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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.
Rectus abdominisadductors, you can't do one without the other. So if you've trashed your adductors and they're floating around in your mid thigh, and then you try to tell me your abs are fine, which is what a lot of people will say, like, it's an adductor avulsion. It's an adductor tendon avulsion. There's a little bit of Kool Aid you gotta drink, but, like, to respect the fact that the abdominal muscles have sustained drastic trauma as well, to only try to just, like, bolt the adductors back where they started is
Dr JJ Thomas:Half the puzzle.
Dr. Alex Poor:Yeah. And it's missing the whole the whole core. Welcome to the Doctor. JJ Thomas podcast.
Dr JJ Thomas:For those of you that have been with us
Dr JJ Thomas:a while and those of you that are just joining us, the the intention of this podcast is really to serve as a resource for both clinicians and patients who are looking to educate themselves more on different ways to get better, get recover faster, stay healthy, get fit, all of those things. And so today we have a very special guest Doctor. Alex Poor, who's a core muscle surgeon and expert. An amazing doctor, an amazing person, and I've had the opportunity to work and share, collaborate on patients with Doctor. Poor through the last couple years and I'm excited to share him with you because he's got he's very knowledgeable.
Dr JJ Thomas:Thanks for being here.
Dr. Alex Poor:Yeah. Thanks for having me.
Dr JJ Thomas:Yeah. So if, if you I know there's gaps in like, I know little things like I know a little bit about your background and how you got into core muscle care. Can you fill the audience in for me?
Dr. Alex Poor:Yeah. Absolutely. So yeah. I'm a general surgeon by training. I went to medical school at Jefferson Medical College.
Dr. Alex Poor:I'm a local I grew up in Bucks County, went to Germantown Academy. Really enjoyed sports. They were a huge part of my life coming up. So that was my main reason for picking a college, which is a bad reason to pick a school, but then got into the sciences, obviously, just kinda following interests. Went to medical school, discovered surgery, kind of fell in love with just the mechanical nature of putting things back together.
Dr. Alex Poor:Picked my residency, which is the surgical training at Hahnemann, which is affiliated with Drexel. And the chairman there was Bill Myers, who was this famous liver surgeon who took out liver tumors down at Duke for, like, 20 years, and he was kind of a huge name. And I was really excited to learn that from him. And when I got there, the first patient I remember him having was on the Philadelphia Eagles. And I was a little as a local sports fan, I was like, man, this guy's got liver cancer.
Dr. Alex Poor:That's terrible. I can't believe. No one knows. And it turned out he had a groin injury.
Dr JJ Thomas:Yay. Well
Dr. Alex Poor:And, yeah, much better, than the alternative. But it turned out that that's what he was doing. And so by the time I started with him in, like, 2,007, 2008, he was really in full swing. He had recently repaired Donovan McNabb's core muscle injury and just basically people are starting to understand that this was a much more common injury. And so I just happened to step into that place.
Dr. Alex Poor:Yeah. At the perfect time and spent a good 4 or 5 years training under him. When I was getting ready to figure out what I was gonna do as a surgeon, he asked me to join him. Then I had 2 more years of training to finish up real quick.
Dr JJ Thomas:Wow. Real
Dr. Alex Poor:quick. Joined him. Yeah. It was a it was like a major pivot in my life because I thought I was gonna be doing cancer surgery, which was really cool, but then taking care of athletes, getting people back into doing the things they love just was incredibly satisfying. And being kind of associated with the athletics world is always, something that I enjoyed growing up and getting back into it after kind of a 10 year hiatus was just really, really fun.
Dr. Alex Poor:And, so then I joined him, and I've been at Vincero now for coming up on 11 years.
Dr JJ Thomas:That's so cool. Yeah. Yeah. So those of you that aren't local to Philadelphia region, Vincera Institute is a phenomenal institute. We were talking before hitting before starting recording how it's just, this feel similar to what we have here at Primal.
