Episode 6: PAIN with Greg Lehman

Today, guys, I'm back with another installment of "On the Shoulders of Giants," where I, Jarrett, have interesting conversations with interesting people. Today, I'm really excited and privileged to bring you a conversation I had with Greg Lehman.

Greg Lehman really needs no introduction. He's the Canadian physiotherapist and chiropractor who has been the voice of a generation, I feel, in terms of many new graduates, videos, and Kairos coming out in the past 15 to 20 years. He's often controversial but always very articulate in his views, and he's someone I look to for inspiration all the time.

We had a varied conversation. The object of our discussion was to talk about pain and his interpretation of it, how he communicates to patients regarding pain. But then we veered off and talked about a bunch of other things in terms of graded exposure, loading capacity, and all of these things.

I really hope you enjoy today's discussion, and without further ado, I bring to you Greg Lehman.

Okay, here we are with Greg Lehman. We were just chatting a moment ago, and I think Greg has been the voice of a generation. It might sound a bit crude talking to you, but I really think that. I'm 33, 34 years old, and I think that Greg has been the voice of us as we've gone through university over the last 10 years or so. So I want to thank you for that, Greg, and I also want to introduce you as well. Thanks for coming on to chat with me.

Yeah, thank you. Looking forward to it.

No problem. You're quite interesting in your background. You've had, as far as I'm aware, training in chiropractic and also physiotherapy, and you've also done some post-grad or master's work in biomechanics, is that right?

Yeah, I did that first before the chiropractic physio.

Cool. Okay, so I think that puts you in a really unique position to have a very interesting voice on pain because you've seemingly got both sides of the coin covered in terms of biomechanics. I know you're quite an advocate of the biopsychosocial approach to pain as well.

Could you just sort of speak to how your interpretation of pain started when you were doing your studies in biomechanics and all of that, and then we can sort of come to how it's evolved over the past 10, 15, 20 years?

It's actually funny; it hasn't evolved much. I didn't have to go through any cosmic shifts like other people did. I was actually introduced to the multi-dimensional nature of pain 20 years ago. When I was in my undergrad, just in kinesiology, I was reading John Sarno. I was reading about how posture influenced mood. I even asked to do my thesis on it, and that wasn't allowed. That was weird, but I wrote a paper on it during my master's in an ergonomics course. I wrote a paper about where the pain was coming from. That was in 1997, and I wrote about central sensitization. I got into more nociception, you know, like the pain fibers. I was a little bit wrong there, but we still talked about how it's influenced by a number of factors.

The professors at the University of Waterloo at the time—my supervisor was at McGill, but his supervisor decades before was Bob Norman, who was an occupational biomechanist. He and they would go in and try to prevent injuries at a workplace, but they always talked about the psychosocial factors being a big driver of pain. One of my first papers was on spinal manipulation, and in it, we talked about how spinal manipulation might influence central sensitization.

Honestly, I was pretty lucky. I would just go through bouts in my career where I probably, like, not necessarily overemphasized the biomechanics because I still think they're important, but I got it wrong in how biomechanics was important. So those are the shifts I've had, but I never had to change my view on how pain was multi-dimensional.

That's fascinating, in contrast to probably a lot of people's experience over the last 10 to 15 years. Certainly in my training, psychosocial factors were worked on in the last paragraph, essentially, of a case study. You looked at everything; it was about tissue irritability, strength testing, range of motion testing, all of these things. Then, potentially, if that didn't explain it, you looked at some other factors.

So I'm fascinated that despite your heavy biomechanics training, you were exposed to that quite early. Why do you think that hasn't potentially gathered more momentum over the last 10 years?

That's always been my disappointment. I would give lectures decades ago—gosh, even in the year 2000, that's when I started lecturing. I was quite young, and I was a student at the chiropractic college, but I was lecturing in the grad department just the way it was set up. I always found that all these biomechanical ideas could be challenged by biomechanics, and people would hold on.

People would say, "No, it doesn't work that way. The SI joint is not out of position. C3 is not stuck on C4. There's no adhesions. There's no scar tissue. That's not why you have pain." You know, this is Active Release Technique jargon that we did here in chiropractic college. I'm like, "None of these make sense."

People get pissed because we were like, "Well, what the hell do we do then?" There was like a vacuum. Alright, there's like, "Well, if none of these things are really valid, then how do I practice?" That's why I think people held on, because they had to do something, and they were also helping people. So their explanations might be faulty reasoning, but they still helped people.

