Dr. Bo Babenko: Injury Myths and Misconceptions (Podcast)

Welcome to the “BarBend Podcast,” where we talk to the smartest athletes, coaches, and minds from around the world of strength. I’m your host, David Thomas Tao, and this podcast is presented by barbend.com.

Today I’m talking to Doctor of Physical Therapy and trainer, Dr. Bo Babenko. Bo has won many hats in fitness over the past decade. Physical Therapist, triathlete, CrossFit regionals competitor, and more.

Our conversation focuses heavily on what’s changed about physical therapy and recovery during Bo’s career so far, along with the most common myths and misconceptions when it comes to injury recovery. We’ll get right to it because this is one episode that can be useful to just about anyone who strength trains.

I do want to take a quick second to say we’re incredibly thankful that you listen to this podcast. If you haven’t already, be sure to leave a rating and review of the BarBend Podcast in your app of choice. Now, let’s get to it.

Bo, thanks so much for joining us today. The first thing I got to ask because you’re always constantly learning, every time we chat, you’re talking about something, whether it’s like a new module you’re learning, something you’re learning something new from. What is the latest in physical therapy and recovery that has your attention right now?

 Right now, it’s bringing everything back to the basics. We’re recording this during still quarantine times, and people are getting caught up with at-home workouts and things like that. I think that it’s a great chance.

What I’ve been doing a lot of my clients is, with the research, going back to the basic primal movements. How well do you push? How well do you pull? How well do you include tempo? Are we looking at tendon things that have been bugging you for a few years and you might have been pushing through?

At the end of the day, as much as I keep learning it all comes back to the same basic stuff of the body is what the body is. The rules are the same. We can keep trying to find all these cool new things that technology could be bringing at us.

At the end of the day, it comes back to how many tempo push-ups can you do and bodyweight things? In the physical therapy world, it’s coming back to let’s really look at injuries. This is a time to reset a lot of these constant simple concepts.

Let’s talk about tempo because that’s something that…I know you and I were sending some workouts back and forth at the beginning of quarantine.

I know that for a lot of time, people didn’t have access to their gyms. Some people still don’t have access to their gyms, so they’re wondering how they can get that resistance stimulus at home or with lighter weights, and tempo is a term people keep bringing up, and bringing up, and bringing up.

As an athlete, a coach, and a physical therapist, because you’re wearing all three of those hats, how do you view tempo as factoring into a resistance training protocol?

It really, again, comes down into the individualization of it all. If I’m taking a look at you and we’re talking about some concepts, I’m saying, ” Oh, you have a little niggle in your elbow that’s been there for a while.” How do we address that? Can we do one-armed tempo work? Do we need to do a bicep tendon type of program?

That’s one thing that I will come back to saying that tendon work tends to be very poorly understood. Heavy slow resistance training is the gold standard for me, at this point, of helping people improve their “tendinitis.”

Which, again, we can go further down that rabbit hole of what that means, [laughs] but as far as tempo goes, I wish I could give a simple answer. I know on these podcasts it’s great to give an easy answer of like, ” Hey, everyone should be doing four steps down, holding at the bottom for three seconds,” and that kind of thing.

It really comes down to progressively overloading that. I’ve been recently working with a lot more older folks too. For them, it’s really coming down to we just want to move nice, and slow, and smooth through that range of motion so you’re not rushing things as well, so you don’t have faulty movement patterns either. It’s got to be individualized in my really generic answer.

Let’s dial way back. When I first started strength training, I saw two different realms of thought. You could go really fast. You could do the weightlifting style power movements, moving with speed. The faster a barbell moves, the lighter it’ll feel.

Then on the other end, I saw powerlifting — and this was a misunderstanding on my part — powerlifting was very slow, it was grinding out the reps. We obviously know that to not necessarily be the case, but I saw it as two ends of the spectrum — very fast explosive movements and the very slow grinding movements.

I heard people telling me that both of those at different times are bad for you. If you move too quickly and you catch weights with a lot of force, it’s going to be bad for your joints. On the other end, you shouldn’t grind out reps because that’s going to be bad for your tendons and your joints as well. Neither of them are completely right.