Dr JJ Thomas:It's it's not your traditional, you know, clinical setting. It's it's at the Navy Yard. You know, you just pulling up to the institute, you're like, okay. This is something that's not cookbooked, and it's super special.
Dr. Alex Poor:Yeah. I think the location is really helpful. We're just, you know, a short walk away from the stadiums. We're right by the Eagles practice facility, so we're convenient for a lot of athletes to get to us. And it's also I think there's just a little bit of an understanding.
Dr. Alex Poor:Yes. Much like when you walk into your facility where you just know that that someone's gonna be, like, they've taken the care to kinda put this place together in a way that makes sense, and we're gonna take care of everything that kinda needs to be figured out. And, hopefully, when you leave here, you're gonna walk out with a real plan, which I think is, it's a lot of fun. It also just I do a lot of explaining of kind of who we are and what we do because it's not always directly apparent from the outside.
Dr JJ Thomas:It it amazes me how I talk about this all the time, and I'm curious to hear your perspective on it. But, you know, patients we talked about before the, before we started about how we we treat the body as a system. So a lot of times we'll look at things and it will head us to the core very readily, you know, the the abdominal region, not just the core meaning the abdominal region, but the entire core abdominal back
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:Diaphragm, pelvic floor. But, but people for some reason, the abdominal region seems like there's no touch zone for people and and, you know, when we say, okay. We're gonna have to work in your abdominals. They're like, what? You do that?
Dr JJ Thomas:Like, yes, we do that. It's a muscle. What do you what do you mean? Why wouldn't I do that? Do you find that it's the same people are just shocked?
Dr. Alex Poor:Yeah. I mean, I think one of the other things is for me, I'm I'm, you know, probably 90% of the injuries that I treat involve these attachments of these muscles to the pelvis. And that's just like people don't even wanna tell me what hurts. You know, they come in and they're like, it's actually lower. It's kinda, you know, like or they're freaking out and they've been to the urologist and they don't have testicular torsion or epididymitis and now they don't know what the heck's going on.
Dr. Alex Poor:And no one feels good talking about genital pain. And so there's a lot of just kind of yeah. No one wants to be touched on their belly. No one really wants to talk about their perineal pain. Mhmm.
Dr. Alex Poor:And certainly, I think when you're comfortable talking about the pelvic floor and you're comfortable I mean, I think as a woman, you are probably easier to talk to than as a guy.
Dr JJ Thomas:Like Yeah.
Dr. Alex Poor:It's just not a really I
Dr JJ Thomas:also as a woman therapist. I mean Yes. But you're right.
Dr. Alex Poor:I I just think, like, the whole, like, urologic world versus the OB GYN training, like, there's just understanding of kind of, like, pelvic anatomy, pelvic symptoms, pelvic pain that, female therapists and female physicians are just kind of more in tune to. And I can tell you, like, your average high school male kid is not that in tune to, and that's a lot of people who end up treating. And so just kind of getting over that uncomfortable nature of, like, are you gonna press on my
Dr JJ Thomas:Right.
Dr. Alex Poor:Belly? Are you gonna talk about my testicular pain? And once you get into that world, you realize it's not that big a deal, but there's just a lot of fear associated with it.
Dr JJ Thomas:Yeah. One of the things that first impressed me about you when we first started, collaborating on patients was that, and I I use this as a guideline oftentimes when I'm, picking my favorites. You know? But, I remember, sending you a patient who I knew had a a clear umbilical hernia. And, and I remember thinking that you were going to I remember thinking he probably needed a repair, first of all.
Dr JJ Thomas:And I remember thinking that you were gonna tell him that he needed a repair. And you sent him back, and you were like, I don't I don't think you should we should repair it yet. I think you should try a little bit more therapy. And and I just I always respect that when doctors have their own system of clinical judgment on when not to do surgery.
