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Welcome to The Dr. JJ Thomas Podcast! Here I'll be talking all things physical therapy, raw and unplugged, giving you the unfiltered insights you've been searching for in your cash-based physical therapy business. If you're caught in the grind of the traditional model, swamped with paperwork, or feeling like you're not reaching your full potential as a physical therapist, this podcast was created just for you.
So unfortunately, when you don't look for the cause and you just treat that symptom, that's a very common time that we'll see patients that come back and they say, oh, I was sore for like 4 days. Welcome to the doctor JJ Thomas podcast. Hey, everybody. Welcome to doctor JJ Thomas podcast. I'm doctor JJ Thomas.
Dr. JJ Thomas:Thanks for joining us today. For those of you that are new, our podcast is intended to help clinicians of all kinds, basically clinicians that are specialists in the neuromusculoskeletal system, so physical therapists, chiropractors, orthopedic doctors, massage therapists, strength and conditioning, coaches, people who work with the neuromusculoskeletal system. We hope to help you up your game. We hope to help you have better results with your patients, and so all of our episodes are geared towards giving you tools to be able to get your patients and your clients better faster. Some of those tools are gonna relate to evaluation methods, some of them are gonna relate to, techniques that we can use, and some of them are gonna relate to exercises and exercise prescription in particular.
Dr. JJ Thomas:So today's episode, we use a lot of dry needling in my practice at Primal Physical Therapy, and, and we have a lot of success with it. Those of you that have are not new to our our episodes know that I'm an instructor in dry needling, and I've been using it in my practice for a long time, since 2009. And so I teach dry needling in our dry needling master classes and, I have a lot of valuable information to share with you, hopefully. Hopefully you'll see that in a little bit. So today, what I wanted to share with you, one of the questions I get frequently from, newer needlers is, hey, I had a patient and I thought I I worked on the right thing and they were sore for, like, more than a day or 2 days or 3 days or even 4 days.
Dr. JJ Thomas:Is that normal? It's not ideal. Right? We wanna dose our treatment in an appropriate way, and we wanna be able to have an effective strategy for using dry needling in a way that gives the results we want, but doesn't take the patient out of the game, so to speak, for more than a day or so. It really should only take soreness, post needle soreness, which should really only be 24 hours or less for most people.
Dr. JJ Thomas:So today's episode, we're gonna look at reasons why someone might be sore for longer than than 24 hours. And are there things that we can do as clinicians to, decrease that soreness time and do a better job of getting the results we want without the negative side effect which is is potentially, excessive post needle soreness. So one of the first things I see often when someone has excessive post needle soreness, so soreness lasting longer than 24 hours. One of the first reasons I'll see that is if we needled the wrong thing. And that's a very that's a very judgy thing to say.
Dr. JJ Thomas:I'm not trying to be judgy here, but wrong thing. What I mean by that is did we needle the cause or do we needle the symptom? So when, and I've made this mistake in the past, when a muscle or muscle group is highly irritable, I wanna say. It's super tight, it's aggravated, that can happen for a number of reasons. Right?
Dr. JJ Thomas:It can happen because it was overused, maybe it was just had too many reps of something, but often times it's overused because something else wasn't doing its job well enough. Right? So when patients come in, upper trap is a great example, When patients come in and they're like, oh my god, it hurts right here. They're craving. They're craving for you to get that upper trap and and, they almost give the impression that if you don't touch that upper trap they're gonna be unhappy.
Dr. JJ Thomas:Right? But you have to really seriously ask yourself, is there upper trap tightness truly from upper trap tightness or is the upper trap tight because something else isn't doing its job. For instance, is their cuff tight? Are their lats tight pulling on their shoulder? Putting them in this position, now upper traps are trying to prevent that downward pull.
Dr. JJ Thomas:Are their pecs pulling them forward? In our primal foundations class, we teach how to analyze movement, in a more effective way, in a more efficient way, so we can uncover these underlying causes. These underlying movement deficits that will, manifest into tightness in regionally interdependent areas. So what I challenge you to do is when somebody's complaining of that very tight upper trap or whatever muscle is very very tight, ask yourself, is that the cause or is that the symptom? If it's a symptom of something else and you go ahead and you needle that repeatedly and you're trying to get that thing to release, guess what?
Dr. JJ Thomas:It's number 1, it's not gonna release well. You're not gonna get a very good release because it's tight for a reason. It's tight because something else is not doing its job. Number 2, you're gonna make them really sore. It's tight because it's doing the job of someone else.
Dr. JJ Thomas:So it's already, when I say it's aggravated, what I mean by that scientifically is it's electrically, biochemically, and structurally deficient. It's it's in a altered state. It's in panic mode. It is trying desperately to compensate for something else. So when you go ahead and you needle that multiple times and you disrupt that tissue, that tissue is already disrupted.
