountain town, Jackson Hole, Wyoming. We’re up near Yellowstone and Grand Teton National Park in a beautiful area, surrounded by national park, national forest, and just lots of land to to play. I always knew I wanted to work with

Professional athletes and endurance athletes and high level athletes. I didn’t know what that would look like. In the South, that usually revolves around football teams and pro like soccer teams and baseball teams. So the travel part actually was what made me kind of switch and end up in Jackson. I I wanted to establish a community and a home base more so. So moving to a mountain town out west.

seemed like the right move to continue to work with high level athletes after PT school. So came to Jackson and put my roots here and haven’t looked back since. So I’m here and I work with a lot of trail runners and skiers and climbers and paragliders and our ski patrol and any type of endurance athlete that are doing any type of crazy things in a mountain town. We we see it all.

So they’re a super fun population to work with, very aggressive and go getters and outgoing and pushing the limits. So it’s it’s a constant challenge for me and my world every day.

Garrett Salpeter, NeuFit (02:39.895)
Awesome. So with that population, what are the what’s your typical caseload like in a in a week? And does it vary between summer and winter? And give us a sense of what your practice is like there day to day.

Julia Grace Gillen (02:53.069)
Day to day, week to week looks similar. We have I have a lot of ACL tears, as you could imagine. but it’s one of these unique places where the treatment and the injuries depend on the season. So you look at summertime and we see a lot of chronic injuries with our trail runners, mountain bikers, and endurance athletes in that realm. So we’ll see a lot of Achilles issues, which is

common tendinopathies and things like that or IT band syndromes or a lot of those chronic issues we run into with our ultra endurance athletes. But then you also see mountain bike crashes and paraglide crashes and and very acute injuries in the summertime, people pushing those limits. And then in the wintertime we see a lot of ski injuries. So that’s when we see a lot of our ACLs, whether they’re post-op or

meniscus tears, ligament tears, shoulder injuries from falling while skiing and snowboarding. snowboarders, we have a lot of that outstretched fall on the shoulder. So we see a lot of labral tears and rotator cuff tears. so it’s very seasonally dependent in our world, but a weekly basis could look like ACLs, lit shoulders, ankles, hips, you name it.

Garrett Salpeter, NeuFit (04:18.445)
All so we got a sense of the caseload. In terms of that that more active crowd, I’m just curious if is it any different treating an athlete in Jackson compared to, say, Birmingham, Alabama or Charleston, which by the way is where she went to PT school?

Julia Grace Gillen (04:34.579)
It could be. It can be. I think the biggest difference would be the mental component of most of the athletes and patients that I’m seeing. Our in Jackson, it’s unique. We are tied our identity, I identity is tied to the mountains a lot of the time. So there’s a lot of pressure on doctors and physical therapists to get our patients and clients back to sport and back to recreational activity as quickly and safely as we can.

Because our identity, why we live here, why we live in Jackson is to to be outside and to recreate in these beautiful places. And when you can’t do that here, it’s it’s a very big mental struggle. So that actually ties in perfectly to how I came about with the neubie and how I started practicing with the neubie because I knew what we were doing was working and I was very confident in my rehab skills.

But it just wasn’t fast enough. It needed to be quicker and faster and more efficient. And when I was introduced to the neubie, that was the exact ticket of how we got our rehab and our treatment faster and we got people back to recreational activity faster. So it’s interesting how it changes living here and having that extra pressure and like where the neubie comes into treatment.

Garrett Salpeter, NeuFit (05:58.136)
Yeah, I can certainly relate to that, having been an athlete myself and working with other athletes over the years, when if you’re injured and it sort of gets in the way of something that you like to do and it’s an annoyance, that’s one thing. If it if it gets in the way of you being able to live into your identity, holy smokes, that’s another thing altogether. And you’ll move heaven and earth to to do that to get back to get back to the thing that you so deeply identify with. So one one of the reasons that we

Julia Grace Gillen (06:19.446)
Exactly.

Garrett Salpeter, NeuFit (06:27.375)
talked about and plan to do this podcast together was to be able to cover post op treatment. And you have a lot of experience here. So there’s a lot of different different parts to this that I think will be helpful for our audience to hear. And to kick it off, I’d like to hear your perspective just sort of broadly. So if if two people get the same ACL reconstruction from the same surgeon on the same day, why does one come back at

say six or seven months and one comes back at thirteen, fourteen, or eighteen months. What makes the big what makes the difference?

Julia Grace Gillen (07:01.985)
That’s a the million dollar question. I think the neubie is one of the biggest differences when you’re looking at rehab and being able to use efficient tools in your rehab process. The the physical therapist definitely comes into play here and what their timelines and structure looks like and then the the mental component and the drive of that.

that patient comes in. It’s like, how much are they willing to do? How much are they willing to listen to you as a physical therapist and to their body? really, you can put a lot of the rehab process on the client and the patient and how in touch they are with their body is one of the biggest factors. And that’s where the neubie comes in and changes things because the neubie allows that patient to connect with their body again after surgery right away.

So we’ll talk about that in our our today in our protocol and like how quickly we start using that neubie. But overall, when you look at how successful someone’s gonna be, it’s the the tools of the physical therapist and their drive and the willingness and drive of the client and how they’re gonna progress and how they’re going to really dedicate the next few months to their rehab process. And

We talk about this a lot in in the office and the the gym, but I always tell my clients, you know, this is almost gonna be like a full-time job coming back from a surgery. It requires a lot of attention and a lot of thought and a lot of work. And I think the more open and honest communication you have about that with your clients, the better. There’s no sugarcoating it. And sometimes our surgeons are like, okay, great, we’re gonna have this surgery, we’re gonna get you in and out, you know, you’re gonna be

walking like the next day or something and really putting it into perspective as a physical therapist is one of our main jobs, education and and timeline education on how things are gonna work and how things are gonna go. And I’m really clear with timelines with my patients of okay, by this six week, you know, this is our goal. And can we meet that goal? And then once we meet that goal, we move on to a different goal and and just having a very clear understanding of of working together with your patient on

Julia Grace Gillen (09:23.158)
On the ultimate goal, which is full return to life.