So that's why I think there hasn't been a massive impetus to change. I would also say it's not like biopsychosocial-informed interventions are dramatically outperforming ultrasound or back cracking or whatever in studies. That's going to hold people back too.

Yeah, that's a great point because the effect size is pretty small for exercise, similar to manual therapy and everything else. So despite the fact that it may be more accurate from a scientific perspective, results-wise, it's not a slam dunk.

It always disappoints me. Evidence-based practitioners are so quick to, like, shit on things, and then they say, "Do this instead." I'm like, "Where's the evidence for that?" There's a nice clinical review on patellofemoral pain, and they say, "Don't do ultrasound." You know, there's no evidence for it.

What they mean is when you look at the ultrasound trials, they have a sham group. So both groups for knee pain, if they get ultrasound and one sham and one real, they'll have decreases in pain, like 30 to 50 percent. But the real ultrasound doesn't outperform the sham. So then they conclude, "Oh, it's all sham and placebo."

But then they'll say, "Do exercise or change movement patterns," or "Do gait retraining." Then you go look at those studies, and they recommend those things, but those studies never have a sham group, right? They never have a good control group.

Although those are the things that I do, and I don't do ultrasound, I'm not defending it. I'm sort of questioning our thinking here. It's only because we can only recommend exercise or gait retraining because the studies aren't as well controlled.

Yeah, I mean, maybe they will outperform a sham, but who knows? This is pure cognitive dissonance, isn't it? When you can believe two opposing things, and it's well on that. There's a paper that just came out a week or two ago, and I'm into shoulders on exercise versus placebo or sort of non-exercise intervention.

Really, a systematic review for rotator cuff tendinopathy, and the result was pretty startling for an exercise advocate. It's a clinically insignificant superior benefit for exercise versus non-exercise. I also see both three or four papers in view to be included in the systematic review, so more work to be done, but interesting.

I know, I hate it because I'm like you. That's my bias—gait retraining, exercise, you know, cognitive restructuring. Often, it's not better, but you do—I mean, whatever one says. You know, we all say, "Well, there may be a subset."

Yeah, I just think that speaks more to individuals being different at different times, and it's really hard to scientifically capture all of that in these reviews. I'm not saying we shouldn't study it and be rigorous scientifically; I just think it's always going to be a similar outcome with these studies because everybody is different.

Yeah, that's—I mean, and it's difficult because people have been trying to subgroup for twenty years and doing classification, and those often don't outperform because you can't have subgroups. You can, but everyone's a subgroup of one.

That could be tested. You could test tailored treatment to non-tailored, but I actually believe—and that might piss people off—but there are general things that all of us could recommend to our patients, and we're going to help out a massive number of people.

Why I think therapists don't like it is because we want to think that we're mechanics and we're diagnosing, diagnosing, and we've figured out exactly what to do for this person. General things are less sexy; it's simpler. But I think general good interventions can help a lot, but people hate that.

Yeah, well, and then the nonspecific kind of exercise really speaks to that in terms of the literature as well, doesn't it? It all works, and this is the non-superiority over different exercise interventions, it seems, for a lot of conditions. Some people don't like that as well, and I can understand that.

Also, as it's videos, we want to use our intellectual faculties, our training in movement analysis, and all of these things, right? We want to have this huge effect, but pragmatically, probably as long as we're recommending a couple of different things, we actually don't ever think that sleep—all these thoughts of things—are going to be helping people mainly from that perspective. What do you think?

No, that's what I'm saying. I think there's a small subset of people who we do need to tailor it to. Like, we start my course—my favorite thing in my course—my favorite thing I love this question. It says, "When do we need to be specific?"

That's how we start in my course. If it was 20 years ago and you were a Mulligan practitioner, you'd be like, "Oh, a lot. You need to—if you know C3 is not moving on C4 in this direction, you need to be very specific in your line of drive."

If it's elbow pain, you have to specifically glide the radius laterally. You know, now, no, no, no. You get symptom-defined. But I still think there's probably times where if we could find out principles of when you need specificity.

So here's an example. Everyone's listening, "Alright, what the hell do you mean?" It would be something like if someone tears their ACL or someone has kneecap-related pain, there's a subset of people who will unconsciously protect that knee, and that knee becomes unloaded.

If you do a squat and you look at them, they'll look symmetrical, but they're not loading the pain door, the reconstructed knee, the same amount. There's less stress on it, and you can't see it, right? So they're protecting that knee.

