Attention
We spend so much of our lives trying to get it. Coworkers recognizing our input, bosses acknowledging our effort, our other half appreciating our actions. Social media is driven by the desire for attention.

Sandeep Swadia recently wrote about what can happen if we invert everything and GIVE attention instead. His story is about showing up to an appearance with an umbrella that had broken earlier in the day. Following the appearance, he was unexpectedly, and seemingly unnecessarily, given a brand new one. Someone had noticed. A seemingly menial action that made Swadia’s day. 

And that’s really the point of his piece. What can happen when we pause, become fully present and connected, and make someone feel seen and/or heard. Especially in everyday life. A gesture so very small, but with an effect so very huge. Paying attention to the person in front of us. 

Today, “how are you?” is often less of a question and more of a greeting.

Let’s bring it back to being a question.

Sandeep Swadia gives us his HAT principle: Help, Appreciation, Time.

But I’ll let you read that.


On Losing Attention
Before we can give someone our attention, we have to stop losing it.

A paper I came across this week starts with the question, “Do you expect to read this [article] without interruptions [caused by your smartphone]?”

Probably not.

Task interruptions are part of everyday life, and always-on connectivity has become normal. Notifications certainly have benefits. Communication, collaboration, feeling connected. Timely business activities. But they’re also interruptive and increasingly frequent. And every time our attention shifts, there can be a cost. 

The authors looked at how these notification-caused interruptions affect strain and performance, and why turning them off might affect different people differently. Overall, reducing notification-caused interruptions improved performance and reduced strain. But there was some nuance.

​The performance benefits of reducing notifications may be smaller for those high on FoMO. The authors suggest anxiety when notifications are disabled as a possible explanation. 

​Which brings me to another study that coincidentally showed up on my feed this week: Attention hijacked: How social media notifications disrupt cognitive processing.

This time participants performed a Stroop task while being exposed to smartphone-style notifications. Essentially, the authors wanted to know how much a notification can pull us away from something we’re already doing.

The main finding was that cognitive processing slowed for roughly seven seconds following a notification. Even more so when the notifications were personally relevant. Though they can still capture your attention when they’re not.
One of my biggest takeaways was that notification volume and checking frequency mattered more than total screen time.

This was interesting.

Because we always harp on screen time.

Maybe it’s the distractions that actually matter more.

And maybe that says something about just how fragile our attention can be. So rather than continually harping on screen time, which is pretty much a useless endeavour anyway because no one likes a nag, perhaps a simpler place to start is turning off most, if not all, of the notifications on our phones.

On Listening
Which brings us back to what all of this attention is actually for.

Dr. Aubrianna Jones recently wrote a short yet important reflection about the difference between understanding a clinical presentation and appreciating how and what that clinical presentation means in someone’s life. The unspoken expressions of someone’s condition and the silences between their words can sometimes tell more of their story, if we’re listening. If we’ve given them our attention. Our full and undivided attention. 

Dr. Jones talks about patients as storytellers, and their stories as rarely linear. Stories layered with grief, fear and, at times, resilience. She describes knowing the clinical details of a patient’s chronic pain, yet not necessarily knowing what that pain meant in the patient’s life. 

And with an ever-increasing trend and movement toward quantitative, objective technology, I fear the subjective is going to get pushed further under the rug.

Personally, I believe the subjective is more important.

I’ve always believed that one of the greatest gifts you can give someone is the opportunity to tell their story.

But in order for someone to tell their story, someone else has to be paying attention.


Downstream Effects
And this is where mentorship enters the picture.

Dr. Aubrianna Jones also talks about how mentorship was important during her training. Mentorship afforded her the space to sit with uncertainty, interpret what was left unsaid and, perhaps most importantly, learn what it means to care by watching how care was modeled. Those relationships were grounded in humility, vulnerability and shared meaning-making. 

There’s a cross-pollination in all of this.

Her mentorship experiences helped shape how she would ultimately give attention to her patients. But only because those mentorship experiences were themselves grounded in attention.

This is the downstream effect.

Attention given to someone who then learns to give attention to someone else.

​
Critical Non-Essentials. Again.
I wrote about Critical Non-Essentials in the last Cross-Pollination. The little things that aren't necessarily essential, but can still make a difference. Because not everything needs to be essential to be important. 