You talk about a lot of these nagging tendon issues. Whenever you use the word tendinitis, I know you tend to use air quotes. This podcast is not for medical advice, it’s just for informational purposes and enrichment.

Why do you use air quotes when you talk about that in the context of resistance training and time under tension?

Tendinitis, by medical definition, the “itis” refers to the initial inflammation that’s happening. If you’ve had this for more than three months, that’s no longer is an itis. When we get down to the nitty-gritty of the biochemistry, biology of it all, if we look at it under a microscope, if it’s been there for more than three months, that’s technically tendonosis. It’s not an itis.

It gets a little tricky, you can have a re-inflammation and acute on chronic as we called it. I do think it’s important that we understand what phase of injury you are in. I use the term “injury” also with [laughs] air quotes because it’s not necessarily injury, it’s something we can constantly be working through.

If you start to feel it when you’re first warming up and it goes away as you start doing some lifts, you start adding some load, that’s a sign that when we’re talking as one-on-one, we might have to say, “Hey, this might lead us to try this intervention.”

I think it’s important that I’ll go a little deeper into the physiology that we talk about here. Tendons, when they are healthy, are stronger than steel. They are lined up in parallel.

When you have that initial inflammation, that itis, I’ll use the CrossFit example. Someone jumps in the class. They do a workout like Murph where they do a 100 pull-ups, 200 push-ups. I know some people that was one of their first workouts. Bottom line is that it’s like getting punched in the face.

Your jaw might be a little clicky, so it’s a little out of place. What happens to those parallel, lined-up tendons is they get a little wiggly. It’s like fraying rope. That’s the other analogy we use. If that’s going on for three months plus, and it’s not getting back to straightened out, the longer you have that issue and it gets more disorganized and more frayed, that’s what the osis is.

Some people have this for years. I can talk from my own personal situation. In my elbows, I know that I was always poking around in there. It didn’t cause me issues. There’s a lot of grip stuff in training for CrossFit that I mostly did. I knew that was there. It would go away most of the time. It never lingered for me. I would do as much as I could to thwart this as possible.

Now, as I’m a little further out from competing at a higher level, I am seeing some of that pop up now as I’m going to driving more, and being at home more, and not having access to as much weight as possible. I have a limitation of 185 pounds. I’m lucky for it, but at the same time, I’m used to having more weight, so my body is jumping at that saying, “Hey, I want more weight,” basically.

I’ll bring this all back to your question of specific adaptations to imposed demands. This is one of the most basic concepts in strength and conditioning, the SAID principle, S-A-I-D. It’s what our bodies adjust to. When we talk about tempo, to your other point about fast versus slow, if you’re only doing fast stuff, yes, your body will probably not do well with it.

If you’re only doing slow stuff, it’s going to have these effects on your body. Your body will adapt to whatever you impose upon it and it’s going to have other implications. That’s what we have to pay attention to.

That’s where we have to come back and say, “David, what’s going on with your body? How’s your stress? How’s your sleep?” All these other factors as well, “How’s your digestion?” Things that we can easily ignore.

When we look down at the workouts, the physical implications of it all, we have to say, “What is happening? What has been happening? What is your training age?” All these different factors, and how do we then steer the ship in the right direction.

What are some of the over adaptations that you see? Let’s start with CrossFit because that’s a sport that you trained in at a pretty high level and you’ve worked with numerous clients on. You talk about folks who just train fast or just train slow, that’s going to have implications. It’s going to work its way down the chain.

What are some of those implications you see in CrossFit training when it comes to certain biases in their training and in their movement?

The biggest one that jumps out is I joked around that day. It’s going to be lack of lats syndrome. In CrossFit, it’s very easy to not use your lat muscles for those…latissimus dorsi, those big muscles that help us do pull-ups.