So that person, you know, wants to get back to sport, so high demands. They're able to somehow modify their moving patterns to keep protecting it, so they'll never—you could argue they'll never get enough of a stimulus during the activity, the goal, like running or squatting, to challenge that knee to catalyze it to make it stronger.

It'll always have that deficit. Now, most people, that's fine if they're not going back to a high-demand sport, but the person who has to go to the high demands, they probably need specific kneecap quadriceps strengthening that won't just come from running or playing the sport or whatever, like tumbling or gymnastics.

They'll need that specific exercise because they might get into the situation where they can't compensate, and that weakness will show up, and you actually need strength in that specific situation, and then they get every injury.

So there's like a small subset, and that's probably why—and that might only be 4 percent of people, where the vast majority of people will get lots of benefits from general stuff, but that 4 percent, 5 percent, I don't know, 8 percent, they need it, and then that'll lead to re-injury.

So that wouldn't show up in a research paper, but there's like the clinical reasoning. I know I think you'd be really sorry I'm talking too much.

A real cool research paper to find out what are those cases. Alright, so psychosocially, you might say like we know that pain science education in general doesn't help, but there might be a subset of people where if you don't change that unhelpful belief, like that they have a rotator cuff tear, and that means they have to protect it, and then they'll just stop doing, and they'll never get better unless they actually start to use their shoulder.

But they'll never use their shoulder unless you convince them that they're safe. So you need, you know, pain science. It's like you need to change a cognition. So there might be like specific cases like that. I don't know if research can ever go into that, but I like the thought process.

Yeah, well, kind of a little bit. They're improving in the shoulder with the importance of expectations and self-efficacy and all this sort of stuff where, you know, we can maybe improve expectation via adequate and appropriate advice and education.

I totally agree with what you've painted there as a conceptual anyway in terms of biomechanics for sure matters, and low tolerance and capacity and all these things that matter for a subset of people. The argument should never be that it doesn't matter; it matters for certain people at certain times.

But for the vast majority, where pain and function and just getting back into activities of daily living or something like that, it may not matter. And if we can still pursue it, we can still pursue it.

This is really key, and something that I'm researching a little bit at the moment is when we look at all the trials with shoulder pain, for example, actually, people don't get stronger in the intervention in randomized controlled trials, but their pain and function dramatically improve.

So what's the application of load or exercise doing? They're doing something else.

Yeah, that's my other favorite question is like how does exercise actually mediate recovery? You know, when does the strength matter? I think strength, for the most part, is just a byproduct. It's an epiphenomenon. It's a side effect that doesn't drive the most clinical improvements; it just happens if it does happen, and it's secondary.

Yeah, I'm not—but strength training in and of itself is helpful. You just don't need to get stronger. Strength is emergence, much like consciousness and all of these things potentially when you undergo a rehabilitation regime.

Yeah, yeah. No, I was just going to say that some people, again, don't like that because our history is find a weakness and impairment, correct it, and they get better. And so they argue, "Oh, you need to build hip strength," and I would say you don't need to be weak to benefit from hip strength training if you have low back pain or knee pain, right?

The pain is the reason to do the hip strength training.

Mmm, like we all want to be, you know, like mechanics where we plug that thing into the car and find out exactly what's wrong with that, but it's too complicated. It's like we're trying to create a tornado, and I don't know how—again, I know that's just complex.

Let's take a butterfly somewhere. I don't know. What's that? That's more of what we do, I think.

I don't want to get into chaos theory, but I know what sticks will stick to pain because we can keep talking for hours on this, I imagine.

Oh, what a—so is what we've started out that potentially you've always been woke, as it were, into the multi-dimensional nature of pain. So can you, for everybody out there, potentially what is your current interpretation of pain? Do you define it in a certain way? Do you have a model that you kind of defer to?

I know it's semantics with definitions are pretty frustrating, but what's your take on it?

No, I'm a simpleton. I don't like all the discussions that people have. I don't know. I don't think it helps anything. Like, so if someone says they hurt, that's all I need to know is that something hurts there. That's pain, and it's bothering them.

What about in your head, though?

Oh, that's it. Yeah. Oh, handbook on Greg. So surely you've got some info.

So I'd like, in terms of definition, but in terms of what I can tend to focus on is just solutions. That's what I'm more into. Alright, what's—and the only reason I want to understand, like, I would recommend people understand pain or go into the details of what drives pain and sensitivity is that it often helps people make better choices.

As soon as people can realize pain is more than just their knee caving in when they walk or when they squat, like, and that, no, you're safe to start walking again. Who cares if your knee caves in? Like, that's a huge messaging.

