My visit to the Washington University in St. Louis Physical Therapy Program

Posted on September 3, 2012

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This turned into a behemoth of a post. I started writing this on the plane ride home and well, the cute girl next to me could only distract me so much. Next thing I know I had 15 pages. (Remember in college how you had trouble writing 10 pages, double spaced? Weird.) There is a mixed bag of things going on here but the predominant theme is treating knee pain. If you don’t have knee issues I still think there are things you can learn from my visit.

I had an impromptu 2 days off in a row recently and decided to do something I’ve been wanting to do for a couple of years: Visit the Washington University in St. Louis.

While their physical therapy program is consistently ranked in the top 1-2 every year, I don’t care too much about college rankings. (For those curious this is primarily because I went to a highly ranked private school and could not think less of my experience there. Especially considering the cost. Another rant for another day.) What I do care about is this is the house Shirley Sahrmann helped build.

Shirley Sahrmann

For those familiar with my writing and Sahrmann’s you know I have been HUGELY influenced by her two books.

shirley sahrmann

I wrote a bit on how influential her first book has been for me in my Reading / Resources page. Said another way, I flew from San Diego to St. Louis for 48 hours – out of my own pocket – just to visit this program. I’m not sure anything else I say will illustrate how valuable I think their work is.

I had two goals for my visit. 1) To get a continuing education experience. I wanted to see how their clinic approaches a new person, see some of the assessments they use, their process, etc. 2) Have my surgically reconstructed knee / leg looked at.  I’m almost ready to go full bore back into sports and I really needed an objective eye to give me an assessment. I’m sick of looking at myself. Also, there is no better way to learn an evaluation process than to have it done on yourself. So 1) and 2) go hand in hand.

Before I get into the details of my visit, let’s go over the important things:

Lest us not forget St. Louis is the home of the Anheuser-Bush Brewery. Talk about an experience. They have actual Clydesdale at the Brewery.

I had a few free hours on my visit and this did not disappoint. Highly recommended.

Second,

St. Louis has a restaurant entirely devoted to Mac and Cheese. Yes, heaven DOES exist. Awesome place.

Alright, my visit.

Specifically the things I wanted looked at were my knee as I still get some anterior knee pain. While it is much less than months ago, it’s something I’m aware of. Second, my right hip. I had a good idea of what was going on with my hip before the appointment but again, I wanted an objective pair of eyes. Third, I wanted to talk with the therapist about my right foot. I have a supinated foot and it’s something I’ve been more aware of lately. I wanted to see what the therapist thought about this and if they thought it was affecting my knee.

Basically I wanted my entire right leg evaluated.

Jenn, my therapist, greeted me about 30 minutes before our appointment was supposed to start, which was great.

We went over my history and goals for therapy. I should point out here that I’m an atypical client for Jenn, to say the least. I flew from California to see her, meaning I’d only be seeing her once (making her job tougher). I’m very, very familiar with the clinic’s approach to physical therapy as I’ve read their books multiple times each and have applied their work to countless of my own clients.

This can make assessing me a bit tougher as I often know what the therapist is looking for. An important part of looking at people’s movement is to get a feel for their natural, non-coached movement. This is the problem with assessing yourself. I know when standing on one leg I’m not supposed to let my femur medially rotate, thus, every time I assess that movement I don’t let myself do it and go, “Yup, looks good.” When in actuality this might not be true. What am I doing at the times when I DON’T think about it? Therefore, Jenn and myself had to be sure I was “relaxed” and moving “naturally” during the assessments.

Finally, because of my background and personality I’m going to be more talkative and ask a lot more questions than your average patient. This can be good; this can be tough when you only have so much time with a person.

From my own experience a lot of times a person who has no idea what they’re doing can be easier to correct than a person who does. The former person can be treated as, “Do this, not that, done” while the latter can be prone to overthinking and not doing the few things that are necessary.