Garrett Salpeter, NeuFit (09:28.771)
When you talk about those progressions and timelines, first I think you’re doing a great job of managing expectations, which is a huge part, that’s half the battle right there. And I’m also curious when you when you talk about these timelines and reaching certain milestones, I’m curious throughout this, if you’re doing more time based or criteria based progressions, even before that though, curious about how much are you having

Protocols given you by surgeons that they’re expecting you to follow versus how much do you have your own? And are there any tensions there? Or are you on much more collaborative terms with all the surgeons and everyone’s aligned? What what’s that dynamic like in terms of protocols and progressions versus people and and your own sort of ability to do things more autonomously?

Julia Grace Gillen (10:18.86)
That’s a great question and a great one to dive into, especially for our listeners. I am in a very lucky situation in Jackson where we have a great relationship with our surgeons. We work very closely with them. It’s a small town, small community, but I have my surgeons I text them all the time. I we are on a phone call text basis of our clients, which is great, but they have full trust in me as a physical therapist. So

I’m following my timelines and protocols based on what I have seen work and what is going to be clinically appropriate for that patient and based on that surgery. So they give us full autonomy in the rehab world, which is excellent and awesome. Obviously, there are precautions that we follow based on, you know, if a meniscus is involved and whether there’s non-weight bearing protocols involved. Those are are strict, but we’ve worked together with the surgeons.

to nail those down. But I always encourage people to have that open and honest communication with your surgeons because you want to be communicating. You want to be able to say, hey, this patient, I don’t think they’re where they’re supposed to be. Something might be wrong. What do you think about this? Because, you know, it’s a team effort between the surgeon, the physical therapist, and the and the patient. We should all be working together and collaborating. But luckily in Jackson, we have a great relationship and it’s it’s on me.

to do the rehab process and it is a big honor and a big and a big pressure because it’s all coming down to you. They’re like, well, you’re JG is in charge. And if you have questions with rehab stuff, it’s it’s under her control of when you’re being returned to sport, when you’re able to do certain things like get back on the bike or get back skiing or hike up our local hill again and hike downhill. so it’s a lot of constant

check-ins with the patient and knowing where your patient is with timeline and how their functional capability is and that differs a little bit person to person. So we are lucky that I’m following my own protocols with based on my research and collaboration throughout the years of of experience.

Garrett Salpeter, NeuFit (12:34.945)
Awesome. And I think there’s a great lesson in there in terms of strategies for communicating with surgeons that many clinicians listening to this can certainly take to heart and learn from. And then let’s also dive into you, you’re talking about your protocols. Let’s dive into some of that and let’s let’s start chronologically start at the beginning. How important is it to get started right away? To what degree does the first week or two of rehab influence what happens months later or change the trajectory of of the recovery?

Julia Grace Gillen (13:04.276)
The most important, I also will back you up a little bit even more. talking about the prehab approach to surgery with our post-ops is huge. When you look at a prehab situation, if you have time and it’s not immediate to go into surgery, being able to use the neubie and turn your muscles back on after the guarding that we have. So when we have

The incident itself that warrants surgery, whether it’s say an ACL tear or a post like a total knee replacement. Having when we have that, like if it’s been a while and surgery is scheduled a few weeks out, we know from research it takes two weeks for muscles to atrophy, just two weeks. So if you’re in the longer window than that, you should be on a very strict prehab program to make sure that you are strong and your muscles aren’t totally turning off before you go into surgery.

Because if that happens, then you have the surgery and then you come out the other side, we’re we’re starting at at negative at that point. And that is really difficult. And that determines somebody’s rehab process because they’re really swollen or they’re super weak from before surgery. So then you’re just starting steps and I would even argue miles behind at that point. So even before we start right away post surgery, if you can

Put your patients on a strict but feel-good protocol before surgery where they’re getting quad activated or muscles activated and you’re getting swelling down pre-surgery, that actually significantly improves our outcomes after surgery. So if you are a neubie user and somebody is scheduled for surgery, continue to see that patient.

you can get the swelling down, you can get the range of motion back. And I actually have surgeons in this town that I’ll get referrals to and say, Hey, actually before I have surgery on you, I need you to go see JG to work on your range of motion, your swelling, and your muscle activation, because I won’t do surgery on you until that is back.

Garrett Salpeter, NeuFit (15:18.233)
Great, great insight there. I’m glad I’m glad you brought us back. I was I was gonna skip over that altogether. So so yes. Thank you. Yes, great, great insight there. So okay, so excellent, excellent point there. Now let’s go to post op. How is it how important is it? I mean, you gave us some of the answer right there and in just a couple weeks, of course, atrophy happens significant. In you know, artrogenic inhibition happening after surgery, often atrophy. So how important is it in your experience to to get started right away after surgery?

Julia Grace Gillen (15:23.598)
We can’t skip that part, but

Julia Grace Gillen (15:41.506)
Yes.

Julia Grace Gillen (15:47.905)
Right away. This is one of my favorite topics to talk about when I do clinical support with our New Fit Nation because people constantly ask, when are we starting to use that neubie? When can we? When is it safe? Right away. when you look at your post op patient, we know that we have that inhibition from surgery itself. We know we have that swelling, and we know we are gonna have decreased neural connection to that area because your brain is gonna try and protect it.

So right away, most of us don’t get our hands on our patients until their one day post op. most of the time, the day of surgery, they’re make they’re in the hospital making sure everything’s okay and then they go home. I always try and have my patients in the next day. It’s a little bit of a mental test as well. Everyone sometimes walks in and says, is this a was this a test to try and get me out of bed, to try and get me dressed?