So my messaging is really simple in a book. It's like pain is more about sensitivity than damage. You can have all these things that are messed up with you, and none of them have to change to get better. Like, I think you can spin the complexity of pain, which is like, "Look at all these things that can affect and influence pain," and be like, "Oh no, I messed up. I have all these things wrong with me."

But the optimistic spin is like, "Look at all these things that can influence pain." So that means I have lots of options on how to get better. So that's how I tend to look at pain—more pragmatically rather than academic discussions.

Yeah, for sure. How would you describe it to other clinicians, for example, or up-and-coming new graduates who potentially have just been exposed to a nociceptive model of pain? Is there a simple way in which you could sort of get them to shift their understanding of it?

Sure, I'd be like, "Think of a cake that you had recently and ask them what's your favorite ingredient in that cake." Like, what—you know what I mean? You can't taste the sugar or the flour or the egg, but they all went in there. And that's sort of how pain works. You have all of these factors that influence it, and then it's like you said, it emerges. It's greater than the sum of its parts, right?

And it's a homogeneous kind of mixture that is inseparable. All its constituent components are separable from each other.

Yeah, yeah. Or you can look at it like a chemical equation if that's their background. Like, pain is multifactorial. It doesn't mean it's additive. You know, it's just like a dad, and boom, suddenly there's pain. You can have one little change, and you can have a massive, massive change in the pain that we have.

So it's, you know, it's exponential sometimes, right? You just—you don't sleep well, you're stressed about something, you run a little bit more than usual, and just boom, you're set off. And then we get into a cycle.

I guess I do use the word overprotection when it comes to pain protection. When we seem to keep having pain, I like to view it as like you're helping yourself too much.

Yeah, no, I think—I think I got a little sentence from your handbook just—I was looking through it before. It's, "Pain prompts action," sort of. It stimulates the person who experiences it to do something.

Could you?

Yeah, so that—I mean, that's a largely David Butler thing, but I'm sure other—actually, maybe I didn't hear it from them because I actually was only introduced to Laura Mosley like ten years ago. I didn't know his stuff before. I'm kind of embarrassed about that. He wasn't one of my original teachers.

But that's more of their idea. Pain is an alarm that wants to get you to do something, right? And the problem with alarms is, you know, they can't tell you how big the fire is. They can't tell you if there is a fire. They can't tell you how much smoke. It's just triggered.

And then the other issue with alarms or with pain is after a while, whatever the initial cause was, that can be gone, and the alarm's just going off. So, and then when it comes to alarms or like the protection idea, they can be more easily triggered. We just become more sensitive.

That's—and that's what sucks. There's not a lot of wisdom in a lot of alarms. Sometimes it's absolutely accurate, but sometimes it's not.

Yeah, Lerman's been a big influence in my career, and all Australian videos, obviously. And we sort of grew up with his model. And it's interesting too; there is some work out there actually looking at pain as an alarm and prompt protective action and safety-seeking behavior, you know, and all these sorts of things.

You sort of explained it quite nicely in your handbook where—and I don't know if it's exactly what you say, but the argument is that pain is an alarm, and from an evolutionary perspective, it's going to go off more often than it should because the cost of not going off at all would be catastrophic for the organism, right?

So it'll go off to alert you to something, and then we can cognitively rephrase it. But that alarm going off doesn't always mean that there's something sinister or pathological going on.

Yeah, and I would even run with that more because that seems illogical to a lot of people with pain. I would say that's the default for a lot of human function is that we overdo these protective responses.

So again, like my third favorite thing in my course—no, it's my third. My third most favorite thing—it's my favorite one—is it's really fun to have people say, "Okay, think of all the times where you overprotect," and then people can't think of any.

Then you start pulling them out, and it's amazing how many times the body isn't that wise. Like anxiety is a great example. When people have like a panic attack, it's normal to have anxiety. You should be worried about a number of things, but we overdo it.

If you break a bone, you normally produce more bone. You get hit in the quad with a baseball; some of us will have myositis ossificans, right? It's both over-healing scar tissue or like keloids when you get burns. You know, we all like autoimmune disease. It's like we want to have an immune system, but sometimes we overdo shit, right?

That's the problem. So it's not weird that we overdo pain if you actually frame it in that model. And then you can start finding out all of these examples where we are overdoing, like, shit. That's just what humans do.

Yeah, that kind of gets to a whole other—perhaps persistent pain and whatever you want to call it is a simple epiphenomenon or byproduct of the human pain experience. And whether we can actually truly change it manifestly in society at large scale, I don't know.