Will Guidara recently shared another nice example of this. A family was in an Uber on their way to Hollywood Studios at Disney. The driver noticed their Star Wars shirts and, with the kids getting restless in traffic, put on some Star Wars music. That's it. The driver didn't work for Disney. There was no requirement to do it. Just an unexpected, seemingly unnecessary gesture that made the ride part of the experience. 

The littlest thing, at the most perfect time, can have an immeasurable effect.

But again, only possible with attention.

How often do we do things we aren't required to do? Even holding the door open seems rare these days.

​In our cases, maybe it's turning down the lights or ambient music volume for someone who looks like they've had a long day. Maybe it's telling a patient to book at the end of your day so you can give them some extra time and attention. Maybe it's covering for a coworker when you hear they're having some challenges at home.

None of these things are required. And none of them are particularly big.

But you have to notice first.

All of this lies on a foundation and has a prerequisite of attention.

​The more we give, the more we can give.

On iterating.

Iterating is prevalent. But it isn’t new.

Strength and conditioning has been around for decades, if not longer.

Calisthenics - Barbells - Olympic lifting - Nautilus - Periodization - Sports Science - Monitoring - Technology…

I’m missing many, but you get the point.

Each builds upon what came before, keeping what’s relevant and tabling what may be important later.

Iterate.

Performance therapy - observe, intervene, train, feedback loop.

Iterate.
According to the Oxford dictionary: to repeat a mathematical or computing process or set of instructions.

The Cambridge dictionary says it’s to repeat a process.

And Merriam-Webster dictionary - to say or do again or again and again.

Sound like something that’s rapidly becoming part of our lives over the past two years?

Hint: AI

We try things. We keep some. We change others. We steal from different disciplines.

We Cross-Pollinate.

Turntablists and mixmasters. Iteration is their wheelhouse and how music is made.

Take something that already exists. Sample it. Scratch it. Mix it with something seemingly unrelated. 

Cross-Pollinate.

Not from scratch. But from something that was already there.

But we have to get in the arena and do the work.

Iteration isn’t about the end product. It’s about the process. About the practice. 

It’s not so much about getting ahead as it is not being left behind.

Iterate.

Critical Non-Essentials 

CNEs are Paddi Lund’s idea of deliberately improving the small details around a customer’s experience that aren’t essential to delivering the core service, but are critical to how that service is perceived and remembered.

Being good at what you do is a must. 

But also being good at the non-essential things can be a difference maker. 

Similar to Unreasonable Hospitality by Will Guidara.

And no different when it comes to training:

The main program drives the adaptation.
And the accessory work supports one’s ability to keep doing the main work.

They’re non-essential.

Until they’re critical.

It’s the conditioning work that gymnasts do and the deliberate warmups and GPP that we see in track and field.

Maybe the fill gaps where the programming may lack. Maybe they expose limitations in movements outside of those that are normally required or performed. Or maybe they merely help distribute load across the system. 

I don’t wan’t to use the term preventative, because I’m not sure it is. But I’d like to perhaps suggest durability promoting. Perhaps.

Again, 

The main program drives the adaptation.
Everything else supports one’s ability to keep doing the main work.

The  Critical Non-Essentials.

Because not everything needs to be essential to be important. 


Tipping

Wrote about transactional vs transformational and performative vs transformative last week.

A principle in coaching that I connected to the current landscape of social media.

But as I go about in my daily work and coffee purchases, I think the same applies then.

With colleagues: it’s easy for us to be transactional. A “how are you” that’s more of a greeting than it is a question. Looking down at our phone/computer while talking to a peer.

At the coffee shop: this is where it got me. Tipping.

This is getting out of hand. Coffee baristas pointing to the POS machine and asking for a tip without asking about your day. I don't mind tipping, but it’s about the interaction, the service. Isn’t that what a tip is for? To thank someone for their GOOD service?

Because if you’re just transactional, I don’t see any reason to tip…especially at Starbucks.

But if we strike up a brief conversation, meaningful pleasantries, then I’ve likely enjoyed my experience and would be more than happy to tip.

But back to when working with our athletes/patients, for many of us, being transformational is a genuine skill. But when interacting with our peers, it’s often easily forgotten.


In season tendinopathy

The current process is that tendinopathy generally needs load. In the off-season, I think that’s relatively simple, though not necessarily easy, to do.

During the season however, I think it’s trickier. 

Microdosing?

Is more load actually the answer?

In large part, for many structures…I think so. Yet for others… I don’t know. 

We know that most loads, when dosed appropriately, are stimulative.
And other loads are analgesic. But is that always the solution?