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:And so I was curious if there's a way I'm sure that what goes into that decision is very deep and convoluted, but if there if there's a way you can summarize it in some shape or form, who's who's a good who's a good clinical decision to do surgery on and not. And I'm sure some of it's gut, but anything concrete, I'll take.
Dr. Alex Poor:Yeah. It's I will admit there's a lot of kinda intuition there. But I think one of the biggest things that I've tried to be mindful of in sports medicine is that surgery has to be thought of as a tool just like many of the modalities that you have. Mhmm. And when they run out or they're you're obviously gonna run into problems with this strategy, then surgery is another tool.
Dr. Alex Poor:And I think that's how I try to think about it. So there are people who have surgical injuries that I've diagnosed who are in a place where they're throwing 92 miles an hour and their arm's fine and they're doing okay. I you know, I'm not gonna tell someone they need to shut it all down right now. So, really, my job is really the same job as yours, which is get people back to doing what they wanna do. Mhmm.
Dr. Alex Poor:And so when you've got somebody who's compensated, understands they're injured, but is in a place where they're getting stronger, they're feeling better. Yeah. The modalities that they're trying are working. Well, then I will often say, let's carry this through and see how far you can get.
Dr JJ Thomas:That's great.
Dr. Alex Poor:Yeah. I think also timing is a big part. For a lot of athletes, that means getting to the end of the season or getting until you're a little bit less dysfunctional. Let's make you a little more proprioceptive, a little bit more body aware, and then we can put you through surgery as opposed to trying to have you figure that out post op. And then, also, I just don't want people to jump into surgery because there's a lot of surgeons, and I think clinicians in general will kind of tell patients what to do.
Dr. Alex Poor:Mhmm. And you can get sometimes you can get a feel when someone feels like, well, I gotta do it because everyone's telling me I gotta do
Dr JJ Thomas:it. Right.
Dr. Alex Poor:But if you're not really committed to it, this, especially mostly procedures that I do, doesn't work unless you do the PT afterwards.
Dr JJ Thomas:That is great.
Dr. Alex Poor:Yeah.
Dr JJ Thomas:Also, I the last thing that you said is I think it's huge because we have that we have that philosophy in here too. Like, we really and you didn't say it this way, so I'm I'm not I'm not meaning don't take his his phrasing this way. But here, I say often, like, if a patient doesn't really wanna put in the work, we don't really wanna work with them. Yeah. Because because, first of all, they're not gonna have a good outcome, and and we'd rather spend our time on the patient that's gonna put in the work and gonna, you know and and it doesn't it's like they may get there.
Dr JJ Thomas:I'm not saying we never wanna see that patient again, but they're just not mentally ready for it.
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:So that's where that timing piece comes in. It's like, you know, maybe they'll be ready for it in 6 months or maybe, and it's probably the same kind of thing with surgery. Like, they just have to get there mentally.
Dr. Alex Poor:Yes. And I think, when it comes to surgery, like, so much of the right around surgery, it just kinda stinks. You know? Like, it hurts. Yeah.
Dr JJ Thomas:You have
Dr. Alex Poor:to take narcotics often. You have to just kinda drive around to visit. All of a sudden, you're you're a patient. You're dealing with, like, being ill.
Dr JJ Thomas:Yeah.
Dr. Alex Poor:And you don't wanna undertake all that and then just kinda be bitter about the whole experience. Like, you have to understand that that's the launch point to then getting you back to where you wanna be. And if you don't see it, then it's really not worth
Dr JJ Thomas:But, also, I've seen patients where they think that the surgery is gonna be the end all be all.
Dr JJ Thomas:Yeah.
Dr JJ Thomas:And I'm I'm always so fearful of them because I'm like, you just like you said, like, if you don't strength if you don't reeducate those the core muscles after they've had surgery just like a knee. That's the other, you know, I always makes me laugh how people treat different muscles differently. Like, you would never have surgery on a knee and then not go to therapy for it.
Dr. Alex Poor:Right.