Is that something that is worthy? Of course it's worthy, but is it realistic?

I think what you're asking there is maybe like how much do our beliefs really drive this overprotective response? I think that they do in some people, but I think there's a lot of people—if you told them that they had scar tissue and they have faulty bonding, can you set all the negative things to them, and their x-rays were horrible, they'd still do fine.

But I think there's a subset of people who really respond negatively to what they've been told. So I don't know if that would be like the best use of money of public funds.

Yeah, it just—there's some people who have proven as conceptual, and in some work on it, who have just this phenotype that is when something happens at some point, there's a nociceptive event or a pain event or something that all of these factors that are intrinsic to them as human beings will cause pain to stick around longer than somebody else who has a different thing.

So I am sort of cautious and a little bit cynical on how much we can materially change somebody's pain apart from that perspective. And there's not much work done on how we can change expectations or self-efficacy or all these thoughts of things. We know they predict outcomes, but can we change that expectation to change in our—that's not really been studied, as far as I'm aware.

No, I've read some negative stuff about changing self-efficacy where it's hard to read. Very hard to change in some people.

Yeah, so I'm not sure. I'm not sure if you can change other things that would help you cope with low self-efficacy, but I don't know. That's one of the things. The only thing I do think about with people like that—yes, some people are definitely more predisposed to pain, but there was a time in their life when they didn't have pain.

So that always gives me some hope, you know? And they probably had these same traits of low self-efficacy or whatever. So what was it that changed? Like, how can we get them back to the way they were before when they were doing okay?

Yeah, that's a great way to look at it. I tend to say that if somebody's come in, the pain has just gotten stuck for a period of time, and it's an alarm, to use your analogy, and others, that it's just going off.

And maybe we can diminish the sound by a decibel or two, and so ultimately it goes away to a manageable level where you can recover to meaningful activity. That's how I look at it.

Yeah, I like it too. And that's why, I mean, if I were to take another course, I'd be interested in taking like the ACT courses on pain—the acceptance and commitment. That's that idea where you can cope with these things.

Like using the anxiety model, it's really unfair to someone who has anxiety to say, "We're just going to get rid of all your anxiety." That's not happening. It's how you cope with those thoughts.

You know, like my middle daughter has that stuff where she'll just have these thoughts that really get in the way. Like she—yeah, last night she said, "When I have a shower, I have to make sure I have this thought where I have to make sure I get water in my eyes because then if I don't, I won't go to sleep, then I'll die."

Alright, buddy, so what are you going to do with that? And so she has these all the time. She was really upset. It was her older sister's birthday the other day, and she came in. She's like, "I have—it's the end of the night. They sleep in the same bed."

And she's like, "Can I—I told Violet happy birthday properly?" I'm like, "You told her." "Oh yeah, but I don't know if I did it right. Now I keep feeling like I have to tell her happy birthday."

Well, how many times have you done it in the past hours? Like ten times. "But I'm not sure I'm doing it right."

So yeah, so anyway, I like things like that. We're not going to cure her of this, right? That's her trait since she's like a little kid, right?

So it's coping and managing with that, and that's the idea, I think, sometimes with pain. You can have pain, but you can help with the suffering and the disability would be the idea.

I think we could learn a lot as physios from the anxiety model because then I think often you do a mechanical intervention, like you do physio stuff. You just have like a process of maybe prescribing exercises, their movements, and explaining it.

That kind of uses this anxiety model. I think that's where we can evolve and get better, including me.

That's really well articulated, and that is a really important point. So let's, if we can, maybe have a bit of a practical example. Say you're interested in running, I think.

So knee pain—somebody comes in, they've got anterior knee pain. It's developed over a period of weeks, months, on the background of increasing activities or training. There's a bunch of other risk factors there.

So potentially, there are some underlying depressive or anxiety symptoms. There might be some sleeping issues. There might be some weight issues. They might not be doing any strength conditioning.

I know I'm making this quite difficult, so where would you start there?

Oh yeah, so I mean, I work with all kinds of runners, and some are ridiculous, like running 200 kilometers per week and stuff like that and fast marathons. But I always start with ruling out sinister pathology. That's always number one. Be a good clinician first.

And with a runner, especially a female, you want to rule out stress fractures. Those are the things that worry me. And then even that stratify it. Like, you don't like a femoral neck fracture is more concerning than a fibula stress fracture.

