“The more you know, the more you know you don’t know” Aristotle

I’m currently in the thick of completing my final 12 week clinical at IFAST PT under the tutelage of Bill, and I can honestly say I’ve had at least one “aha” moment every day for the past 6 weeks. During these 8 hour days, Bill has provided me with enlightening insights which have furthered my current understanding and appreciation of the human body (and quadrupeds too), shifted my ideas and philosophies, or expanded my mind to something I never even considered. Getting to spend 40 hours per week in the 10ft x 10ft Purple Room with Bill has truly taught me the meaning of the Aristotle quote above because I now understand how much I truly don’t know and I will never be the same because of it. Here are 5 concepts that I have learned in the first 6 weeks…

1. Don’t be afraid to fail- This is important for me because as a student I’ve been conditioned to be afraid of failing. Bill said this to me the first day and he always reminds me of it. In the context of the Purple Room, and most physical therapy in general, the risks are relatively low since we avoid inflicting harm to our patient, and for most students, our CIs would stop us if they thought we would. So, unlike a surgeon, we are provided a little more leeway if we make a mistake. The three basic options that can occur from a PT intervention is 1.) something improved (ROM, Strength, Pain decreased, etc) 2.) nothing improved or 3.) something decreased. And even if something decreased (ROM, strength, pain increased), it’s not the end of the world because most people can live with a 5-degree decrease in hip IR, so don’t fret over a setback. But the important part of choosing the incorrect intervention is figuring out why it failed and trying to learn from it. Numerous times Bill has gladly let me complete the incorrect intervention that I chose because he knows I would gain insight because of it, and it is a no-risk situation for the patient. You are able to learn something from every patient, the ones that improve and especially the ones that don’t, so don’t be afraid to try and don’t be afraid to fail.

2. Context Always Matters- I can’t count how many times I’ve asked a question and Bill responds with “what’s the context/goal/situation?”. It may sound like an arbitrary answer but it’s important because the context of the question will determine the answer. The reason for doing a right lunge vs a left lunge in certain setups will change depending on the context or goal for that person. The context can be as simple as the muscle action changing when in an inhaled vs exhaled state or as complex as how does the environment affect the desired goal you are chasing.

An example of when context matters might be a person has normal ankle dorsiflexion in passive ROM but visibility limited during a squat. Context matters because when standing the person might lack hip control for any number of reasons and might resort to the plantar flexors as their main stability point. So, the PF muscles might be tonically active in standing which would limit DF in the squat. But on the table, you “ruled out” decreased DF as the limiting factor in the squat. Thus, taking information in one context (table ROM) and extrapolating it to another (squatting ROM) might mislead you and your decision making process.

3. Ask Yourself Why? This simple question will lead you down rabbit holes which will further your understanding of a subject at multiple levels. Asking yourself this question will allow you to critically think about a subject and truly comprehend the material because you will have to work through the problem step-by-step and find the correct information. A question Bill asked me this week was “why do gorillas throw like a grenade toss and not a baseball pitch?”, and then I found myself looking up gorilla anatomy at 10:30 at night. But the answer will teach you why humans have anatomy/physiology the way we do and might increase your gorilla trivia potential. I admire Bill because, after 25 years in this field, he is still asking why. He has given me a new appreciation for quadruped mammal anatomy because comparing dogs and humans can surprisingly answer a lot of “why” questions about our own anatomy, like why do humans have huge glute maxes? Quadruped anatomy will help answer this because comparatively, they have tiny glute max’s because we function differently. Answer: because one function of the glute max is to keep the trunk upright, and since dogs don’t typically stand on two legs they don’t need one.

Dead Guy Anatomy

Learning from Bill has taught me that the muscle actions from a dead guy on a slab of steel are vastly different (and sometimes misleading) than a living functioning humans. These are always “aha” moments for me because it gives greater meaning to the anatomy of our bodies and a new lens to look at movement. Here are 2 of many.

4. Why might someone get Achilles Tendonitis vs Patella Tendonitis? Both are similar tissues that are in the same plane of movement (Sagittal), so what would predispose someone from getting one or the other? To answer this, you need to look at the functional anatomy of the quads and the gastrocnemius. While both primarily act in the Sagittal plane in knee extension and ankle plantarflexion, a deeper understanding of their functional anatomy is where they will differ. All four quads have transverse plane actions across the knee from the patella tendon, acting to IR or ER the tibia or femur, depending on position. While the gastrocnemius functionally attaches to the calcareous through the Achilles’ tendon, the two heads act as the reigns on a horse that will individually invert or evert the heel in the frontal plane. So, while both Achilles and patella tendonitis are Sagittal plane results, a limitation in one of the other planes, frontal or transverse, might determine where and why the condition will arise.

5. Is the Flexor Hallicus Longus just a big toe flexor and plantar flexor?
The attachments of this muscle are the interior two-thirds of the posterior fibula, interosseous membrane, and base of distal phalanx of the big toe (sorry for the flashback to anatomy class). But what will the FHL do when the big toe is on the ground right before push off? If you follow the path the tendon travels, it slides right under the Sustentaculum Tali and the medial longitudinal arch of the foot. So, if the toe is on the ground during heel off and this muscle contracts, can’t you see how it might prevent excessive pronation, help control frontal plane position of the calcaneus since it is under the Sustentaculum Tali , and help provide stability of the Fibula because of its proximal attachment. Why do you think that some muscles have an angled attachments? Because the angle helps contribute to multi-planar motions and control. So, this tiny muscle that I thought was relatively useless in my anatomy class can play a huge role in ankle and foot function just based on task and position of the body.

These concepts have answered many questions for me but have me asking many more, as I hope they provide some thought stimulation for you as well. The first 6 weeks have allowed me to expand my depth of knowledge, altered my perspective, refined my critical thinking skills, and furthered my own desire for answers all thanks to Bill. And I will say this has been a full-service clinical because I have learned about everything from how gravity works by comparing it to laying in bed with your girlfriend, to what having a “DA” haircut means, and countless 70/80’s rock band and television show references.

Karl Busch, SPT