To try and get my b my teeth brushed to like is this a mental test? And honestly, yes, a little bit is mental saying, hey, you gotta the work starts now. We we don’t we’re not wasting any time, you’re not laying on the couch. it starts now. So within 24 to 48 hours, I really like to start with our patients and get them on the neubie right away. when we work on that 500 hertz, that 500 pulses per second, we have a calming effect.

And we have a decreased swelling and decreased pain effect. So everything right away with the neubie will be on that 500 setting to calm down things to get swelling down, use the glove work around those bandages. That’s gonna be fine. We don’t need to take any scar bandages off, but anything that’s gonna shift us into a like a calming state is gonna feel really good. And then we know.

That on that 500 with the neubie and that direct current, we’re gonna start to get enhanced blood flow to that area. So we’re gonna kick start the healing process. And the sooner you do that, the better. So right away in that twenty-four to forty-eight window, forty-eight hour window, as soon as you can get that patient safely back in your clinic and on the neubie, the better.

Garrett Salpeter, NeuFit (18:05.429)
Awesome. So one of the things you mentioned was of course following surgeons’ restrictions around if there’s meniscus involvement and it’s non-weight bearing, for example, that looks different than someone who’s just a a so-called clean ACL and and can go into weight bearing right away. So what does it look like or or what other additional commentary do you have comparing those scenarios to each other?

Julia Grace Gillen (18:31.596)
Absolutely. The the tricky part is some people are like, well, I I hear this all the time. They say, Well, I can’t do anything for six weeks. And you hear that a lot with shoulders too, because they say, well, surgeon said or I can’t do anything for six weeks. I have restrictions. That we understand and we will we obviously respect and take into consideration, but that does not mean that your physical therapy does not start for six weeks. You will be behind if you wait until six weeks to start.

Your post app rehab. We, if you start six weeks later, you have decreased neural connection for six weeks. You have increased swelling because you didn’t do anything to address that swelling and expedite that healing. We have a lot of stiffness and issues with range of motion and scar tissue development. So the quicker, like I said, even if you have those restrictions and you’re not weight bearing.

You can still be on the table getting neural connection back to all the muscles around. You can still be doing quad sets. you can still be doing inflammation and pain control to the knee. There’s there’s so many things that you can be doing in that six-week like limitation mark, especially if you’re looking at shoulders as well. You don’t want to have the neubie high enough to where you can cause a muscle contraction, especially if it was a lab roll or rotator cuff repair, but you can

you can do a lot of work to the upper trap and to the neck. How many times do we see our patients at the six week mark and they can’t turn their heads or look up because their neck is so stiff or their elbow doesn’t move because they have had it in a sling for so long or their fingers have lost neural connection. So there’s so many things as a clinician that we should be doing in that so called restrictive phase.

Because you they will be behind. And we’re doing actually a disservice by saying, okay, we’ll start your rehab in six weeks. So with the neubie, it’s very powerful because you can be on the settings that are helping with blood flow and neural connection and preventing that atrophy before it even happens. And one of the biggest signs of whether a patient is going to return to sport is our strength indexes. And if you have no strength control or no strength work in six weeks.

Julia Grace Gillen (20:52.086)
that’s gonna affect you at the six month mark and the seven month mark and the twelve month mark. One hundred percent.

Garrett Salpeter, NeuFit (20:58.831)
Yes, for sure. I think that’s beautifully said. And of course, one one thing to highlight there, of course, if someone is non-weight bearing, you can do open chain movements, things like that. One of the keys there is if someone is immobilized, if they have a had a shoulder, say superspinatus repair, and they’re supposed to move that at all. You mentioned turning up the neubie, but even below the threshold where it’s gonna cause muscle contraction, and might actually cause them to move unintentionally.

And still still getting some activation and blood flow there. So there’s always something you can do. And then working on the neck and these other things you mentioned. So I think I just really like that point and wanted to emphasize that that there’s there’s always something that can be done. And this sort of goes back to the rewriting the the rice paradigm, the rest ice compression elevation. We understand now that when one simply rests, of course, we need rest. I’m not saying we’re on 24 hours day, but generally speaking, when one is

Julia Grace Gillen (21:44.418)
Yes.

Garrett Salpeter, NeuFit (21:55.042)
excessively sedentary, resting too much, that is a signal to the body, to the nervous system, to the brain, signal that, hey, we don’t need to use this tissue and our we’re oriented towards conserving energy and making sure we live to see tomorrow and protecting against the famine. So the body that’s why the body starts to atrophy, these catabolic processes that break down tissue. That’s why neurological activation is suppressed. It takes a lot of energy just to maintain neurological pathways and to send those those sodium potassium

Pumps and send action potentials. It takes a lot of energy to do that. So if those areas aren’t used, there is a signal to down-regulate all of that. I think that’s vitally important.

Julia Grace Gillen (22:33.29)
Extremely important. And if I could shout what you just said from the rooftops, I would. And and in my head, I call it my my G, my garage feel. But I talk about this all the time because it’s so important. And I think there’s a lack of education and awareness of this with clients and patients in the physical therapy world. So explaining this, how it does take energy to maintain neural connection and and how many times have I explained to a patient that they’ve lost.

this neural connection because of disuse, because the brain is going to shut down that area. And it’s just so important to understand the neurological connections that we have in our body and how quickly they can change. And on the the positive part of that, you know, we can change them so quickly with the Nubian direct current. When you do, I do see a lot of people that come to me who are in a stagnant place with rehab.

Or with their ACL and they’re like, things just are not connecting the way they should, and we’re we’re kind of at a slow. So on the flip side of that, it’s there’s a positive component of being able to switch those neural connections so quickly and turn on that quad muscle. And I think the VMO is one in particular that we look at with post-knee surgeries. It’s shutdowns first. We know that from research that the VMO is the first thing to shut down with a knee injury. So whether it’s post op or not.