So if you have any suspicion, then you've got to say, "We've got to shut it down" or something like that. So that's the first step there. It's like make sure it's just a pain injury or whatever sensitivity problem.

And then you're like, "Okay, well, how—again, I'm crude here—but how can we calm stuff down and build that person back up?" Right?

And they are—you’re trying to think like, "What are all the sensitizers in their life that we could change right now? What are the ones where we just acknowledge that might help them understand their pain?"

And then often, pragmatically, you're usually changing something about their training. That's usually the first thing. Change something. Maybe we drop a speed session for two weeks. Maybe instead of just—if they're running a lot more than usual, we would say, "Let's try running twice a day instead of one long session in the morning."

You're just trying to play with their training and the stressors. And then again, look at all the other stressors. If they're building a house and they're renovating it, then they probably can't always train through that. Yet something has to change.

They like give them some, yeah, permission sort of to be flexible. So I look at the big things like that first, and then you might start talking about adding a little bit of strength training or something like that.

But usually, it's changing the stressors on them in the big areas.

So could you walk away from a consultation like that, and even though you see them a few times over a period of weeks or months, you could just simply modify a variable in their training program or in their lifestyle without implementing a strength and conditioning regime?

I mean, so though I practice very comprehensively because I understand that I don't know it has to be done. So usually, everyone gets three exercises because that's what they can do.

But I would always wonder, do I even need those things? That's the question. So like it—because often the athletes I'm working with have worked with a coach, so I know they've already been managed well in the load management area.

So that's why I'm probably giving more exercise. But some people who aren't working with a coach and they don't do a lot of mileage or they're just building up their mileage, then I think it's more of a mileage-load thing.

But honestly, the past five athletes in the past two weeks or so—very elite runners—they've already pulled back all their mileage, and they all have tendon problems.

So when we talk about when you have to be specific, that's where I'm giving exercises, and I'm just loading them up.

Yeah, because that might—the concept there is we can't—you've already changed the loads. Well, and you should be able to adapt for them, but you're not. So how about we build up a tolerance to increase your ability to adapt?

Or how about we, you know, cause some adaptation so that you can tolerate the running stressors? That's the mindset.

Oh yeah, cool. So if the modification of a variable doesn't seem like it's doing something or it's already been done or somebody else's attempts to play with it, then you can try and change their capacity or change their system to help build it up to match the demand they want to put through it.

Now, yeah, I just don't use the word capacity. I mean, I would have used it 15 years ago. That's an old thought, although it's very popular now. I just think it's missing something.

I think it's not capacity. Like exercise, that assumes that we know the mechanism of what exercise is doing.

Now, if it's building capacity or just changing sensitivity, something. So the way the capacity for my—which Jill Cook and all that sort of talked about—is it's just doing something without aggravating symptoms or injury.

And I think it's meant to just be broad. I like it. I don't care. I think it's better than using strength, which is often what's used around. You know, you've got to feel strength in your shoulder.

I think that—I think a patient can commission quite quickly, and especially strong people who come in. I get a lot of bodybuilders and heavy lifters coming in. Last night, I can bench 200 kilos. What are you talking about?

So it's different from that perspective, I think.

Yeah, you know, if it's used generically, like I use the term comprehensive capacity, and I need it as generic as they can get, you can get. I think it's not specific at all.

So I just started using—when people talk about load, I think it seems a little too physical anyway.

That's, yeah, loads now. The interesting one when you talk about load, and I think it's really helpful to define all these terms, especially for young guys as well—load, resilience, capacity, tolerance—all of these things.

Somebody really knows what they mean. When you talk about load, you've got to kind of separate external load and internal load.

And the internal load is the thing that I think is always forgotten about, which is the response to an external demand. And you can't have one without the other.

No, and so the pragmatic, again, what are we doing? Are we changing life's loads? Are we changing our response? You know, and you can use that, I think, at a more mechanistic level.

Like there's an argument we always have—nociception. We always have that tissue irritation, but it's what we do with that that leads to pain. So that might be what happens with tendinopathy.

We don't actually change the capacity of the tendon. There's always—there's some things change in the tendon. There's nociception, but exercise might change our response to that nociception at the spinal cord, at the level of the brain.

And that's why I'm so—like Jill Cook is so adamant, like you need to build the tendon and the whole system to tolerate that. And like, don't never stretch, and manual therapy sucks, and that it—like you can only be so certain when you know the mechanism of what's happening, and we don't.