Dr JJ Thomas:And it's the same thing with core muscle injury. It's like, if you're gonna have surgery, you have to reeducate those muscles so that they support your spine and pelvis.
Dr. Alex Poor:Absolutely. Yeah. And I I I do think there's, like, a a regimented approach to some some surgical procedures that just everyone's kind of vaguely aware of. You know? Like, oh, yeah.
Dr. Alex Poor:Aaron Rodgers, Achilles, you know, everyone kind of has an understanding of what that means, and they know it's a long road. But, yeah, I think certainly with the core muscle injuries, there's just a lot more mystery associated with it. So people, yeah, sometimes come in and say, I I want that thing that you did for that guy. Yeah. Make me better.
Dr. Alex Poor:And it's like, okay.
Dr JJ Thomas:You're a different guy.
Dr. Alex Poor:We're gonna talk about this a little bit. Yeah.
Dr JJ Thomas:That's right.
Dr JJ Thomas:Yeah. How about, I'd love to hear if there are different is there anything you can share about how the procedures themselves have changed throughout the 11 years of practice?
Dr. Alex Poor:Absolutely. Yeah. So the the anatomy of the core from my perspective, really starts at the origin of the rectus abdominis and obliques on the rib cage. The most important area is where these muscles then insert on the anterior aspect of the pubic bone, And that also happens to be just about where the inner thigh adductor muscles arise, or at least 3 of them, the adductor, longus, pectineus, and brevis. And so, basically, where they then insert on the distal femur is kinda the end of my domain.
Dr. Alex Poor:But everything in that part of the body is kinda fair game for me. And so one of the things that I think is really fun is, so I was a resident learning the basics from doctor Myers, kind of like rotating on his service for a couple months and then off for the rest of the year, and then did that every couple year or every year. And I watched him kind of evolve in terms of his understanding of this anatomy. And the biggest thing that this is all coming from is that just believing, and there's a little bit of you have to convince yourself and understand it, that the abs are really continuous with the adapters. And so
Dr JJ Thomas:Amen.
Dr. Alex Poor:Yes. Thank you.
Dr JJ Thomas:Thank you.
Dr. Alex Poor:This is why I love hanging out with you.
Dr JJ Thomas:It's so true. I mean, we don't yes. I'll I'll gush later, but you go you you finish.
Dr. Alex Poor:And then it goes on. So as a surgeon, that's where I emphasize it. But then, you know, pelvic floor
Dr JJ Thomas:Yeah.
Dr. Alex Poor:Spine. The the interconnectivity is just so vital and that's what you have such a wonderful grasp of. And, like, it grows exponentially from there. But to keep it simple for me, rectus abdominis adductors, you can't do one without the other. So if you've trashed your adductors and they're floating around in your mid thigh, and then you try to tell me your abs are fine, which is what a lot of people will say, like, it's an adductor avulsion.
Dr. Alex Poor:It's an adductor tendon avulsion. There's a little bit of Kool Aid you gotta drink, but, like, to respect the fact that the abdominal muscles have sustained drastic trauma as well, to only try to just, like, bolt the adductors back where they started is
Dr JJ Thomas:Half the puzzle.
Dr. Alex Poor:Yeah. And it's missing the whole the whole
Dr JJ Thomas:core. Again, like, I I keep drawing analogies to the knees because for for many people, the knees are very, an easier image. Right? But, like, you would never treat a knee without considering the hip position. Right?
Dr JJ Thomas:Right.
Dr JJ Thomas:And it's the same thing with the adductors and the and the abdominals. It's like they're they have a common attachment. They largely affect each other. And like you said, if one's inhibited or injured, the other is gonna be affected.
Dr. Alex Poor:Absolutely.
Dr JJ Thomas:Yeah.
Dr. Alex Poor:So where we've kind of evolved is I remember in the old days, in the early 2000, the not so old old days Yeah. My perspective, the the the, like, adventurousness into the adductors, it was always kind of, like, alright. We have to fix these adductors because they're damaged. But, like, it was always a kind of feeling out process. And then I had, like, a good 2 years where I was, like, an old school apprentice where we just did all the cases together.