Because why are tendinopathies still challenging?

And what about load distribution and dispersion?

We saw through the Buchheit and King paper that squeeze test readings for the adductor are whole system outputs. Meaning that indirect improvement (i.e. addressing limitations upstream) can positively affect and show improvement in squeeze test values. Without direct training of the adductors. 

In runners, glute med tendinopathies are common. Especially in hobby joggers.

So should we directly load these as well? Possibly. But what if they’re relatively elite and run 100+ mile weeks?

Could we then create overload?

I don’t know. I’m just thinking out loud.

Is more load always the answer?

Are clamshells and captain morgans sufficient? Are single leg squats and suitcase carries sufficient?

And what if someone needs a better functioning system more proximally? What if they need stronger quads? Or improved foot and ankle stretch shortening?

But back to the in-season. Adductor issues in hockey. 

Load monitoring?

How about load distribution and dispersion.

We talked about this. Again, the Buchheit and King paper.

Maybe this is where we need to spend more time. At least between games 20-60, if not beyond.

Because the load is there. Often it’s high.

Maybe we just need to distribute it better.

Maybe it’s not just about tissue capacity. 

Maybe it’s also about above and below.


Random Closing Thoughts
​

• Frontal plane problems sometimes have sagittal and transverse plane solutions.
• If the scapula isn't moving properly, stop looking at the scapula.

Learn what exists.
Learn what works.
Learn what matters.

Whether it’s:

• A new idea.
• A new intervention.
• A new (piece of) technology.
• A new system.
• Or a new way of thinking.

This is the process.

First, we learn what exists. What’s out there.

Sometimes we may create. Or at least think we create.

Then, through trial and error, we figure out what actually works.

Finally, we figure out what matters.

Because what’s out there isn’t necessarily effective.

​And what’s effective isn’t necessarily relevant.

If nobody adopts an invention, uses it, or changes because of it, it may still be an invention. But it isn’t innovation.

It’s just an invention. With little point.

Trial and error. Lateralizations and Regressions. If we’re working with intent, we too may “come up” with different iterations and variations. 

Some will work. Some won’t. 

And some of those that do work, don’t matter.

But after we learn what works and what doesn’t, over time we learn what matters. Eventually. After being in the trenches.

In due time. 

And we learn that it’s dependent on the person in front of us, the problem in front of us, and the environment in front of us. 

The goal isn’t to invent or incorporate.

It’s to expose ourselves to what exists, to experience what works, and ultimately, to know what matters and when.

Was riffing on this in my head recently and after a few iterations, here's what I came up with.
​

I'm open to revisions, so if you have any thoughts, please let me know.

On Attention:

What we think about shapes what we see.
What we see shapes what we look for.
Don't say "don't."
Focus on the "do."

Yes, I know what I did there. It was intentional. To make a point.

We all know that it is unwise to tell someone who's upset or stressed not to be upset or stressed.
Some of us know that it is useless to tell someone doing a bridge to not use their hamstrings (tell them to drive into the ground).
Our minds just don’t work that way. 

Because if you say it, “it” will immediately jump to the front of the line. Top of mind. Locus of attention. Especially if you tell someone NOT to do something.

The kids. Think about kids. 

“Don’t touch the stove!”

On the other hand, if you don’t say it (and tell them what to focus on instead), it is more likely to stay hidden. From consciousness. Not top of mind.

​So focus on the do.

On Service:

Thinking about modern use of social media reminds me of the contrast between being Transactional and being Transformational. Straight from Joe Ehrmann's book, InSideOut Coaching. One of a number of books that were recommended to many of us by Coach Mike Boyle. Essentially, the difference is this:

Transactional - A one way street. I coach, you comply. This isn't necessarily negative, just a transaction. Instruction, action. Service, payment.

versus

Transformational - A two way street. Symbiotic growth. Incorporates soft skills and connection. Prime example: Patch Adams.

Growth and connection.

And its relationship with today's social media?

Performative and Transformative.

Many great accounts exist. One's that truly do help us grow. Unfortunately, many more are performative. Really just nothing more than production.

Austin Kleon says showing your work is important. I agree with him. Showing your work often allows others to grow themselves.

But...Showing yourself? That's different. Merely a call for a pat on the back. Meh.

Current social media algorithms tell you to document yourself. That’s what gets views apparently. But documenting yourself without any substance behind it, without any actual work being done is simply performance for performance's sake. Jersey shore and Kim Kardashian-like. At least in Big Brother they’re actually playing a game.