So I can't throw any treatment under the bus so readily, right? I bet there's a massive number of people with tendinosis and tendinopathy who will respond better to manual therapy than they will to a graduated loading program because there's nothing wrong with the quality of their tendon or their muscles.

There's some just goddamn sensitivity issue, alright? That's what—because if we know people can have tendinosis and have pain, then why do I need to build up the tendon around it?

How do I know it's not just a nervous system thing?

Yeah, so I can't—I just can't throw shade. I can't be so, like—and I was before a little too strident and like, "That's bullshit."

And I think that once you understand the complexity of pain, then you should be open to how other things could be helpful or at least be open to knowing that you don't know everything.

That is—I totally agree. It's, again, it's cognitive dissonance. If you're going to say pain is complicated for that sake, but this is how you have to do it, yeah, they don't agree with each other.

It's, I think in fairness to Jill, some of her students, so every REO and Shawn, they've published on what the local effects of loading in capacity and then the system or organism capacity kind of issue as well.

Because then it's—they look at the tendon capacity, and then I look at the sensitivity or general person's level as well. So some of her students have gone on to also—there, but all of them are great. She's fantastic. She's pushed the needle the right way.

I'm just like hesitant when people are so like, "Seven things not to do." And then we all pretend we're evidence-based, and you're like, "Where's the research?"

Like I was like, "Don't stretch your ITB or stretch your Achilles," and you're like, "Where is the study that compares a stretching protocol with a loading protocol?" It doesn't exist.

Like if you want—you know, there's a few papers where they just stretch the Achilles, and people get better. I mean, even—I always forget his name. He's down there by you. He's an interesting person to talk to.

He did an Achilles—he's a sports medicine doctor, and a decade ago, he did an Achilles loading program that was stretching in it. He held it like it was stretching-based. It was an eccentric loading, but they were doing higher than 15 reps and then holding it for 30 seconds.

He's getting comparable results to everybody else. What the hell? He's a sports med doctor.

Yeah, he always argues with Jill Cook. It's hilarious.

Oh, that's interesting. I used to be in the UK, and I did a bit of work with some Alfredson.

Okay, the eccentric guy. And that was a fascinating conversation because he clearly is still into eccentric loading, and then he does a lot of this debridement surgery now with very good outcomes.

Now, this—he honestly—and this might be too much, but he has like a 95 percent success rate in terms of Achilles debridement surgery.

So, you know, that speaks to an element of adhesions or whatever you want to talk about between the pair, tendon and tendon.

So it's not a slam dunk with loading and tendinopathy.

Well, look at—so people say, "Oh, stretching's useless," or "Endurance exercises are useless because it won't change the stiffness of the Achilles tendon."

The Achilles tendon, you know, has to undergo, you know, four and a half percent strain to adapt. That's about 70 percent max exercise, which is, you know, twelve reps.

So you have to train heavy, and yet the Alfredson eccentric program is fifteen reps. It's about sixty-three percent of your max, and it's comparable to doing heavy resistance training.

So the most famous program that seems to help lots of people that won't even change the tendon quality.

So how important is building up the tendon quality when someone has tendinopathy?

If doing it—or like hopping—hopping is great, of course. I would have all my patients with Achilles tendinopathy get into hopping if they need to.

But at the same time, I know that hopping is not going to change the quality of the tendon. It's not consistently. It'll do something else.

So then what's driving your treatment? You're just—what I think you're saying is, "What does this person have to do? Okay, let's do that."

Oh yeah, yeah, I know, right? When you can talk about all this stuff, and then you're like, "Ah, do what you want to do."

But back it up a fraction, back it off, and then like—or you break it down and just do—you do more in the gym than what you're going to do outside.

So the gym prepares you, so what's outside is easy. That's the simple way to look at it.

Yourself, a buffer for the real world, right?

Yeah, capacity here, capacity—sorry, I know you don't like that term.

And then your requirements here, right? Give yourself a bit of leeway.

I think I don't like it because it's too much like me. It's like I would say it, and then I just—something has changed in me where I'm like, "There's something wrong about that."

I'm tired of hearing it all the time. I can't quite put my finger on it yet, but I don't know because everybody else is using it.

That great—I think it's like a lot to be contrary, honestly. Like the capacity model where people always quote Scott Dye from like, "Mmm, that bullshit."

That was Stu McGill in 1996—the same thing. He's like, "Here's the loads. Here's your tolerance. Just don't have the load go above your tolerance."

And everyone quotes that guy. That was 25 years ago at the end of a loafer function.

Yeah, I can't believe it.