Even though CrossFitters can do 100 pull-ups unbroken, the criticism online, of course, is that, “Oh, they’re just flailing around.” I do think that there is a place and a skill that kipping and butterfly pull-ups, we can certainly have that argument. That’s not what we’re going to do today, but the lack of lat muscle engagement.

I personally suffered from this. At some point, my best, I believe I was able to do 55 unbroken butterfly pull-ups, whatever that’s worth in the grand scheme of life.

The important thing there is that I ended up with a few shoulder small injuries as I went because I was focusing on overtraining that skill set of doing muscle-ups, doing a high volume of pull-ups, toes to bar.

It just never required that I engage my lats isolated or specifically, even if I was doing strict pull-ups. I could still do strict pull-ups. That is one of the things that I’ve seen happen in a lot of CrossFitters, and that’s what also can lead to, because everyone’s going to compensate a little differently.

For me, it was more of my backside of my shoulders, my posterior around the scapula. I had little knots buildup. That caused some pain down the line that we had to deal with. Other people, I see a lot of biceps tendinitis, tendinosis, whatever, whichever, how technically we want to go down that path.

A lot of biceps issues that start to pull into that because that, to geek out on a little, connects into the labrum of the shoulder. If you’ve heard of a torn labrum, probably more in the sport setting if you’ve been in around a CrossFit gym, I’ve seen a small percentage of folks who eventually end up needing laberal surgeries. We could go down the path of what’s the place for surgery, things like that.

Overdoing it in CrossFit, the number one thing is shoulder issues. Number two would probably be going too fast, not paying enough attention to form, probably some back stuff going on.

Earlier on in CrossFit, we used to joke around. Maybe when you and I met back around 2010, it was we called it shark fin syndrome where you just get that over development of the erector spinae muscles around the low back because people are just rounding. Their backs can adapt to that to some extent, but eventually, it’ll probably cause some issues.

Those are the two biggest ones that I’ve definitely seen. We could talk about hips, knees, and go down the path, but the shoulders and those lower backs are the two biggest in CrossFit.

Just to time peg this, I think we met around 2012. I’m not as OG in the spaces as you are, so I have to tip my hat to that. 2010 is literally a decade ago, but it’s like two decades ago in the realm of functional fitness and the CrossFit community, especially when you compare what was expected of elite athletes then versus what’s expected of elite athletes now.

Sometimes, just your average exerciser these days seems like they could give a very elite athlete in 2010 a run for their money.

Absolutely. It’s mind-boggling to see the evolution of the sport. You’re right. It was 2012. I started 2010. I always associate you with my entire CrossFit journey.

You’re right. For those listening at home, the funny anecdote here is when we met at CrossFit NYC, which was the most prominent gym in the area, I saw you over in the corner there. For some reason, maybe it was the afro — the afro added a few inches and body dimensions — but I really swore like, “Well, who’s this? Who’s this huge human being?”

I was coaching a class, I think. I looked over. You were doing something over on the side by the squat rack over there. Turns out you’re not as huge as [indecipherable 14:16] . [laughs]

It is weird, because you had this perception. I remember the first time we actually worked…I think we back-squatted together. We front-squatted or something like that together.

Do you remember just being really surprised at what I was lifting? Afterwards, you’re just like, “I’m going to be honest. I’ve only seen you out of the corner of my eye before and just assumed there was a lot more weight on the barbell and that you were a lot bigger.”

I didn’t really know how to take that because that both means that maybe I present as being this very big, strong guy, but up close…I just got to keep people at a distance because they’ll assume from a distance, certainly.

Let’s talk a little bit about how your approach to what you do in the professional setting has changed in the past 10 years. You came into CrossFit, I believe you were already practicing in physical therapy at that point, right?

Correct, yes.

Let’s specifically go with athletes here. How has your approach to working with athletes evolved over the past 10 years? Maybe a better question, what are some ways in which it has evolved? I’m sure it’s evolved quite significantly, as anyone’s profession does over a decade.

Bo: It’s been similar to the CrossFit evolution. It’s leaps and bounds from where it was in 2010. I got my doctorate in 2008. I had my CSCS. I had to unlearn a lot of things.