Dr. JJ Thomas:That tissue is already under duress and it's gonna get sore, it's gonna ramp up and potentially not not reduce at all. So unfortunately, when you don't look for the cause and you just treat that symptom, that's a very common time that we'll see patients that come back and they say, oh, I was sore for like 4 days. And then your next question to them, well, were you better for it afterward? And if that's the case they're not sure. They're like, maybe a little bit, but it's not like, oh, it was worth it because I feel much better now.
Dr. JJ Thomas:It's usually like, I was just happy the soreness stopped, but I don't know that I'm much better. So if that happens to you, that's the first thing I want you to think about. Did you needle the symptom or did you needle the cause? Number 2 in that same sort of pattern is if you have poor technique. And what I mean by that is if you're not doing a good job of redirecting the needle.
Dr. JJ Thomas:Now if you're not new to my needling, episodes or lectures, then you're very familiar with this concept. If you are new to me, what I mean by redirecting is when we're pistoning up when we're bringing the needle and redirecting it, a lot of people when there are newer needlers, they haven't developed the skill of knowing when they're coming out into subcutaneous tissue yet. Again, this is something we teach heavily in our master classes, and a lot of my friends and colleagues that teach certification courses in dry needling do a good job of explaining this too. It's important if you don't know what I'm talking about and you're a needler that you make sure that you know what we're talking about. So, redirecting the needle.
Dr. JJ Thomas:Basically, you tap the needle in, you go in one path. As you go to redirect the needle, you have to make sure that you're pulling out enough that you get to basically subcutaneous tissue before you go into a new path. If you're not doing that and you're just doing this, the needle again and again and again, and you're not carefully redirecting out of sub q, you're going through that same path again and again and again. Heck, yeah. You're gonna be sore in that muscle because you just went through that muscle repeatedly again and again and again.
Dr. JJ Thomas:You you damaged or injured that tissue to a point where it's not even beneficial anymore. It's it's overdone. Now, is it going to heal from that? 100%. You know, you're not damaging them to a point that's unrecoverable, but you're putting them beyond a level of repair in a typical 24 to 36 hour, window of of inflammation that we would see in, like, an inflammatory process.
Dr. JJ Thomas:So poor technique, redirecting the needle. If you don't know what I'm talking about, make sure you find someone who can teach you, either locally. And if you're not sure, reach out and, shoot me a DM or comment. I'll be happy to help you find someone to help you with that if you're not local to me. The third thing we see often when people come in and they've been, had soreness longer than 24 hours from needling is that they were either over treated or under treated.
Dr. JJ Thomas:And so, what do I mean by that? If you've heard our episodes before, emphasize the test retest strategy. Part of the reason the test retest strategy, meaning we do an intervention, we do a couple, you know, I might do 1 or 2 muscle groups, area within that, say I have a say I'm working on someone's shoulder and they're in the prone position, and I'm gonna treat before I even touch them, I'm doing a prone shoulder flexion test and maybe a prone external rotation test. I'm looking at their quality of motion. I'm looking at where I think I might want to address, what limitations, like what do I actually see looks restricted in that pattern.
Dr. JJ Thomas:And And then I'm gonna put a couple needles and and work them there, and then I'm gonna retest right away. So every, you know, potentially 2 to 3 needles, I'm taking those needles out, throwing them in the in the container, and then retesting right away. Because the the real art to doing a good job of treating our patients effectively and not overtreating them is to as soon as their range is what it needs to be, that's it. Right? And each time what you find when you use this strategy, this like test, retest.
Dr. JJ Thomas:Test, do an intervention, retest. Test, intervention, retest. When you do it that way, you become very skilled. You develop your own clinical patterning and you really hit the nail on the head with that patient in terms of catching at each reassessment phase being able to say, okay, great. Now they're opening up better in the anterior shoulder but I still see them sucked in and and tight tight in that infraspinatus teres minor major region.
Dr. JJ Thomas:That little that little triangular space right here. And so I'll needle that and then I recheck. Good. Now that's opened up. So when you when you treat that way, you minimize the risk of this overtreating or undertreating.
Dr. JJ Thomas:Right? Because we're using our movement, we're using their movement as a as a way to measure our effectiveness with the needle. When we do that we don't miss it often. But if we just go through and we're like the first time we evaluated them they're restricted here and I I have this list of 10 muscles and I just power through and I do all of them, I have a greater chance of doing this over treating which kinda presents as, like, what would happen if you used poor technique. Because you're just over damaging the tissue.
Dr. JJ Thomas:You're over you're creating more inflammatory inflammatory response than needed for the response that we're looking for. Now, undertreating is a different scenario. This happens often when clinicians, you know, this happens most often when clinicians are working with a patient that maybe doesn't tolerate the needling so well. And unfortunately, you know, most of us that got into physical therapy we wanna help people, we don't really wanna hurt people. So sometimes if somebody's not tolerating the needling well, you may find that you wanna stop early.