Ricci is so simple. Everyone loves it. Like it was preceded by so many other people, yet that's the one that gets popular.

Isn't that funny? It's the same thing with progressive loading, right? And acute chronic workload ratios and all these sorts of things.

Get me started.

Yeah, that's funny because that's starting to be quite challenged now by an Australian guy, Franco.

Oh, sorry. Anyway, so what?

No, I've talked a lot about that with Franco. He always direct messages me because he knows that I'm an ally.

Well, what we have an issue with is we don't question the concept of which is don't do too much too soon.

No shit! We've been saying that. That's what has always bugged me about the acute to chronic workload ratio.

Like there's nothing new in it. You just reframed it differently. What got popular was that you could actually predict and say there's a certain amount that you have to stay under. There's a certain envelope.

Yeah, and that's what Franco said. No, there's not. That research hasn't been shown.

So the research really hasn't helped anyone beyond just saying don't do too much too soon. Another way, it's not actionable yet. The concept seems great, but right now pragmatically, whatever.

Yeah, arguably, I did—I do think it brought it to sort of mainstream attention, and now you've got LeBron James doing load management, which is insane to me that it had to happen.

Like I guess I've just worked with running coaches for twenty years or actually hockey coaches and basketball coaches because I used to be a strength coach, and they all thought of that stuff.

I always thought that coaches were the first biopsychosocials, right? If you're working with high school kids or college kids, and you hear that one guy's going through a breakup or a stressful time with school, good coaches back the training off or they figure out a way for him or her to adapt.

Like I wrote an article years ago saying that was my thesis—that coaches were the first biopsychosocials, at least good ones were.

Yeah, and that is—that's a really good way to round up this conversation, I think. That's what we should be, right? We should be a coach. We're coaching somebody back to health, and so we need to consider the full aspect of the human condition, which is a nightmare sometimes.

It's not what we're trained for, and that is my biggest bugbear because I was so awkward discussing many—didn't even ask the question if there's something going on in your life because I don't know what to do with the answer.

But I think that's something we should be much more comfortable in discussing, even if we're not going to intervene and treat, which we should not that aspect than we referral.

Yeah, comment.

Alright, just to finish off, we've covered a lot of territory, which is what I knew I was getting into when I was going to chat to you. So hopefully, people get evaluated.

So what do you like to do for a bit of fun, Greg? I see you on Instagram doing some tumbling around and you've got a young family. So what's meaningful for you?

I do like trampoline right now. I rock climb.

What's that? What got you into the trampoline and tumbling?

So when I was a teenager, I just—I taught trampoline, but at like a really low level. I picked it up when I was older. I couldn't do anything. And then my girl started cheerleading, so I used to go in their classes for tumbling.

I was three years ago, and then I just started going on my own. When the gyms are open, I'd go two or three times a week. We have a trampoline in our backyard there at a tumble track. It's like a bouncy thing to tumble on.

Yeah, let's say, how's it going? You get any better?

Nobody, don't. I mean, there'll be more stuff on the trampoline. I can tumble on the ground. It's hard. Like you have to—in order to get better, you have to put in the work, but it's so much work. It's beyond what I can tolerate.

So I was pretty achy when I was trying to do stuff on the ground, so it's a trade-off there. That's hard.

Yeah, and if we're trampoline, I could be able to do it. Like I just did a double backflip before COVID. That was huge.

So you can do that stuff. You can progress that. You can do that until you're 80. That's ultimate.

And any injuries out of it so far? Anything—any acute chronic workload issues?

There was like two years ago, knock on wood, when I was trying to get like back handspring, some backflips on the floor. I had trained so much, so I risked being sore for a long time. They still are, but because I was doing four to five days a week, but I had to do that or I wouldn't get better.

So, and I knew that, so it was just a trade-off.

Isn't that funny? Trying to listen—I can't listen to my own advice when I'm doing—I like to do some weights, and I like to surf. And then when the surf's good, I go out for three hours because it's pumping, and I haven't surfed in three weeks.

I somewhat—but you can't not. I just have to do it, right? And then the next morning is—it's a disaster, and I can't go out if I should have done one and a half hour sessions.

Would have been way better.

Yeah, anyway, thanks for having a chat with me, mate.

Wait, so what's the best platform to get you on? Twitter? What's your preferred?

Yeah, probably Twitter.

Yeah, when you're with your sis, Greg Lehman.

Greg Lehman.

Well, there you go, mate. Thanks for having a chat with me, buddy. I will catch up.

Alright, thank you.