We know that using the neubie and putting a vertical pad right on that VMO is gonna be one of my go-tos. exh right away post stop and just in general, because if you have the knowledge and understanding that that is gonna shut down and then your patella tracking is gonna be off, and then you snowball effect into all the other effects that that does with the knee, you can make a big change really quickly with the neubie by putting a pad on the VMO.

Garrett Salpeter, NeuFit (24:30.103)
And that that brings up another question that I want to ask. In within this concept of protocols and progressions, to what degree are you individualizing versus to what degree would you be following that? Like, like for example, there you just said everybody, or at least we’ll say virtually everybody who just had an ACL reconstruction is going to need that work on the VMO. Whereas if someone has low back pain, it could be.

A lack of ankle mobility, it could be issues in the hip and pelvic control, it can be in the core, right? There’s all these different things where we have to indiv individualize that. So to what degree, at least in that immediate post-op stage, then we’ll move on along the progression to into later stages, return to play, to what degree are you sort of following a similar playbook versus individualizing?

Julia Grace Gillen (25:22.402)
That’s a in the beginning, there actually is a pretty standard playbook, which is great because I’ve been able to share that with a lot of our new fit clinicians all over the world, especially in this country. But it looks pretty similar. The knee joint is one of our more simple joints, all things considered in our body. So we have a really good understanding of how that works and how our muscles work and the pools. So

We it looks pretty similar in the beginning. If you, I would say like put it into the first three weeks of that post-op phase. You know, everyone is gonna, in my world, is gonna get glove work done to the knee to push out some swelling, almost in like a lymphatic distal to proximal realm. so we’ll use that glove work on 505 pulses per second to kind of push out some of that swelling.

And any and that helps with pain and down regulating any trigger points that you find. And that really helps just globally return neural connection to the leg, to the lower extremity. So that is in the playbook. And then right away having one pad, neubie pad on the VMO, and then one kind of horizontal across the Rec FEM and going through quad sets.

That is also going to be vital to the playbook of getting that quad back on, turned on, getting that VMO back on. And there’s really cool settings on the neubie that I it’s like the secret sauce that I tell clinicians that I’m working with where you can use that work time and rest time. So if you have somebody in the first week post op and they’re having trouble getting that quad on, and we’ve all seen it as clinicians, you know, they you say, Okay, let’s work on your quad set, squeeze your quad and the glute is firing and

Their whole leg is moving forward five inches and the hamstring is contracting and they’re moving their foot in weird places. And we see that all the time. And it’s a lot of self-talk to the patient saying, Okay, no, I want you to isolate the quad and they just can’t get it. That’s where the neubie comes in on a deeper level, where I’ll put the work time on for three or four seconds, and then I’ll turn the work time off.

Julia Grace Gillen (27:37.705)
And have them a give them a break. So the newbies feature is that it will automatically come on with that current. And then it’ll automatically come off for a few seconds. And what you’re telling your patient is squeeze when it’s on, relax when it’s off. That’s it. And it’s very simple and it’s r it’s a huge way to get neuromuscular re-education with their body because you simplify it and they’re just trying to overdo it. so that is one of the best things in the playbook.

First week of using that work time and rest time and saying squeeze when it’s off, relax when it’s off, and getting that quad back and just sitting there kind of for reps for a few minutes and really great, like ingraining that in their brain of, hey, I have control over my quad and I can isolate it. And that isolation in the first two weeks is super key because I’ve seen so many patients that come to me and

They can’t it this could be weeks later, this could be months later, and they don’t even know how to do an isolated quad contraction. And they’re using their glue and their lower leg muscles, and it’s just like a spaghetti mess that you’re trying to undo. So using those work, those on and off times with the neubie in the beginning is really helpful.

Garrett Salpeter, NeuFit (28:52.077)
Hearing hearing you describe that reminds me of the the karate kid, the wax on, wax off. Squeeze when it’s on, rests when it’s off.

Julia Grace Gillen (28:56.406)
Yes, yes. Yes, we could do that. Squeeze when it’s on, rest when it’s off.

Garrett Salpeter, NeuFit (29:03.607)
That was great. I got to watch that with my kids, which was awesome. I hadn’t seen it since I was a kid. wonderful, wonderful movie. So as we move through the progression here, between these initial phases and return to play, there’s of course stages of progression. So what what stands out to you most in terms of what’s most compelling or most important that we communicate to the listener about the the progression between that early stage and

Julia Grace Gillen (29:07.598)
It’s a good one.

Garrett Salpeter, NeuFit (29:32.845)
Return to play in terms of milestones, specific to any techniques that you use. What what sort of stands out to you about that that middle long

Julia Grace Gillen (29:40.247)
The middle ground. The middle ground. The middle ground is tricky. in my head, sometimes with clinician to clinician, I refer to it as it could be like the purgatory phase because this is when you could you could go up or down. You can really exceed here in this middle phase, or you could really this is where you see people fall and you see poor rehab. And one thing going back to open and honest communication with timelines and keeping your your patients on a timeline is really important and saying, okay.

By this week, I need you. I’m pretty specific with mine. I’ll say I need you to be able to do 30 sit-to-stands single leg by this time and having goals with those patients and saying, you know, your squat needs to be perfect and not shifting, or 30 single-leg sit-to-stands, or a minute of balance on that leg, or you need to be able to do 30 straight leg raises with no extension lag. And

having very specific outcomes. There’s research that the brain does better when you have a goal and a target. So implementing those into your practice is key. And then using the neubie to enhance that neural connection, they should get to those things quicker, which is exciting because we don’t have that lag of, well, I don’t know if I’m doing it right or I can’t really feel or I don’t get fatigued. And in that middle ground, one of the most important things is that they’re

your patient is feeling muscle fatigue. And that’s where things can go up or down. Some people are like, well, I did my exercises and I say, are you tired? Did you have muscle fatigue? Did you feel sore? If the answer is no, we are doing something maybe wrong and not enough. We’re underdosing. That’s a very common issue in the middle phases of underdosing and protecting that that graph a little bit too much. And some people are like, well, we don’t want to load them. You don’t have to load them.