​Are we optimizing for attention or service?

​Because what does it actually do to the performer? To the one doing work, the work is getting done. Growth. With documentation  and service as byproducts. But to the one merely performing, what does that leave the performer with? 

Transactional (Performative) social media asks? What can I get from your attention?
Transformational (Transformative) social media asks? What can I do with your attention?

On Doing the Work:

​There’s “writing” the noun. And there’s “writing” the verb. The article or book. And all the stuff that goes into creating the article or book – the idea, the layout, the research, the act of putting pen to paper. Or typing. 

“To all viewers, but yourself, what matters is the product: the finished artwork. To you, and you alone, what matters is the process: the experience of shaping the artwork.” - Ted Orland

This used to be true. But today's society is in a rush to produce. The focus is on volume, timely volume. To get ahead of the next person.

And as a result, "the writing," - the noun, or the product: the finished artwork - is all that seems to matter. The product.

AI seems to be doing a lot of the work, allowing much of the process to be bypassed altogether.

So what are we left with?

A lack of accumulated time spent doing the work and subsequently, a lack of expertise.

You don’t learn to swim by reading about water. And you don't learn to ride bike by watching YouTube.

The same can be said for the use of data in the rehab and return to sport settings. Just do.

Knowledge gained through experience is often difficult to put into words. "We can know more than we can tell." (Michael Polanyi)

There are many things we can explain theoretically. But there are things we can only know and become experts at by doing them.

Expertise isn’t accumulated information. It’s what becomes visible after enough time spent doing the work.
​
So do the work. 

I don’t think we should be able to take dry needling immediately upon graduation from a clinical program. In fact, perhaps we shouldn’t be able to take any technique course immediately upon graduation from a clinical program.

Not because techniques aren’t important. But because a technique without a framework can very quickly become the framework.

But I’m going to stick with (and seemingly attack) DN because at the very least, (manual) touch can go beyond MSK.

And with DN…it’s essentially whack-a-mole. I’m not sure there is a system. A framework of thought. Let alone a clinical one.

It’s find the mole, kill the mole. That’s it. As random as it is.

Find the tight spot. Needle the tight spot. Move on.

They may not teach it this way, but it’s certainly what is evident in many practices.
​
Acupuncture is different. TCM, Contemporary Medical. Different. Even Integrated Needling as taught by ISS and the FIT Institute. Also different.
​
I know some will argue against these statements but I’m going to stand by it. 

I’m going to stand by the fact that I think most new grads should start out with as minimal equipment as possible. 

The table. The floor. Your brain. And ok, your hands.

Learn to observe. Learn to examine. Learn to think. Learn to make decisions.

Note, I did say “shouldn’t take technique course” above, but that doesn’t mean not take a system based course. That, I believe is valuable.


Any system, I’m not sure it matters.


What matters most is having an actual thought process.

Something that forces you to ask why before you ask what technique you’re going to use.

​Because the goal early on shouldn’t be to collect more tools. It should be to learn how to think before reaching for one.

Apparently we all need to learn how to prompt now.

How to ask ChatGPT the right question. How much context to provide. How to follow up. How to challenge its response. How to ask it to reconsider. How to get closer to what we're actually looking for.

Prompt engineering, they call it.

(LOL. That'll be my new title. I'm an engineer. The Director of Prompt Engineering)

But the more I think about it, the more I believe it's something we've been doing all along. And when I say "we," I mean I hope "we."

Prompting isn't just asking questions, of course. It's also giving instructions, providing context, setting constraints, asking someone to show you something or describe an experience. In other words, shaping what comes back by being thoughtful about what you put in. The efferent and the afferent as you'll see later.
But questions — and better questions, hopefully — are a pretty good place to start.
Because long before large language models, there was Socrates. And for those of us in clinical practice, before there were LLMs, there was taking a history...
  
An athlete walks into the clinic or treatment area. They have a story. Our job is to try to understand it. And often, the best place to start isn't with a specific question. It's with an open one.

"Tell me what's going on." or "How can I help you?" or "Tell me your story."

Then listen.

Because the moment we start rapid firing or narrowing down our questions, we start narrowing the range of possible answers.

Think: Open questions for the history, closed questions for the physical. Not:

Does your knee hurt when you run? Yes.
Does it hurt going downstairs? Sometimes.
Does it hurt when you squat? No.