When I first started out, it was about assessing and doing these screens that you’ve heard of. The FMS, Functional Movement Screen, is very popular screen, things like that where I’m just looking at movement and looking at faults. In 10 years, I’ve seen thousands and thousands of athletes and probably hundreds of thousands of squat reps.

 The more reps you get with things like that, it should be changing your vision, so to speak. The biggest thing for me is I had to unlearn in CrossFit, we tend to be much more conservative, what was taught to me in school.

It has to be, “Oh, hey, you have back pain? Let’s start you deadlifting.” Oh, 85-year-old grandma, “Yeah, pick up. I’m going to teach you right now how to pick up that 32-kilogram kettlebell.” You’re going to get these faces like, “What, you’re going to break her.”

The reality of it is the human body is very resilient. That’s one big thing. The other big thing, the longer I’ve been practicing, I’ll have to say is…Now you’re making me feel like an old man. [laughs]

That was not my intention. I promise.

That’s all right. I guess that’s payback for me saying you were really big and not at the same time.

The big thing that I feel like I learned is there’s just…Hopefully, this goes the right way, or we can certainly dive into it. There’s just a lot of BS in the industry.

I continuously have to tell folks or have the conversation with folks, especially athletes, of, “Hey, I understand you’re going to see the other practitioner, the other physical therapist, the other chiropractor, what have you. Based on what you’re telling me, I think that all you’re doing is kicking the can down the road. You’re never addressing the actual…”

Again, we talked about that tendinitis, what the rope is fraying. You’re not addressing the rope-fraying. You’re just kind of distracting and snapping the finger over here.

It’s easy to manage the symptoms and to get you to the next training session. I understand if you have a competition coming up. Cool, let’s get to the competition. This is the most common thing I’ve seen in my over 10 years in the fitness space, is people just not willing to take any time off and address and really fix those issues.

Whereas, if you go to the car mechanic and they’re like, “Hey, if you keep driving this thing, in about 1,000 miles it might blow up. You might break your entire thing. It’s going to cost you a lot more money.” We’ll use the surgery analogy, but for the car, your transmission is going to be shot. We see that with athletes.

I’m not trying to be the “Chicken Little” guy saying, “The sky is falling down,” but I’m noticing a lot of these little problems going on.

If we take — and three months sounds like entire years in this space where it’s very compressed time in fitness — but if I’m proposing to them that we take the next three months to really fix, and rehab, and prehab, and let’s address all these issues, so that three months from now you’re going to go back…

I’ve seen it for those who actually buy in. They end up being stronger. Somebody who let’s say back-squats 500 pounds, they have issues, they work with me for three months. They start back at 45 pounds to back squat, and we work them back up to 500 pounds.

All of a sudden they have no pain, and they’re actually back squatting more because we’ve addressed those mechanics and some of those imbalances that are lying deep within their bodies that would never otherwise get addressed. That’s what I’ve learned, I guess. [laughs]

What are some of the misconceptions — this could be among athletes or it could be among the general population — that you see clients coming in with with? Assumptions they have in regard to recovery, or training, or the rehabilitation process?

The number one is the responses. Where you think it is, it ain’t.

Which is a…It’s a very old school saying by Ida Rolf, if you’ve ever heard of Rolfing. Have you ever heard of that [indecipherable 19:42] ?

No, no, I haven’t.

Rolfing is like a very, [laughs] very mean looking type of massage, basically. It’s based in this point of close to probably hundred years of where Ida Rolf was around in the early 1900, and it’s just very mean and vicious. Anyway, we don’t need to talk about Rolfing, worth looking up for some folks or trying…

Is it safe for work? Rolfing the word…

Yeah. R-O-L-F like rolling on the laughing floor, I guess. [laughs] Kind of the reverse of that, but R-O-L-F — look it up. It’s not anything like [indecipherable 20:16] work, but it’s very intense, to say the least. Basically, it’s kind of seeing how much you can take. Almost similar to a Shiatsu massage if anyone’s ever had that, but a little more in depth.