You can increase reps, you can increase time. Instead of having someone do three sets of 10, have them do three set three of 60 second intervals for something. And then they’re gonna get to that fatigue and we’re gonna actually work that muscle. It’s very important in that middle ground to make sure that you are getting muscle connection. And when you use the neubie, the our patients constantly say,

Julia Grace Gillen (32:01.888)
I feel this working. I feel my quad working. I feel my glute working. And when they come out of that third set, they’re like, whoo, that was tough. And we we want that. We want that engagement. We want it to be challenging, but we’re always respecting our timelines and, you know, the the graph itself. We’re not putting them in dangerous positions. You don’t have to reinvent the wheel in the middle ground. There’s nothing wrong with sit to stands, lunges, squats.

all the like we don’t need to reinvent the wheel of doing some crazy exercise you saw on Instagram for the ACL that looks scary and hard and they’re on a bosu ball and they’re throwing a ball this way. Like that stuff is great, but it doesn’t you don’t need to go crazy. You need to focus and master the basics. And I tell my patients that hey this middle ground is gonna be a little boring and that’s okay. We’re gonna get through it. We’re gonna make it fun in the clinic.

And you’re gonna find a way to get through it at home. And it’s okay to be boring, but we need to work. This is where you put your head down and we work in those middle grounds because we have a timeline, and at that six months, I want you to be so I want you to come back to me and say, Hey, these are easy and I am bored and I’ve mastered these. That’s like the best goal, I think, for me when patients come in and they’re like, All right, JG, I’m ready for the next thing, like I could do all these.

and they’re ready to work with the neubie. And that’s when you’re really working a lot in those middle frequencies on seventy-five and fifty-five and forty, and you’re getting that enhanced muscle connection. You’re tapping more into that muscle, you’re recruiting more motor unit fibers. So we’re really working on that.

Garrett Salpeter, NeuFit (33:37.538)
Awesome. Is there anything that needs to be said? Just clarifying question wise here. You you talked about being able to do certain numbers of leg raises without the extension lag, being able to do sit to stands, being able to achieve a squat position without shifting to one side. Is there is there any particular fixed order in your mind? Like there are often progressions where one wants to achieve certain range of motion milestones first before necessarily focusing on strength, before necessarily focusing on on other yada yada.

Milestones, right? So so how how do you think about that in your mind? Just to sort of clarify if any questions came up for someone listening to you describe that purgatory middle phase.

Julia Grace Gillen (34:07.222)
Yeah, yeah.

Julia Grace Gillen (34:15.552)
Yeah, absolutely. I think there’s a lot of stress on the range of motion, especially with knees. And there’s certain, you know, six weeks you want that that range back a hundred percent. And you’re working on that. I also think there’s a little bit of wiggle room here because you have people that are hyper mobile who

If I have somebody who’s hypermobile, they come into the clinic, it could be first week post op and they have negative five extension and they could go past 90, but I don’t need them to go past 90 right now. They’re somebody that I’m not worried about getting their range of motion back. They’re somebody that I’m very worried about strength. Very worried. So they’re somebody that I am really heavily focusing on those quad sets and those straight leg raises and getting those without lag because they’re the ones that are gonna need a lot more control.

they need control for that range because they already have that range. And then there’s people, I fall into this category. I run a little bit more stiff and I do not have a lot of flexibility and mobility in my joints and muscles and ligaments and tendons. So for somebody like me or somebody that falls into that category, we are heavily working on knee extension and getting that knee extension back right away. That is first and foremost.

flexion is a little bit easier and flexion will come. And it’s usually easier to get, you know, with bikes and range of motion and functional movement. But that knee extension is like first and foremost what we want because that will get really stiff. And then once we lose that, it is extremely hard to get back. And then you’re looking at developing scar tissue and potential manips. So that is first and foremost that extension. But when you look at what we’re doing functionally, like when you’re getting those quad sets and you prop up their ankle.

On like a bolster or a half foam roller and they’re pushing down into that extension, they’re getting functional knee extension just as much as if I was pushing down to get just pure range of motion. So the range of motion component is important, but I believe that it lives parallel to your strength. It has to go parallel. You can’t wait until you get a certain amount of range of motion to start strengthening. Cause that could be that could put you behind. So the the biggest takeaway is.

Julia Grace Gillen (36:33.248)
let them work in parallel to each other and see see what’s is what needs to be worked on when they present into your clinic. There’s some days where people come in super stiff and they’ve lost that range of motion maybe because they were focused on strength too much or because they were walking too long the day before. And that’s something that you want to address immediately before you go into that strengthening. But I don’t think one necessarily needs to come specifically before the other.

In a strict way.

Garrett Salpeter, NeuFit (37:05.133)
I think that’s beautifully said that you want to work on both range of motion and strength in parallel. That brings up the old adage about not wanting to have a big gap between active and passive flexibility or range of motion, because if you can get into positions that you don’t have active motor control there, that’s that’s potentially dangerous. So so being able to to scale yeah, being able to scale together motor control, which is essentially synonymous with strength, at least in this context, if not all the time. But

Julia Grace Gillen (37:22.742)
Mm-hmm. It is, which is a good point.

Julia Grace Gillen (37:34.134)
Yes, yeah.

Garrett Salpeter, NeuFit (37:35.288)
being able to to to pair that with range of motion. That’s great. So all right. So we’ve talked about pre surgery. We talked about immediate post-op, talked about this middle ground. Let’s go on now to talk about return to play. So what what tests do you want passed before someone clicks into skis or goes to do their next 30 mile ultra marathon trail run or whatever whatever it might be. What are what are s what are some of the big things you are looking for?