Dr JJ Thomas:That's great.
Dr. Alex Poor:And that really made me comfortable just delving into the adductors. And what I do differently today versus 5, 10 years ago is all of those old adhesions from all the previous growing strains that an athlete has picked up, basically reestablishing the glide between the adductor and the overlying fascia and making sure that fascia's as continuous as possible and as normal as possible is just a huge part of the procedure. Whereas in the old days, we used to just, like, try to loosen up a little bit and get some stitches just to kinda reattach it. And now we're understanding going all the way distally along that muscle is the best way to kind of And
Dr JJ Thomas:when you say going a lot all the way now this is for clinicians, but are you doing are you kind of, like, doing tonotomy along the way, or how
Dr. Alex Poor:do you how do you achieve that? Primarily, it's kind of dividing in the same plane, like, in the same direction as the fascia. So go deep to the fascia by making an incision, And then just there's all these kind of, like, varying degrees of flimsy and really thick adhesions between the muscle and the fascia, which you can attack from a million different ways. Mhmm. But it's sometimes so incredibly simple just to
Dr JJ Thomas:When you see it, I mean, you're, like, looking at it. Right?
Dr. Alex Poor:It's right there. Yeah.
Dr JJ Thomas:Yeah.
Dr JJ Thomas:Yeah.
Dr JJ Thomas:I mean, we're feeling it, but it's, like, it's almost, like, it sounds to me, like, you can take an elongated like, you have a tunnel approach
Dr JJ Thomas:Yes.
Dr JJ Thomas:Where we have to come in from the exterior.
Dr. Alex Poor:Yeah. So we're at 90 degrees and we're underneath it. So it's just a matter of cutting it or even bluntly just dissecting it. Yeah. And then there's all these neurovascular bundles, which are branches of the nerves and blood vessels coming through the muscle that then kind of fan out and spread along the fascia, which is why there's so many pain fibers in the fascia.
Dr. Alex Poor:Yeah. And those little tether points are where things get hung up. And so that's where you get the scarring kind of starting from. And so kind of dividing along those little penetrating bundles down along the muscle, at least temporarily, we can kind of restore normal function there. Because if you're getting a muscle that's getting yanked every time you try to fire it, that inhibits the muscle.
Dr. Alex Poor:And so we're trying to undo that. The problem is anytime we touch anything, it scars down again. And so that's why the post op PTT is absolutely vital.
Dr JJ Thomas:But also, like, just to just to emphasize this point a little bit longer. If for patients now, if you're thinking about, an analogy I would give a patient is if you have a if you have a scab on the knee and you just keep you keep tugging, you know, even if it's even if it's on this part, you know, the the knee itself and you're extending the hip and flexing the knee at the same time, it's gonna open that scab, open that scab.
Dr. Alex Poor:Right.
Dr JJ Thomas:So it sounds to me like by by loosening the adductors or loosening the fascia between the adductors, you're basically improve also improving the recovery of the abdominals because there's less likelihood that that tight fascia and, musculature is gonna tug on that incision that you just made.
Dr. Alex Poor:Yep. That's cool. The key to the repairs because we are sewing muscle back together, which is something that's still controversial. I mean, you know, whenever I meet other clinicians, other surgeons, they say, like, how how do you sew the muscle back? What like, that's and, you know, like, in obstetrics, there's always this debate.
Dr. Alex Poor:Like, you make an incision in the rectus abdominis. Do you put some stitches to reapproximate that muscle in the midline? And, like, 50% of the people that train me in medical school were like, you can't do it because it just pulls through. And the other half were like, if you don't do it, they're gonna have a huge herniardialysis. Right.
Dr. Alex Poor:And I don't know if I don't know if anyone's
Dr JJ Thomas:Decided fully. Yeah.