The Assessment 

The first thing Jenn looked at was my standing alignment. Immediately she noticed my femurs were medially rotated on both legs with a bit more on the right leg. This is something I was expecting. I’ve been working on this like crazy so I was a bit disappointed it was still so readily apparent.

Medially rotated femurs are overwhelmingly the most common cause of knee pain. The tibia often compensates with a lateral rotation as well. If you just think about your knee, it doesn’t mind bending back and forth too much. Twisting though? That it minds.

In terms of assessment one thing this clinic does differently than me is assess medial rotation by looking at the back of the knee whereas I gravitate towards looking at the front. Jenn looked at the insertion points of my hamstrings and based on the fact my medial hamstrings are more prominent than my lateral, she comes away with a diagnosis of medial rotation.

Medially rotated femur

Note how you can clearly see the medial hamstring crease but not the lateral.

I often look at the patella and the direction it is facing. I do this 1. Because I can’t see the back of my own leg and 2. It’s just how I’ve always done it with other people. I’m going to start looking at the back of the leg though and see how it goes.

Next Jenn looked at the position of my femur in the sagittal plane. Based on my symptoms (some anterior hip pain upon hip flexion and hip extension) we both anticipated femoral anterior glide as the movement issue. The most common standing alignment for this condition is one where the hips are held in extension:

Hip extension standing

Again, this was present; again, something I’ve been working on. And something I thought I had corrected fairly well, but I haven’t corrected it enough.

My guess as to why this is going on is I have a tendency to lean forward while standing. Because of my height (6’4”) I tend to look down at practically everything and thus lean forward. Also, I tend to lean forward a lot at work when training people. Think someone laying on the ground and me leaning forward to talk to them.  Finally, my entire life in sports has been spent leaning over. Baseball, track, football, dodgeball, everything involved a significant portion of time leaning forward.

Because of all this I have a tendency to have a forward plum line, meaning the feet are behind my hips, a sign the hips are in extension.

After standing alignment Jenn went into a few movement tests. The first was single leg standing.

Medially rotated femur

The goal here is to observe whether the person’s femur goes into medial rotation when the body’s weight is put on one leg. If it’s already medially rotated in standing there’s a good chance it’s going to rotate / be rotated in single leg stance.

And mine does.

This is something I’m also well aware of. If I’m cognizant of this, I’m able to correct it fairly well at this point. I’ve done a good amount of single leg standing recently, however, this is still harder on my reconstructed knee than it is my non. Something for me to continue to work on.

This medial rotation can cause pain at the knee and or the hip. For me, if it does cause pain, it’s always the hip and never the knee.

Muscularly, so far the common theme here is the lateral rotators of my femur are not working as well as they should be, while the internal rotators are working too much.

If I squeeze my butt muscles (lateral rotators) and focus on laterally rotating the femur while doing some of these things, that medial rotation stops. This is a cue Jenn went over with me.

Next, stepping up and down. This is something I’ve had issues with for years. I can go up and down flights of stairs with pretty much no problem, but if I increase the height too much I have issues.

One thing Jenn noticed is that I have a tendency to move my knee too far backwards when stepping up. That is, rather than bring my body to my knee I have a tendency to bring my knee to my body. This is subtle, but important. See if you can notice the differences here in someone lunging:

Notice in the first version the person’s knee travels backwards to the body, then the body comes forward. We want the knee and body to come up together. I notice this all the time with my clients but didn’t realize I was having such issues myself. Another reason I needed an objective pair of eyes.

I have trouble doing this properly on my own. It’s just tough to see. For now Jenn recommended not focusing on it as an exercise but only in my daily life. I may play around with this a little when I’m in front of a mirror to practice as well. The height of the step will be kept very small though.

Going down stairs is really no problem for me. The only thing Jenn and I talked about was my supinated foot. Going down stairs properly requires a good deal of dorsiflexion and because of my supinated foot I’m a tad limited on my right foot. Because of this I get some anterior jamming in the foot. Meaning I’m limited primarily structurally and NOT muscularly. This is an important distinction.