Useful information, maybe. But this doesn't really get us anywhere. At least at the start, I don't think.

Compare that with:

Tell me about your knee. or,
What's that experience like? or,
So then what...?

We don't necessarily know what we're going to get back. That's the point. It's the athlete's (or patient's) experience, not ours.

Key word - experience. 

In coaching it's no different. A “how did it go?” or “how was that” will get you a “fine.”

But a “tell me about that rep” will likely get you a lot more. Sure, sometimes a "good?" is sufficient, but open ended prompts, strategically and intermittently utilized, will likely turn the coach-athlete discourse from 1080p into 4k. 

Sometimes the best questions aren't even questions.

Back to the clinic however, we (hopefully) learned in school that open ended questions create space for the athlete/patient to tell us something we didn't know enough to ask about. Then we can start narrowing. But the later we narrow, the better.

Start broad. "Tell me your story."

Listen.

Then go deep. "Was it more like this (insert characterization) or more like this (insert another characterization) or was it something completely different?"

Then come back out again. In-out. In-out. It's a dance. Give and take. Afferent-efferent if you will. 

It's called an "intake" after all. You, the clinician, takes it in. Let them do the talking. 

History taking shouldn't be a checklist. I know they teach us that in school (LODRFICARA) but it should be more like an interview. A podcast. And we all know the best podcast hosts are the ones that ask the best questions then let their guests do the talking.

They're great at prompting. Based on curiosity.

Ask. Listen. Unpack.
Ask again. Sometimes go deeper. Sometimes zoom out.
Sometimes ask something that, initially, doesn't really have anything to do with the problem sitting in front of you. At least they - the patient/athlete - wouldn't think so.

An athlete comes in with knee pain. Ask about the knee and you'll learn about the knee. But ask about what he's been up to in the weeks leading up to the knee "experience" and you may learn that running volume doubled. Perhaps he was trying to catch up after coming back from vacation.

Remember "don't bring a manual solution to a load problem?" Or, "first think like a coach than (and then) like a therapist." All of this as they pertain to training injuries.

Anyway, ask what else changed around the same time and you might hear about sleep, work, stress, travel, footwear, illness, or a new training program. Truth be told this isn't easy at first, but the more you think this way, the better you'll be able to "prompt."

The same athlete, the same knee. Different prompt, different picture. And potentially, a very different understanding of how they got there.

Why? Children ask questions. A lot of them.

Why?
Why?
Why?

Or The Five Whys.

It's not about trying to get to the answer as quickly as possible. It's about trying to understand. Like a kid. Yet many of us seem to be more interested in having answers than asking questions.

​Ugh.

The Five Whys attempts to preserve some of that childlike mentality.

Why did this happen?
And why did that happen?
But why did that happen?

And so on. Just keep moving upstream. Not because five is the magical number, but because the first answer is rarely the whole answer. I'd say never.

Upstream. Downstream. The key to success in MSK.

Think upstream when assessing. When taking a history. Truly figure out the why.

Then consider downstream when intervening. Michel Foucault. Randy Travis.

Michel Foucault: "People know what they do; frequently they know why they do what they do; but what they don't know is what what they do does."

Randy Travis: "I guess it's not what you take when you leave this world behind you / It's what you leave behind you when you go."

I'm rambling but again, think upstream to consider the many possible reasons why something is the way it is. Then think downstream to consider the many possible consequences of what we choose to do about it.

Curious about causation. Considerate of intervention.

Broad. Deep. Broad Again. Deep when necessary. The Neo-Generalist.

It's the art of history taking. The art of the prompt.

Start broad. Let them talk. Listen. Something catches your attention. Go deep and unpack. Then come back up and look around again. Alice in Wonderland? Sometimes going deeper gives us the answer. Sometimes it gives us a better question.

Again, the Neo-Generalist. Broad enough to see the landscape. Deep enough to understand the details. Curious enough to move between the two.

But....

What Aren't We Asking? Perhaps this is the more important part.

What are we missing? What haven't they told us? What haven't we given them the opportunity to tell us? I'll often "end" my history taking with, "So what do you think you need from me?"

I also have a sign up that says, "The greatest gift you can give your child is the opportunity to tell their story." (Note: if you're a parent, let your child do the talking!)

Are we asking questions to learn? Or are we asking questions to confirm what we already believe? Admittedly, sometimes we are? Differential diagnoses. Confirm or deny. The art of the exam.