Dr. JJ Thomas:The the risk to this is that if you ramp up, you know, those of you that use a pistoning technique, you know what I'm talking about. You'll have, like, a build in the muscle. You can almost feel it getting ready to to give a local twitch response. And sometimes they'll get one, but you can feel the resistance to the tissue is still limited. And if the patient's in a lot of pain and you pull out at that point, but you haven't really released that tissue, you run the risk of having them have excessive soreness.
Dr. JJ Thomas:Now, is that the end of the world? No. But they may lose faith in you for next time. They may feel like, yeah, I was sore for a really long time and I'm not sure that I really wanna do that again because if you under treat them, you're also not gonna see the movement changes that you need in order to gain their confidence in you and your treatments. And so this, all of these things essentially put you at risk for the ultimate problem, which is you not having the trust and loyalty out of your patients that you need to be able to prove your worth to them.
Dr. JJ Thomas:And and most importantly, get them better in the long run. So, don't needle the symptom, find the cause, needle that first. If you think you might be a offender of having poor technique, meaning you're not redirecting the needle when you think you have been? Find someone to help. The third thing is, are you over treating or under treating an area?
Dr. JJ Thomas:I'll say this happens most often in upper trap for the reasons I explained up here because people think they're treating a cause, but they're treating a symptom, and then they just, they're like, why isn't this thing loosening? This is so tight. I'm gonna needle it, 10 needles, and it's still not loosening. It's not loosening because it's not the cause, it's the symptom. It also happens a lot on the gastrics.
Dr. JJ Thomas:Like, when I first started teaching back in 2012, we used to say, like, the cast, they just get sore when you need them. They just do. And we kind of, you know, we chalked it up to various things. But looking back in retrospect, I think we over treated. I think we were over treating the calf when we should have been treating the underlying muscles underneath more, and that's how I treat now, and people don't get as sore in the calves.
Dr. JJ Thomas:Because oftentimes what I realize now is that more of the causes are those underlying, posterior tibialis, flexor hallucis longus, flexor digitorum longus. Those muscles, treating those muscles more specifically and doing a higher frequency of test retest to find which ones are actually giving me the range of motion change that I'm looking for, patients don't get as sore. If you find those 2 specific muscle groups are getting over sore, excessively sore on your patients, ask yourself if maybe you're doing those things. The last reason that people get sore is something that we have to consider, especially with our athletes overload, especially with certain types of athletes is, do they have the nutrients available to them for the recovery process? Right?
Dr. JJ Thomas:Needling, it it does stimulate an inflammatory response. It stimulates a healing response. And that's part of its value. Right? We're we're biochemically, electrically, and structurally inducing change in that muscle for the better.
Dr. JJ Thomas:We're resetting it. However, if that patient is highly over training at the moment, if they're I treat a lot of wrestlers and grapplers and and jiu jitsu athletes and MMA guys. If they're cutting weight, you have to be really careful with your dosing. Because if they're if they're nutritionally deficient for whatever reason, for some athletes, for runners, you know, they just might be packing on the miles and they may be having a hard time with their relative energy deficiency. You have to consider that in your dosing.
Dr. JJ Thomas:And so when I treat a grappler, one of the first things I ask them is, number 1, do you have a competition coming up? And number 2, are you do you have to cut weight for this competition? Are you currently managing your weight? Because I know that I really have to be mindful of the dosing that I'm gonna give that patient, in their treatment. I'm still gonna treat them.
Dr. JJ Thomas:If you listened to my I did an episode just a couple weeks ago on when to use e stim versus when to use pistoning. This is a 100% a time that I'll use more e stim versus pistoning. Because there's a lower inflammatory response, of the needle because it's really just 1 or 2 passes before you put the stim on, and you'll still get the benefits of muscle recruitment through the e stim without the need for a metabolic response. So, these are the 4 things. Really, I couldn't think I was thinking about this episode and I was trying to think of any other time that I've seen excessive soreness.
Dr. JJ Thomas:This is really it. So, it's not a long list. It's really a very deliberate mindful list. I've been needling, as I said, for a really long time, and I think it's a pretty comprehensive list. So if you think that you might be doing any one of these things and you have any questions, please feel free to reach out.
Dr. JJ Thomas:Leave a comment in the in the comment notes below. I love to hear your comments. I'm very thankful for all of you that have been listening and and, following along and your comments really mean the world because the As I said in the beginning, the purpose of this is really to make the world better through making patients better and to make patients better by making clinicians better. So I'm thankful for you guys and your your your time with me. I wanna continue to help so just hit me a DM if you wanna hear anything else, and if you have any questions on this, please reach out.
Dr. JJ Thomas:Talk to you soon.