Because my primary purpose in the evaluation was my knee we didn’t focus on this too much. Jenn and I went over a couple of ways to mobilize the talus, methods I’ll talk about in another post soon. Also, actually due to insurance reasons, Jenn had to be careful about not going into too much detail on my foot when my reason for referral was “knee pain.” This is something I’ll come back to later.

After this Jenn started doing some specific muscular strength testing. The main muscles looked at were the muscles that appeared to not be working properly during some of my movement tests i.e. the deep lateral rotators of the femur and the posterior gluteus medius. Because of my anterior glide the iliopsoas was looked at as well.

I’m going to go over how to test the strength of the posterior gluteus medius (PGM) and psoas.

Manual Muscle Testing

 

Psoas

This is a simple test.

Due to the line of pull of the hip flexors the psoas is the only hip flexor remaining active above 90 degrees of hip flexion. It’s the only hip flexor still in a position to exert force. Therefore, you have the patient / client lift their knee above 90 degrees and observe their ability to maintain their hip in that position.

An easy way to do this is have the person sit on the edge of a table, allow them to hold on so they don’t compensate by leaning back, then push down on the knee with the hip above 90 degrees of hip flexion.

Posterior gluteus medius

 

This is not a simple test.

The person is put into a side lying position, the leg being tested is on top, and it often helps if they’re elevated like on a table.

(This would be to test the person’s right knee / hip.)

Next, the practitioner lifts the person’s top side leg up and backwards while concurrently placing the other hand on the pelvis.

One of the crucial elements of this test is observing the positioning of the pelvis. If this is a person with lower back, hip or knee history, you’re almost guaranteed that pelvis is going to want to move.

For example, when you lift the leg up and backwards you may notice immediately the person’s pelvis rotates backwards as well.

This is a sign the TFL is tight and the abdominals are underperforming.  The person is placing the pelvis in a position where the TFL can do more work than other hip muscles.

For assessing the PGM we want to prevent this movement so we can truly assess the PGM’s strength. So we go back to making sure the pelvis is stationary.

Next, the leg is held back in a bit of hip extension, the knee is rotated upwards a tad for lateral rotation (these are the functions of the PGM – hip extension and lateral rotation), and once in position the person is told to hold this position without assistance.

Some people will be so weak they won’t be able to hold this. Things to look for are the pelvis moving. For instance, the hip flexing like so:

The knee medially rotating:

This is tough to see, but the knee cap should be rotated upward more.

And the tibia laterally rotating:

If the person can hold this position, then extra resistance is added by the practitioner so see how much resistance they can hold.

While adding the resistance the practitioner looks for the same things i.e. any signs the TFL is dominating i.e. hip flexing, medial rotation of the knee, pelvis movement, and or tibial rotation.

A really cool thing Jenn added to this was turning the test into a PGM strengthener and TFL lengthener.

Once I was able to hold the position Jenn had me move through add/abduction to see if I could maintain this position with movement.

This is where I really saw how stiff my TFL / IT band still is. Because when allowing the leg to fall into adduction, BUT NOT internal rotation, I could barely lower my leg. It just wouldn’t happen. (Note this is stretching the TFL).

I’ve been practicing this myself and with my clients and I can tell you doing this through a full range of motion is HARD. The common response when trying this on people is, “Holy shit.” And two days later, “I can’t believe that little exercise made my ass so sore.”

(Note to people who’ve read my Best damn it band stretch, in that post I talked negatively about this stretch:

I mentioned I wasn’t a fan of that stretch, but isn’t it very similar to the positioning I just went over? It is very similar except for one big difference: the fact the foot is hitting the ground in that picture but it is not in all the positioning I just went over.