Dr. Alex Poor:Yeah. But certainly, there's techniques where you can sew the muscle back together, taking advantage of those kind of different layers of the fascia, but, like, it has to have no tension. The second there's tension on it, it's just gonna be no
Dr JJ Thomas:gonna open. Right. So that's the key piece. That's really cool. Thank you for sharing that.
Dr. Alex Poor:Absolutely. I could talk about that all day.
Dr JJ Thomas:I love that. And I that's like for us as clinicians, that's a gift because we don't always get the one on you know, we know we know the good doctors and the good surgeons because we see how your patients rehab quite honestly, like and you know that. I mean, you probably see the reverse. Like, you know the good clinicians because you see how your patients rehab. Right?
Dr. Alex Poor:Absolutely.
Dr JJ Thomas:Yeah. So, so we know you're good, but we don't always know what makes you guys special. And so it's cool to hear those inside things.
Dr. Alex Poor:Well, thank you.
Dr JJ Thomas:Yeah. Yeah. What about, what other things what so let's go there. What do you look for in a clinician?
Dr. Alex Poor:So the biggest factor for me when when collaborating with someone is, kind of that intellectual curiosity that translates into a willingness to kinda work hard and try things. Again, because there's a lot of mystery and frustration justifiably associated with core muscle injuries in general, and this is also sometimes referred to as sporternia, although that term has a lot of problems, so I try to dance around it. But, you know, there's, oh, they just get better on their own or you just gotta rest or whatever. So anyone who's willing to say, like, alright. I've heard this kind of stuff, but let's see what it's
Dr JJ Thomas:all about.
Dr. Alex Poor:That's the kind of person that's really fun to work with and usually ends up doing a good job even if they're like, let's not know anything about this stuff, but let's talk about this. Yeah.
Dr JJ Thomas:You know,
Dr. Alex Poor:I do a lot of knees. What do you want me to do for this patient? That's usually pretty fun. I think also just a willingness to kind of like be aggressive.
Dr JJ Thomas:Mhmm.
Dr. Alex Poor:Because I I think one of the biggest problems is that when someone has an injury like this, you just kinda wanna put them on ice
Dr JJ Thomas:and Yeah.
Dr. Alex Poor:Not talk about it and not deal with it.
Dr JJ Thomas:Well, I'm glad you said that because it is it goes back to that fear associated with touching patients abdominals for some reason. I mean, I when I teach all the time I I'm I I teach a screen that would point them to the abdominals or not and when I have clinicians in my classes and I'm like, so now we're gonna massage the abdominals and they're like, yes. The abdominals are a muscle. There's no reason not to massage them. You know, we can needle them.
Dr JJ Thomas:We can do all these things. But, but I'm still amazed in 2024 that people are just fearful of it. And so I think that comes down to a clinician that maybe is fearful of of they have their own nervousness about it, and then they're afraid they're gonna scare that patient off. Right?
Dr JJ Thomas:Yep.
Dr JJ Thomas:So you just you have to be confident enough to just do what you think is right.
Dr. Alex Poor:Yeah. And I think there's a way to do it. Yeah. Like,
Dr JJ Thomas:I have
Dr. Alex Poor:to say, like, your enthusiasm is infectious. If you're like, I I got this. I know what you need. It's gonna feel weird at first, but let's do it. I think if you don't really believe what you're doing, you don't play into it, like, it's gonna come off as in genuine and people are just gonna kinda be like, I don't know.
Dr. Alex Poor:That was weird.
Dr JJ Thomas:So That's right.
Dr. Alex Poor:The the manual work and the touching is just it's I don't think we do this job correctly without it.
Dr JJ Thomas:Mhmm.
Dr. Alex Poor:And it's you just gotta move fast.
Dr JJ Thomas:Yeah. If
Dr. Alex Poor:you can't, then it's You do. Just not your
Dr JJ Thomas:And for the newer clinicians out there, that's just reps.