Julia Grace Gillen (37:59.641)
Yeah.

the biggest question. I think one of the biggest things that’s missed, and so that’s always checked off on my end, is I wanna see plyometrics. I wanna see jumping, I wanna see single-leg jumping, I wanna see jump rope, I wanna see bounding forward, I wanna see bounding vertically, and then I wanna see jumping off of a box, like a drop, drop jump. I wanna see all of that in the clinic before anyone’s doing a lot of.

running or clicking back into their skis. I want to see control in fast movements. So I want to see somebody sprint forward and stop and decelerate. I want to see them accelerate backwards and forwards. I want to see them accelerate side to side. We want to look what look at lateral control and even that last component is like diagonal control. So I think this is missed in rehab and it’s not the PT’s fault because it’s

typically an insurance thing where you’re limited by number of visits and coverage, which is really frustrating. And that’s where, you know, I encourage our PTs and our athletic trainers and everyone in the the world out there to have some sort of follow-up program whether you get all of these ACLs together at one time and you run them through an agility like hour.

And you say, okay, you know, every Friday morning we’re having agility. So like once you get to a certain point in your rehab, you’re all gonna kind of come do this agility training where you’re doing a lot of bounding and jumping and back and forth. If it’s something you’re limited by in the insurance world, there are workarounds. Like we can we need to stop letting that be an excuse, honestly. because we’re seeing such a high rate of re-tears and re-injuries. And then if you have a hamstring graph, we see a lot of hamstring strains.

Julia Grace Gillen (39:53.185)
Or Achilles issues like years later. And then we see issues on the other side from overuse. so we have a big role here in the return to sport. I want people to think about it as a return to sport and a prevention of injury. So if you kind of tackle it from both angles and you say, How am I gonna get this patient bulletproof on both sides so that I don’t have a risk of re-injury or retain and they’re ready to return to sport.

That approach is a lot deeper. It’s a you’re gonna think about things a little bit differently. You’re gonna think about moving right to left using both sides in conjunction and that that multi-functional purpose of the body. You’re gonna look at that core, you’re gonna look at their posture, you’re gonna look at the body as a whole. And that’s what you wanna think about when you’re in that return to sport. Not necessarily the return to sport test, not to knock them, but one of them is.

them going side to side for 60 seconds. No offense to to that test, but like that’s not really gonna tell me anything when you’re on a six hour ski day skiing a slope that’s 40 degrees and you’re out all day. So it’s not that functional. the other test that I want to see is time on your feet. I look at time on your feet as one of the biggest indicators of in predictability of whether you’re ready to return to sport. Can you be on your feet all day?

Can you be out walking all day? can you can you handle like a 12-hour day or an eight-hour day on your feet with no issues? that’s a big, big predictor of how you’re gonna do in the in the return to sport. And how do you feel after an intense workout and can you be on your feet the rest of the day? So encouraging patients to do workouts in the morning and then continuing on their day, or if they’re gonna go for a hike or

bike or something, do it in the morning and then see if they can what I like to say, live your life normally for the rest of the day. So just looking at different predictors there, in addition to our traditional strength indexes of being in 10 within 10%, you know, when you’re doing a manual like a dynamometer test and force plate testing, we want to see the strength be within 10% of the unaffected leg, 100%. But

Julia Grace Gillen (42:21.174)
I think there needs to be more testing and there’s other indicators that we can use in addition to just our traditional test.

Garrett Salpeter, NeuFit (42:29.827)
That’s awesome. I think there’s a lot of wisdom in there. I really appreciate that. And one of the things that you mentioned is treating this not just as return to play or return to sport, but also as injury prevention that you might do with someone else who hasn’t even just had a surgery. And and so that gets into some content that I know you’re

passionate about in terms of injury prevention and training and preparation for endurance athletes and trail runners. And you yourself are a trail runner. So can you share with us a little bit of your perspective now coming from this injury prevention angle on what runners tend to get wrong when it comes to their preparation for their activity in their sport.

Julia Grace Gillen (43:09.088)
Yes. Yeah. one of the biggest thing with runners, we talk about this all the time in my world, is is feet strength. It’s a a hot, sexy topic, but the foot has to be so strong because that is the first connection when you’re running. And if your arch is not strong and your big toe flexor and your soleus, those are secret weapons. So strengthening your soleus and your big toe flexor.

Are gonna be really, really important for your running and endurance, especially. your soleus is your endurance muscle in your lower leg. For those of you unfamiliar, the soleus lies beneath the gastroc. It means flat fish in Latin. It looks it’s a flat muscle that sits right underneath, and then you have the two heads of the gastroc top. So the three of those tendons come in and form your Achilles tendon, which is the strongest tendon in our body. So people forget and they sleep on the soleus.

When your soleus is the endurance muscle and then the gastrock, which people refer to as the calf, that’s your fast twitch muscle. That’s the one that’s used for, you know, speed and and vertical and and jump. And we need both. And when you’re looking at an endurance runner or which is or a trail runner, somebody who’s going out for more than just a sprint, which let’s be honest, is most of us, you need the endurance training of the soleus.

And your big toe flexor in the arch. So again, that can come into time on your feet, just being able to be on your feet for a long period of time. You know, we look at our endurance runners, you know, people that are I’m training for ultra marathons like 100 miles, north of 50 miles. And if you can go for a long hike, like for a whole day, like eight hours, get a lot of vertical in, you don’t necessarily have to be running for that training.

You just need to get your body comfortable with moving on your feet and being on your feet. It’s a very underrated training tool. It’s extremely important the time on your feet and training the endurance of just standing on our feet. I don’t sit at a desk very often. And so I have a lot of time on my feet, which actually helps me prepare for my running. I’m constantly on my feet. I’m moving around all day long, and I constantly switch up my shoes.