As soon as the foot hits the ground the only way to achieve any more adduction (stretch TFL) is for the knee to medially rotate, which then lessens the stretch on the TFL and promotes movement we don’t want.

By elevating or allowing the foot to hang off something, we eliminate this and now the knee can be held in lateral rotation the entire time. A subtle but very important aspect.)

Back to my assessment

The most interesting part of all this was I tested fairly well strength wise on all the muscles that one would have thought should be “weak.” So what’s going on?

This is where the critical distinction between working on movement and working on muscles comes in. You can’t just strengthen “weak” muscles and expect to relieve pain. As Jenn said, “Just because a muscle isn’t weak doesn’t mean it’s firing properly.”

What that means is one can have a bunch of strong muscles, but, what you need in order to have correct movement is the correct firing sequence of those muscles.

(Or, Why you’re still in pain.)

An example is the prone straight leg raise:

A person may have “strong” glutes, but if they’re firing after the hamstring, hip issues can arise. Like anterior glide of the femur. Because by the time the glutes start to work, the head of the femur has already moved too far forward; pain ensues.

I use this example because I have this problem. When lying prone Jenn noticed my hamstrings are still firing well before my glutes are. So, when doing this I need to be sure to squeeze my butt first and then lift my leg.

It’s not that my hip is weak, it’s that my hip needs to move better.

That damn TFL / IT Band

I knew this was coming. This is a muscle I’ve been having too many issues with. Hence, the absurd amount of writing I’ve done on it. While my TFL isn’t too tight, as noted by Jenn, it is stiff (there is a difference), and causing issues. And I knew there was something I was missing when trying to loosen it up on my own.

To make a complicated story short, Jenn knew my TFL / IT band was tight by putting me in various positions which put the muscle on stretch. (See the PGM test above.) Often times when it was put on stretch I felt some pulling / pain in the knee. Once she either gave a medial glide on the knee cap, which helps loosen the band, or gave in to the tightness somewhat by abducting my femur, my pain would alleviate.

For instance, take the TFL / IT band stretch I’ve written about:

tight TFL causing knee pain

In a person with TFL issues they’ll often get some pulling / pain at the knee. If the practitioner pushes medially on the knee cap or allows the knee to abduct, this pain is often diminished.

Medial glide:

Abduction:

Also, my issues with excessive femoral medial rotation are consistent with TFL issues. The underactive lateral rotators of my femur are offset by the overactive TFL (internal rotator of femur).

One thing Jenn went over extensively with me, something I haven’t been doing enough on my own, is working my leg through abduction while laying on my side. Jenn went over different variations of the side lying leg lift according to what I could perform.

As I mentioned, what I have to be very aware of is not allowing my knee to medially rotate as I go through this. That is, I need to make sure I’m using the posterior gluteus medius to abduct my leg and not give in to the TFL.

I believe this was one of the big things I was missing i.e. not working on proper movement enough in the frontal plane / through abduction.

Different variations of this include straightening the leg more as well as extending the hip a bit. I know a variation is too hard for me if I’m feeling pulling in the knee (the TFL is too tight) and or I cannot prevent my knee from rotating. Here are three variations in order of easier to harder:

Harder because the hip is more extended.

Don’t underestimate these types of exercise. They’re boring as hell but done properly they can stretch the TFL, work the PGM, and correct movement impairment at the same time. In fact, I feel a hell of a burn in my ass (insert joke) when I do these.

One other note on form: I mentioned the pelvis moving backwards; do not let it move laterally either. It should be completely stationary. Too often people substitute abduction of the thigh for lateral flexion of the trunk. Watch the abs here:

Stop worrying about how high your leg gets and start worrying about only using your butt to lift the leg. It’s an exercise that works the movement of the leg but uses the abdominals to prevent movement of the spine.

Summing up the assessment and subsequent treatment

 Here I am from a movement diagnosis perspective:

-Femoral anterior glide (issue at hip)

-Tibiofemoral rotation (issue at knee)

-Knee hyperextension when standing (I lock my knees too much. This coincides with tibiofemoral rotation for me. When I correct the rotation the locking corrects as well.)