Anyway, the saying is, “Where you think is, it ain’t.” You asked me about these misconceptions that people come in with.

They come in, they pointed their back or they pointed their shoulder, and then if I’m looking at their big toe to say, “What’s going on? You’re a powerlifter or you’re an Olympic weightlifter, we need to check all the way up and down the chain.” Where usually the pain is, is not usually where it’s coming from. It’s usually where the majority of the stress is happening.

Again, when we look at lower back pain, sometimes it’s because you’re deadlifting and you’re rounding your back sometimes. Again, the body’s very resilient and does adapt to those things pretty well.

A lot of times it’s because the hips are misaligned or there’s an issue in one of your toes, literally, that you don’t have enough great extension and press off for that toe. A lot of times again, we tend to blame…As a patient coming in, I certainly understand, “I have pain in my back.” We need to address that, but the back pain is the victim.

A lot of times, we think of that as the criminal whereas the criminal is somewhere else. We got to find that criminal, basically. That’s the number one misconception that I see in clinical practice.

What are some of the assessment tools that you utilize these days? Again, this is specifically talking to athletes, or looking to and working with athletes, when it comes to movement patterns that might trigger a little alarm to say, “This is something that…”

Like that car example you gave. This is the faulty transmission, or this is you stripping the clutch that might cause you some trouble a little bit down the road. What are some of those assessment patterns that you like to take people through?

My favorite analogy there is actually driving with the emergency brake on that. Kelly Starrett, one of my role models, talks about that. He tells a story where he pulled up in Mexico or something like that. They pulled up to the hotel and didn’t realize their engine was on fire. [laughs]

They actually had the emergency brake on the whole time and was just driving like that. [laughs] The number one thing that we see as far as that, was that…?

What are some of the assessment tools and practices you’re using?

Oh, assessment tools. At this point, because a lot of stuff is also virtual, I still have relied on just basic movement patterns. Let’s take a look from a couple different angles with those, at this point again, millions of reps, let’s say. [laughs] In the course of my career, I think I’ve become a very good assessor of movement faults.

We break it down to the seven basic movement patterns that the primal body can do is push, pull, more in the upper body. Hinge, squat, lunge in the lower body. Twist, and then gait, or ambulate, so to speak, as the seventh. We look at as much of that as possible, and that gives us a lot of information.

In physical therapy practice too, we’re going to talk for 30 minutes. Make sure that you’re telling me your story, you’re telling me what’s going on. I’m going to pull out whatever information I deem most relevant of like, “I didn’t even realize my neck has a thing going on here, and I feel a little tingling in my arms.” Whatever that is, those things certainly add up to me.

The other big piece that I utilize is a handheld dynamometer which costs about a thousand dollars. I’ve had it for a while, and the batteries are very hard to find. In the old school practice, there used to be these huge Cybex machines which were the size of my room that I’m in currently or that you’re in now.

Those things cost tons of money, and they eventually got fossilled out, dinosaured out. They became extinct. They’re still use a bit in high level performance.

With my hand, being able to provide some resistance against, say, your arm holding out in front of you and pushing your arm down, in traditional physical therapy practice, we rate that on as on a manual muscle therapy scale saying, “You have a four-plus out of five.” There’s different ways that we categorize that.

In athletic populations, those numbers are very difficult to utilize, especially if I’m working with someone who’s really strong. I’m just not going to be able to break them, no matter how much force I put on or what mechanical advantage I take.

With the handheld dynamometer, it allows me to say, “Your right shoulder flexion provides, when I put the handheld dynamometer on, 72 kilograms of force. When I do it with your left, it’s only 52 kilograms of force.”

We’re doing this over a few reps, it gives us very objective numbers which the majority of us athletes that we’re talking about that we’re working with, they like to see, “How many kilograms of weight did I lift?” Or pounds, for some, [laughs] or stones for the British. “How much did I lift?”