Julia Grace Gillen (45:30.358)
So I actually technically am training every day for my running health. But the lower the lower leg strength training is important and people sleep on that because they’re like, I’m gonna do my squats and my lunges. But we need to look at the lower leg. That’s that’s where a lot of that comes comes comes from, that strength. And a lot of our injuries can be related to like a foot collapse, collapsing in or running on the outside of your feet and not using your big toe and poor sole strength.

And then training plyometrics is the biggest. I tell people all the time that are trying to work on their running, get a jump rope. Get a jump rope back out. It is so small, it is very cheap, and it is one of the best training tools you can do for your running to work on that speed and that quickness and getting up and off your feet. Running is a single leg sport. Single leg jump rope. People forget that too.

running is a single leg sport. You’re not on two feet at once. You are in a flight phase or a single leg stance phase. And if I am testing somebody and they they come into my clinic and they can’t do a single leg squat jump, we have issues with our running. Like that’s you’re not re that’s not you’re not ready. so there’s simple things that I encourage people, if you’re listening to this, to to try a single leg squat jump and see how it looks right versus left.

that’s one of the first things you could do to look at your running form.

Garrett Salpeter, NeuFit (46:55.907)
That’s beautifully said. Great, great wisdom there. And I’m so glad we spoke about that topic for a few minutes. Really good wisdom there. one of the other things I wanna talk about before we wrap up is to hear some of your experience. So I mentioned that we’re very grateful to have you as a part time consultant or member of our team at Newfin. Yeah, she’s definitely a definitely a member of the team. So

Julia Grace Gillen (47:03.081)
Yeah.

Julia Grace Gillen (47:23.638)
Yeah.

Garrett Salpeter, NeuFit (47:24.643)
But you also have your own practice, right? So you’re split so splitting time. And so one of the things that you do is go and do these on-site trainings where you’ll be with the Colorado Avalanche or University of Maryland football or some of these other you know, many, many, many stops that you’ve made. And I’m curious to hear your perspective on what it’s like to train mostly athletic trainers, certainly some physical therapists in there.

Julia Grace Gillen (47:39.031)
Yeah.

Garrett Salpeter, NeuFit (47:52.076)
As we transition into that, I’m also curious what are the biggest differences that stand out to you in terms of the type of care that you may be providing in your clinic, which of course is different than ones that are more reliant on insurance and have fewer visits or less latitude versus then the professional athletes? What what stands out to you in that environment?

Julia Grace Gillen (48:13.536)
Yeah, I’ll answer the the first question first of going to these on sites and being a part of the New Fit team is something I am so grateful for and so passionate about. I am so passionate about the neubie and everything Garrett stands for. It works, it’s amazing, it’s great technology, and being able to be an educator in this space is a huge honor. And I love educating and I love teaching people.

It’s so it fills my cup. It’s truly, I think, one of my passions. I get very excited and very very energetic when I get into these, walk into these athletic training rooms. It’s it’s something I get super pumped for. And I go in and you’re you’re the expert in this topic and you’re you’re able to teach so many other clinicians and then the reach just gets so much bigger, which is something that is so powerful to be able to teach a group of

Of 5, 10, 15, 20 clinicians, and knowing that they’re gonna be able to take this knowledge to so many other patients and athletes is a powerful, powerful feeling and and honor to be able to teach them. It’s the energy is is electric, no pun intended. It’s everyone’s excited about it. You’re teaching someone how to enhance treatment and to treat someone faster and better.

What’s better than that? it’s it’s something that people can tell I’m so passionate about when I come in and teach. And then being a f a full-time clinician really gives you a lot of credibility in that space because you’re working with patients constantly and we’re in that professional athlete and high-level athlete space in Jackson. So having the credibility to speak very firsthand with all these people and then being a resource once you leave, saying, hey, like.

You know, we had this athlete and this happened and I’m gonna try this, this, and this, and they’re on the right track, and you just tweak it a little bit and you add in all these little clinical pearls. It’s it’s really awesome to see other clinicians work so strongly and diligently with their athletes. And it’s something that I knew I always wanted to do. I didn’t know how that would look in a space, honestly, as a PT, because you’re usually patient-facing and you’re trying to teach your patients, but there’s just something that is

Julia Grace Gillen (50:38.292)
unparalleled to teaching other clinicians and being able to stay in touch with them and get random texts and phone calls of what they’re doing with their athletes. And it’s it’s really awesome to see. And it’s one of my my favorite things that I do. And I hope I continue to do that for a very long time. But it’s yeah, it’s really awesome. I mean I before this podcast I just hung up with Central Europe. We work with I work with New Fit clinician

Garrett Salpeter, NeuFit (50:57.027)
So do we. We hope so too.

Julia Grace Gillen (51:06.862)
clinicians in Central Europe and they’re crushing it and they’re doing a lot in the the neurological world and it’s it’s really cool to see the nation that that Garrett and NewFit has built. We’re very close. We’re very supportive to everyone and I that sets us apart significantly. And I am always here to answer any clinical questions that anyone might have with NewFit, whether it’s via email or my work phone. I love it. And I always tell people you’re not going to bother me. I want to

answer these questions and to help. So that’s something that I’m really grateful for and it’s it’s awesome to do. And thank you, G, for that opp opportunity. But the your second question, just the difference between going into, you know, the athletic training rooms of these like NFL teams and pro hockey teams and the MLB teams, very different than going into a clinic that is insurance based. Both super fun and super important.