These are very common movement impairments. Ironically, I’ve delt with many of own clients with these very issues.

As Jenn mentioned, I have some pretty small things going on. It’s not like I’m writhing in pain, or you watch me move and go “Hollllly shit, this is going to take a while.” But, I definitely have things that could be better. And a preemptive strike is better than a reactionary one.

Before I go into some of my corrective exercises I want to mention again that I was a unique patient for Jenn. Jenn mentioned a few times, “I never give this many things to a new person, but you’re a bit unique.” What Jenn primarily meant is that I won’t be flying back to St. Louis every week for follow ups. I’ll talk more about this in a second.

The exercises as prescribed by Jenn:

-Side lying leg lifts of different variations

-Prone straight leg raise

-Prone bilateral knee flexion

I didn’t go over this one yet. This is another way to loosen up the TFL / IT band.

I’ll go over this is in more detail one day but for now, for me, the thing I have to work on is making sure I do not achieve knee flexion by lower back extension. Because the TFL pulls on the anterior portion of the pelvis you’ll often see people with TFL issues do this:

Notice the lower back moving? When that lower back is extending the hips are flexing. Therefore, the TFL isn’t actually being fully stretched because it is shortening at the same time you’re trying to stretch it. This is an example of a stiff TFL as well as rectus femoris.

Get the person to really pull their abdominals up and inward and you’ll likely notice the amount they can flex their knees diminishes:

I’ve been working on this on my own a ton but Jenn helped me sure up my form.

-Single leg standing

Pretty simple. Stand on one leg, with the femur in proper position (NOT medially rotated) and don’t let the femur rotate while in stance. Progressions can include moving the arms around then closing the eyes.

-Proper walking

There are two things I need to focus on while walking. 1) Squeeze my butt every time my foot hits the ground. This will insure the femur does not rotate inward because the lateral rotators are firing.

2) Focus on lifting my heel off the ground quicker. As I mentioned I have issues with my hips being too extended when I stand and walk. Part of the issue here is my foot is on the ground too long.

Think about it this way, the longer your foot is on the ground the more your foot is going to be behind your hip. By focusing on lifting the heel off the ground quicker the foot isn’t on the ground as long, thus, the hip isn’t as extended while walking.

Note how far extended the hip is here compared to below with the heel lifting sooner.

This was a little simple thing that I know is going to be important for me.

And that’s it.

This was well worth the trip. I left this trip a little smarter and one step closer to blowing someone’s face off with a dodgeball.

I came away feeling satisfied and for the first time in my life I felt confident in what a physical therapist was telling me. Jenn was great and went out of her way for me. She gave me an extra 30 minutes of her time and couldn’t have handled me better. I only wish more physical therapy clinics were like this one. Thanks a ton Jenn!

Miscellaneous notes

1)   5 corrective exercises. Only 4 if you don’t count walking as an exercise.

Remember how I said Jenn mentioned, “This is way more than I normally tell people to focus on the first day.” 5 things to focus on = way more. Think about that for a second. How many things are you trying to focus on? Think about that new program you’re on where you’re trying to perform 20 different exercises with proper technique.

I have battles with my clients over this. The longer I do this the less I tell them to work on the first time I have them. I’ve gotten to the point where 3 exercises is my absolute max. Honestly just getting people to sit better on a regular basis is WORK.

Yet everyone constantly wants to think they’re different.

You’re not.

Don’t complain you want to do this exercise, or you want things to be tougher, or ask why your lower back hurts when you’re still sitting like a gymnast all day.

2)   There’s no need for pain…sort of

This was something I thought Jenn did phenomenally well. Anything, and I mean anything, that remotely caused me pain was immediately modified, eliminated, and or not focused on in the treatment protocol.