But at the end of the day, it's about remaining open-minded. Seeking the truth. Asking the why? Then asking the why again. And again.

Which brings us back to AI.

​An LLM (Claude, ChatGPT, whatever...your choice) is given a prompt. It responds. You give it a narrow prompt, you usually get a narrow response. Pretty much an answer constrained by the boundaries you created.

But open the prompt and now you get, or should I say create, possibilities you may not have considered.

Then you narrow. And add context. Then go deeper. Sometimes even challenge the response. Ask "what am I missing?" Ask what else might explain it. Ask it to consider another perspective. Look upstream. Consider all the considerations that you may not be considering! (lol).

Then think downstream. Ok, so what happens next? And if we do this, then what? Zoom in, zoom out. Dance. Left foot, right foot. Afferent-efferent. Start broad, go deep. Go this way, then go that way.

The technology is new. And there will be even newer LLMs that come out.

But the thinking isn't. 

We clinicians and coaches have been prompting for a long time. At least the good ones have been.

A clinical history is a prompt.
A post-rep debrief is a prompt.
A conversation is a prompt.
If you're curious, you're a prompter. A Prompt Engineer. The Director of Prompt Engineering.

And what I think you'll find is this...Cross-Pollination. Love that word!

Cross-Pollination: Making seemingly random connections across disciplines. Because the answer is often found in the question you weren't even thinking about.  And because sometimes the thing that changes how we think about rehabilitation comes from places outside of strength and conditioning. From psychology. From engineering. From business. Or somewhere else. 

So perhaps "prompt engineering" is simply the newest manifestation of something that's been around since Hippocrates. 

History taking. Podcast interviewing. The first date.

Questions. Instructions. Context. Listening. Knowing when to stay broad and when to narrow.

The quality of what we get back from an athlete, a patient, a conversation, or an LLM is often determined by the quality of what we put in. It's an art. And maybe it's not about AI after all. Maybe it's better questions. Better prompting.

The Art of the Prompt.
​
Stay curious.

Time under tension.

In the gym, we know the concept well. If we want something to adapt, it needs an appropriate stimulus. And in general, if we want a muscle to grow, we need adequate load, sustained for (relatively) long periods. Time under tension.

I think professional development works the same way.

The long summer that we’ve (unfortunately) had this year has afforded me the opportunity to spend a lot of time in the gym. Not necessarily for my own training, but in support of others.

It’s what I’ve done for years.

Time.

Performance therapy. Trackside therapy. Or in this case, “rackside” therapy.

Watching. Listening. Asking questions. Putting my hands on someone. Often suggesting an exercise or making small adjustments. Other times doing absolutely nothing.

Mostly, just being present.

Under Tension.

It (the long summer) has also reminded me of a few posts I wrote many years ago about the guiding framework behind what I do and, perhaps more importantly, how I think.

At the time, I wrote about starting with a technical model, sticking with basic principles, thinking motor learning, understanding regressions and progressions, and not being a slave to our methods. (See the post here)

Later, I simplified some of that thinking:

Know what you see.
Know what you don’t see.
Know why you don’t see what you don’t see.
Know how to best get what you want to see.
…so that you can see it consistently.

(See those posts here and here)

Looking back now, more than a decade later, I don’t think the underlying principles have changed that much.

But I have.

I think. I hope.

Because frameworks aren’t particularly useful if they don’t (generally) evolve with experience.

Which brings me back to time under tension.

I’ve spent many years doing this. Many hours in the clinic, in gyms and in sporting settings. Many conversations with athletes, coaches, other practitioners and athletes. A lot of observing movement and performance. A lot of examining. A lot of intervening.

A lot of load, sustained for (relatively) long periods.

Time under tension.

Trial and error. Practice. Reflection.

Trying something. Watching what happens. Questioning why it happened. Adjusting. Trying again.

Professional development time under tension.

Working and practicing with continuous and dynamic intent, paired with self-critical appraisal.

Time under tension.

So as this off-season nears its end, I find myself thinking about what my guiding framework looks like today.

Interestingly, in a landscape where almost everything seems to be getting condensed - social media, reels, less long-form writing, etc - I’ve thought about how I can condense my guiding framework as well.

Not that I needed to. But simply because that’s where my mind went.

Observe with attention.
Examine with curiosity.
Intervene with intent.

So that’s probably where I’m at today.

​At least for now.

I recently read two papers back to back. 