But the the energy is a little bit different because there’s a little more creativity involved with the the pro teams because they’re not bound by insurance and documentation. So we see their minds, their wheels turn a little bit differently, in terms of what they’re gonna do with the neubie and things that they wanna try with the neubie, which is really cool because you’ll see them doing the craziest training things for their hockey players or athletes. And it’s really cool to see their minds start to turn and

they start to think about the patients that they’re working with and how they’re gonna use the neubie and how they’re gonna implement it. And you know that when they start asking you questions about certain athletes, you know they’re gonna be neubie superstars because they’re already thinking about how to implement it as they just learned it. So that’s really cool. Same thing happens when you’re in a a clinic that’s insurance based as well. They just are thinking about it in a a little bit different of how are we going to bill for this. and usually that’s in the neuro re-education billing standpoint.

And I help people with their billing and how they’re gonna do that insurance-wise, a lot with our consultation with our clinicians in the new fit world. And there is a way to do that based on your state and your practice acts. So we see it’s a different energy, but both really powerful with how they’re gonna help their patients. And these people in insurance, like they’re always thinking, maybe this is my ticket to cash pay treatment. And

Julia Grace Gillen (53:34.049)
Maybe this is my ticket to starting my own practice. I’ve talked to a lot of people that have bought a neubie themselves and gone out on their own, which is something I did. So I’m very passionate about that and not taking business away from any anyone’s like practice, but it is really cool to see the empowerment that clinicians get with the neubie and how they

Turn it into their own niche thing. And there’s so many different things you can do with the neubie, whether it’s vestibular, whether it’s concussions, whether it’s neuromuscular and MS and spinal cord injury or pediatrics or sports ortho. There’s just so many things that we can do with the neubie. It’s almost hard when you get on a phone call and somebody’s like, So tell me if like, how do I use this thing? It’s like, where do you even start? So it’s it’s really cool to see.

Different people, like you’ll go into a clinic that’s insurance based and there’s twenty of them, and they each come up to you during lunch break and they’re like, Okay, well, I work with concussions, so I’m gonna use this for X, Y, Z. And then one of them is vestibular, and then one of them is pelvic health. So it’s really cool to see all these different walks of clinicians using the neubie in so many different ways. It’s almost overwhelming.

Garrett Salpeter, NeuFit (54:58.063)
That’s awesome. And I I love hearing you describe that. And ultimately, some people may hear that and think, what are you trying to be everything to everybody? But everyone has a nervous system. And whether you’re dealing with pelvic health or some neurodegenerative condition or a post-op ACL, the nervous system is relevant to their current state of function, to whether they’re experiencing pain, to how they’re going to adapt and improve and heal or not.

So it it is ultimately when you’re working with the nervous system, there’s a great opportunity to help people in a whole range of scenarios.

Julia Grace Gillen (55:32.288)
Yes, exactly. It all comes down to that nervous system.

Garrett Salpeter, NeuFit (55:36.6)
Yeah, yeah. So when people ask who who is it good for? I sometimes say, Well, people with a nervous system. it’s half half joking, but all all good jokes have at least some truth in them too. So as as we wind down here, JG, what are the best places for people to to follow along to see your content?

Julia Grace Gillen (55:43.406)
That’s a great answer. I I might need to change my answer. That question stumps me, honestly.

Julia Grace Gillen (55:57.26)
Absolutely.

Garrett Salpeter, NeuFit (56:04.227)
JG the PT website, Instagram, where where do you want people to to go if they want to see you in action?

Julia Grace Gillen (56:07.882)
Yeah. See me in action. The best place is on my Instagram, JG the PT, and I collab a lot with the New Fit Instagram, which is great. You’ll see me on there a lot. I try and post things that I’m doing in the clinic to help our clinicians and I’ll post an exercise that I’m doing with the frequency settings, with the intensity settings. I’m trying to do that a lot more to help people out and give them ideas.

you can always find me on the NewFit website with my NewFit email. Please shoot me a text if you have any clinical questions that I can answer for the NewFit users. and then you’ll probably get my my work calendar for a for a Zoom meet or my work cell for for a call. But I have clinicians that text me pictures of pad placements and they’re like, is this right? Is this what I’m doing? Is this great? And it’s nice to

have quick access to to some of that and give them a nice little thumbs up. or that’s awesome. And then I when people share their client wins, it’s even, it’s even better. So you can find me on Instagram and my new fit email and wherever G is somewhere out in the world. We’re not close behind. We’re close behind.

Garrett Salpeter, NeuFit (57:23.567)
Awesome. Awesome. So I have one final question I like to ask all of our guests. And I’ll give you two options. So the first first is if you have any message you could shout from a rooftop or mountaintop for everyone to hear or put on a billboard for everyone to see what that message would be. It could it could be you could choose to a message to everybody or you could choose a more narrow message to that you would share with someone who’s going to have an orthopedic surgery.

So you can you can you can you can choose which message you’d like to give.

Julia Grace Gillen (57:55.48)
Or choose.

I’m gonna choose the latter and I’m gonna say to anyone having an orthopedic surgery, find a PT with a neubie. One, do your prehab with the neubie and get on the neubie post op as quickly as you can. As quickly as you can.

Garrett Salpeter, NeuFit (58:16.111)
All right.

JG just came down from the mountaintops with those words written on a tablet. So we we got those words from from on high. Very good. JG, thank you so much for joining us. And it’s a tremendous honor to be able to to have you as a as a part of our team. I appreciate you working it in among your patients and all the other things you have going on. It’s a it’s a tremendous honor. We’re grateful to have you. And thanks for coming on the show and sharing your wisdom and experience.

Julia Grace Gillen (58:22.71)
Yes.

Julia Grace Gillen (58:26.721)
Awesome.

Julia Grace Gillen (58:45.6)
Yeah, thanks for having me, guys. I’m so excited to finally be on the podcast and to share some wisdom. Thanks for having me.

Garrett Salpeter, NeuFit (58:52.643)
Thank you. Yes, that was an absolute pleasure. And thank you, Newfound Nation, for tuning into this episode. We look forward to seeing you on the next episode of the Undercurrent Podcast. Goodbye for now.