It gives us that very clear number of 72 to 52, right versus left. It tells us something’s going on. It puts into that whole equation of everything going on. Unfortunately there’s no magical system. Sometimes people are looking for, “What’s the next thing? I need diagnostic ultrasound,” or “I need blood flow restriction training,” all these things.

There’s places where they fit. There’s things that each of these modalities will do, but I try to keep it old school, so to speak. Guys like Dan John, who you’ve had on, which was a great episode. People should go back and listen to that one.

It goes back to the simple assessments of how many kettlebell swings can you do in a certain period of time? If you don’t have pain with that, awesome. If you have pain with certain things, then we’re going to need to figure out why that’s going on.

It becomes this global ambiguous almost testing, but it’s definitely based out of, “Hey, this is the…” This is where, speaking of the current age, and we joked around about not going into political climate, but there’s a lot of AI coming along, technology, some of those conversations.

That’s where physical therapy might, we joke about it, but I don’t think it’s going to have a place for AI to come in and say, “If you have X, Y, and Z, we have to give you this intervention,” whatever it is. You need surgery if you have these things. There are some of these clinical prediction rules out there that the researchers have tried to come up with.

I just don’t foresee any time in the near future taking the science that we have and turning it into this very definitive thing. There’s this art form of coaching and art form of being a practitioner, which is why they call it physical therapy practice, or medical practice. We’re all out here.

If there was a rulebook, and let’s say it again, if David Tao blinks with his left eye, then we have to [laughs] give him a cortisone injection in his right knee. If it was like that, then we’d all be out of a job, but would it be a better world? I don’t know. I don’t know. That’s not for us to decide.

[laughs] You’re taking on the role of investigator oftentimes. The person, the subject that you’re interviewing is inherently unreliable because we cannot be perfectly objective about ourselves. If I’m describing pain, or I’m describing my movement patterns, or my lifestyle, or my training as I see it, it’s not going to be objective.

I’m going to have some subjective bias there when I describe it to you. You have to take that information, you have to cross reference it with what you’re actually seeing in the physical realm, and you have to see where the deltas are.

Where is the patient or the client being a little bit unreliable? Where they may be not seeing things, because if they’re being purely, truly objective about themselves, they might not have trained through that injury or they might not have pushed that movement pattern so much.

Absolutely. What that brings up for me is the actual model of evidence-based practice — that’s a term that gets thrown around — or research-based or research-informed. What that true model that I believe in is by Sackett et al in the research space. What it looks at in evidence base is there’s three parts to the way we should practice.

One is clinician experience. In my thousands of patients that I’ve seen with that similar condition, what have I seen? Second there would be what does the research say? If it’s saying elbow tendinitis, medial epicondylitis, whatever fancy term we’re going to use, this is what the research says.

Then the third part is that patient experience. They have cultural things going on. They have — that’s very well documented — that different cultures have different tendencies for pain. Men and women have different [laughs] tolerances for pain. Things like that. Yet, what are you willing to push through? Things like that.

It’s putting all three of those pieces together. Have you seen “Dark” yet, by the way? We were talking about that on our [laughs] text thread. It’s all about the triad man. It’s all about the triad.

I knew there was going to be some pop cultural reference that I didn’t get.

It wouldn’t be a conversation with Bo Babenko if there wasn’t a pop culture reference that made me feel very unplugged. I’m glad we hit that. I’m glad we got that in there.

There you go. I needed to get it. I know we were running down on time so…

We could do a whole other podcast on the pop culture references that I should understand, and you’re disappointed in me for not understanding. That’s a different episode, part two.

Bo, where is the best place for people to keep up to date with the work you’re doing?

My Instagram is usually the best place, and I just started a podcast of my own, “Bo Knows Stuff.” I think that’s available on all major podcast. Instagram is @drbobabenko. I wanted to go with Dr. Bo knows, but that’s actually taken. [laughs]

It is what it is. Hopefully, that finds you guys.

My company is FitCare Physio. If you care about your fitness, you’re going to be able to avoid the health care system. fitcarephysio.com.

 Excellent. Thank you so much for joining us. We’ll make sure to have all that in the show notes.

Thank you.