Coincidentally.

One on the hip adduction squeeze test. The other on ankle dorsiflexion.

Totally different authors, totally different joints, zero reason these two should have anything to do with each other.

Yet both of them had A LOT to do with each other.

Cross-pollination.
​

​The Squeeze Test Isn't Lying to You — It's Just Not Telling You Enough

Groin pain, adductor strain, osteitis pubis, yada yada yada. You get the point. Squeeze test's become the go-to way to flag it. And the reflex, in most places, is basically this: low score → prescribe adductor strengthening → move on to the next athlete.

Buchheit and King aren't coming for the test itself. They're coming for that reflex.

Their whole point is that the squeeze test is measuring whole-system output, not some clean isolated reading of just the adductors. Trunk control, pelvic position, cross-segment coordination — it's all mixed into that one number. So when the score's low, it could genuinely be coming from four different places:

• Pain - Protective inhibition kicking in. Just stop the test here.
  
• Direct deficit - The adductors themselves really are lacking.
  
• Indirect deficit - Something upstream isn't doing its job to optimize the output.
  
• Test execution - Way more common than we like to admit — bad cueing, no warm-up, athlete never actually gave a max effort.

The point is this — in more than one study (they cited), squeeze scores went up after rehab that never addressed the adductors at all. They worked on intersegmental control instead, and the system just got better at producing force in that position. Not the same thing as the adductors actually getting stronger, but the number climbed anyway.

So their proposed solution: Record pain and force, every single time, not just force. Ask if a low score is painful or painless before doing anything about it. Check the indirect stuff before jumping straight to adductor strengthening. And test unilaterally, eccentrically, through range — because testing bilateral and isometric and only in inner range is not dissimilar to testing hamstrings at 90 degrees of knee flexion and calling it a day.

My review: A squeeze is not a squeeze is not a squeeze.


The Ankle Is Basically the Same Story

Swap "squeeze test" for "weight-bearing lunge test," swap "adductor" for "ankle joint," and you're pretty much reading the same paper again.

Restricted dorsiflexion gets simplified every time, by default — same stretching, same mobilizing, same cranking, no matter what's actually causing the restriction.

Basically whack-a-mole.

Yet as astute, intentional clinicians will tell you, restriction can come from the joint, from a muscle-tendon issue, from neural tissue, or other and each one needs a completely different fix.

So this paper’s answer is a three-step reasoning chain built around a test most (not all) of us are already using anyway:

1. Quantify and qualify. Get your WBLT score, but also pay attention to *where* the pain or the block actually shows up. Anterior, anterolateral, medial, lateral, posterior — they all point somewhere different.
   
2. Confirm. Each zone has its own follow-up test to actually nail down the structure — posterior talar glide, a hallux-loaded WBLT, an inclined WBLT for the fibularis, a slump test for the tibial nerve. (My personal thoughts are that even more zones were left out - intentionally or not - yet are equally important to assess for)
   
3. Treat what you actually confirmed. Joint stuff gets graded mobilizations. Tendon tightness gets dosed stretching. Nerve stuff gets neurodynamic work. Three different problems, three different toolsheds. (My other personal thoughts are that there are other methods you can use to treat, but they included these so we’ll just go with them)

Same message as the squeeze test paper, just different anatomy — the test tells you *that* something's restricted, not *why*.


The Cross-Pollination

Neither paper cites the other. Neither set of authors necessarily even know the others (although I believe they do).  But put them side by side and they're making the exact same argument in two totally different area codes of the body.

Neither one's telling you to stop testing. Both are telling you to stop stopping at the test.

A low squeeze score isn't an adductor problem until you've ruled out pain, an upstream deficit, and bad execution. A stiff ankle isn't a joint problem until you've figured out whether it's actually the joint, the tendon, the nerve doing the blocking (or other - in my opinion). Same reflex both times — squeeze's low, strengthen the adductors; ankle's stiff, crank the joint — and same thing getting skipped both times, which is the one step that actually matters: figuring out what's really going on underneath that number.

Cheap, fast, reliable screens aren't the problem here. Treating them like the finish line is.

But I get it, most are done during preseason medicals.

But the takeaway, cross-pollinated out of two papers that have literally never been in the same room, is this: measure it, go figure out *why* it measured that way, then treat the thing you actually found — not the thing the test made easiest to assume.

There's a million roads to Rome once you get to the "how." But the "why" has to come first. Every time.