People often times try to bully their muscles into the positions or stretches they want and it just doesn’t work. I’m guilty of this with myself sometimes.

One caveat I’ll mention here is it’s important to consider the population you’re dealing with.

With my case, and thus Jenn, she is dealing with someone seeing her for one purpose, to alleviate some pain issues in the leg. I’m not there for weight loss, I’m not there to get stronger, I’m not there to get in shape, to get toned, I’m there for my leg to feel and move better.

Contrast this with the population I often deal with: Person who wants to lose anywhere from 20-100lbs, tone up, get stronger, get in shape, make their lower back feel better, make their knees feel better, make their shoulders feel better, and have all this accomplished next week.

In Jenn’s case (I sometimes have this as well) you can truly hone in on the one or two issues and avoid all painful activities.

In my case and the population I deal with, this can be harder. What I mean by this is are we more worried about you not having a heart attack or whether your lower back is a little achy today?

If a person has lower back and knee issues it’s unlikely I’d ever say walking a few miles a day would be healthy. If the person has been sedentary for three decades and is on the verge of diabetes it’s going to be hard for me to recommend anything involving them moving less.

“Healthy” isn’t always straight forward.

2)   Why do I have these movement issues?

I think my issues can be traced back to my sporting history. I played a lot of sports growing up. Sports primarily concerned with cutting back and forth. If you look at the position this puts the knee in you’ll notice it’s one of medial rotation:

I think years and years (20 or so) of doing this caused my issues. I know I’ve had some of these things going on for a while now, but I think my surgery made me hyper aware of them.

Why does my right leg give me more issues?

I planted off of it more than my left.

Why is this? From all the throwing I’ve done. If you look at the hip and knee position as a right handed person throws you’ll see it’s one of medial rotation:

I’m betting a lot this is why my right leg has always given me more issues than my left: I’ve simply done a lot more reps of medial rotating the femur on my right side than I have my left.

3)   Why my right foot is supinated

The throwing ties into a supinated foot. Succinctly, pronation is primarily for force absorption and supination for force generation. You accept the body when you pronate and you propel the body when you supinate. (Usually.)

Take a look at the bottom of a pair of my shoes and you can see I do a lot more damage on that right foot than I do my left:

Supinated foot versus pronated foot.

Left in the picture is the right foot sandal.

What is my right doing with all those years of throwing? Generating force over and over again. At this point, as Jenn mentioned, I probably just need to accept the fact my right is structurally a bit different than my left.

The only thing I’m going to do to compensate for this right now is add a little bit of a support and a heel lift to my right foot when doing intense running / cutting / throwing. This will accommodate the slight lack of dorsiflexion I have on the right foot due to my structure and give me a little cushioning for the foot that doesn’t accept force too well. It does generate force well though, which brings me to….

On a tangent, this is one of those give and take scenarios. My structure and ability on my right side to easily supinate my foot, laterally rotate my tibia, and medially rotate my femur do make me more likely to have hip, foot, and knee issues on that side. However, it also makes me better at throwing things really hard.

It’s like a baseball player’s pitching arm. They typically have a good deal of laxity in that shoulder and elbow allowing them to whip a baseball better than your average person. However, this gain in laxity is offset by a loss in stability. Less shoulder stability = a potentially higher rate of injury.

You get something, you lose something; you can’t have it all. The body is full of these compromises.

This is one reason you don’t see 8 year olds blowing out their arm or ACL. They haven’t acquired the necessary structure or force capabilities to be able to do these things yet.  Oh, how I miss the days of being able to toss my body around like a pin ball, bouncing off of rocks and trees with no repercussions.

4)   The passive straight leg test

This is a test I either forgot about from the books or wasn’t aware of. I love the simplicity though. The purpose of the test is to assess femoral anterior glide.

Lay the person down supine. Raise their leg for them and see what their range of motion is like.

Next, raise their leg with some posterior glide on the head of the femur.

If the person has issues with anterior femoral glide there is a good chance the person’s leg will have greater range of motion when the posterior glide is applied. Simple and easy to do.

5)   These issues are not directly from my ACL injury, but they may be indirect.

I’ll write about this more soon, but at this point my ACL and meniscus rehab is practically over. I’m 8 months out, I have full range of motion, my hamstring (my graft) is finally just about normal (I’ll show before and after videos soon), I don’t have any swelling after activity, I can run and cut well, I have a normal Lachmann / Anterior Drawer / McMurray / etc. There will be some biology going on in my knee until the one year mark but my work directly for that surgery is basically done.

What is currently going on is correcting some movement issues that I think my ACL reconstruction made me more likely to have. It’s not the surgery caused these issues, it just made them more likely to happen.

For instance, I was a potential case for femoral anterior glide before the surgery. I have the surgery, my leg is locked straight for two weeks so I’m basically doing a straight leg raise all day, and boom the chances that femoral anterior glide becomes symptomatic go up. Same thing with the medial rotation of the femur. (That TFL could become more overactive due to having to do a straight leg raise all the time.)

I really think the issue with people coming back from ACL surgery is not the ACL itself. Rather, it’s the lack of attention to the movement compensations that can arise after such a traumatic injury.

6)   I don’t understand insurance in this country (USA)

I had a few odd experiences with booking my appointment. When I first called up the clinic I expected to say, “What’s your availability on such and such week, ok good, no I’ll pay out of pocket to avoid the hassle. Cool.” And done.

I wasn’t allowed to do this. If you know anything about offices that deal with medical insurance you know they HATE dealing with these companies. Doctors, therapists, whatever, they DREAM of having patients who pay out of pocket. Primarily because insurance companies don’t give a fuck about your health; only making money.

Seriously, a customer wanting to pay for a service, no questions asked, and not allowed. The state of Missouri requires one to get an order for physical therapy from my general physician first. Well, I don’t have a general physician. It took me an hour or so to find out that my surgeon could do this. Well, my surgeon was on vacation. Took me another two or three days of phone tag to find out whether someone else could write the order. Took me another day or two to find that person, explain to them the situation, and plead with them to do so. You could tell they needed to be sure they were covering their ass insurance / legally wise.

(Keep in mind this is time sensitive. I can’t wait two weeks for my surgeon to get back from vacation. I only have this two day weekend on one particular weekend. This phone tag shit actually cost me an extra $200 in flight fees.)

Just think about how hard you’re making it for people to run a business. As someone who does it himself I can tell you every little extra thing a person has to do in order to attain your service or product exponentially increases the odds they will not purchase it. For example, Amazon’s one click isn’t there just because it’s convenient and nice for you. It’s there because it lessens the barrier for you to buy = making you more likely to buy = the business making more money.

Why can’t I just sign a waiver when I go into a clinic? Why do I need all these people to approve me for a physical therapy evaluation? I can go skydiving with one signature (my own), but I can’t go into a physical therapy clinic? Again, I OFFERED TO PAY OUT OF POCKET AND WAS TOLD NO.

7)   Insurance companies suck

Yes, more on this. Another thing that baffled me was the fact Jenn had to mention to me multiple times my order for physical therapy was for knee pain. Thus, she had to be careful talking about or examining other body parts. This isn’t her fault; it was more a result of me pressing her for information on other body parts. I completely understand where she is coming from; again, not her fault. It is the insurance companies and blood sucking lawyers.

This reminded me of one of my clients who recently went through breast cancer. When talking to her surgeon the surgeon accidentally let it slip, “My first priority is avoiding a lawsuit.”

This is just fucking sad. Breast cancer patient? How about making sure they survive as a first priority?

Knee pain patient? How about allowing the physical therapist be able to do what THEY deem best to treat the person. Why not knock out two issues in one appointment if it’s possible?

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