Dr JJ Thomas:Yeah.
Dr JJ Thomas:Like and probably same it was probably the same learning curve when you were like, you had that great experience 1 on 1 with doctor Myers. So you were able to you had, mentorship, true mentorship. And so you got those reps under a great mentor, and that gives you the confidence. So, I mean, newer clinicians that the take home here is if you're not confident in it, call yourself out on it and figure out what you need to be confident. And most likely, that's gonna be find a mentor or ask questions with your doctors that you know that are are doing great jobs.
Dr JJ Thomas:Or
Dr. Alex Poor:Yeah. I mean, I think that the search for a mentor, I I really feel for people that I mean, a lot of my friends are, you know, in similar fields, and they don't have that kind of, like, person that will tell them what they did wrong or point out when they're doing something wrong or tell them it's gonna be okay. And Yeah. Figuring that out for yourself is challenging. So I I don't think asking for help is a sign of weakness at all, especially when you're starting out.
Dr. Alex Poor:Yeah.
Dr JJ Thomas:And it's funny. I just had a I don't know why I feel compelled to share this story this but this morning, I had a 6 AM patient, and he, he had a rotator cuff surgery a year ago, and he was doing great. And then he had a flare up. And then I I was we were both out of town. He got a injection.
Dr JJ Thomas:He felt better for 35 days, he tells me. I saw him for the fur and then he's like, then it got worse again. So then I saw him last week for the first time in a long time. I thought it was his cuff just wasn't strong enough. We did some manual work and did some strengthening and when I saw him this morning he was like, it is not better.
Dr JJ Thomas:I feel like it's worse and and at first I wanted to be like, wait a minute, you know, and then I was like put your ego aside JJ. Let's look at this, you know, and then we found an underlying neck thing. So it's it's also being able to, like, listen just listen to your patients. Right? And just be, like, you know what?
Dr JJ Thomas:It's okay to not know everything. That's what prompted that conversation is you saying it's okay to not know everything.
Dr. Alex Poor:Yeah. But, you know, I mean, I think, like, believing in yourself, you're like, well, I did the right thing for the rotator cuff.
Dr JJ Thomas:That's right.
Dr JJ Thomas:So I
Dr. Alex Poor:have to listen
Dr JJ Thomas:to myself. Been better. Yeah. Exactly.
Dr. Alex Poor:Which that's a confidence and experience thing, which you can't really put in you can't figure out when you're gonna have it. But once you have it, that's an amazing tool. And I think that's I feel very lucky in that same way where I I am constantly second guessing what I've done for people.
Dr JJ Thomas:Sure.
Dr. Alex Poor:But there's also, like, at some point, you just need to open up and say, like, alright. What else what else is going on here?
Dr JJ Thomas:Could it be? Yeah. Yeah. What, so core muscle surgery, do you also do other interventions? I know you do.
Dr. Alex Poor:Yeah.
Dr JJ Thomas:Share with me some of them.
Dr. Alex Poor:Okay. So, the the the common theme here is just kinda moving the core muscles around.
Dr JJ Thomas:Okay.
Dr. Alex Poor:Right? So, like, the majority of what I do is sewing muscles back to the pelvis. That does include hamstring evulsions, rectus femoris, some of these ficeal growth plate evulsions that just don't get better or they retract really far for surgical. Some of these things are controversial, but I think as rehab techniques and suture and anchoring techniques have gotten more refined
Dr JJ Thomas:Mhmm. A lot
Dr. Alex Poor:of that controversy has gone away. The vast majority of sports med people agree that you fix muscles when they pull off the bone.
Dr JJ Thomas:I mean, yeah.
Dr. Alex Poor:It's not a huge controversy. It's just 25 years ago, it was too hard to do some of these smaller muscles. Now it's really not that technically that challenging. And then when you get a hernia, some people want their hernias repaired with an eye towards the the hole. And I did train in general surgery, so I'm sensitive to this where I just don't think that was, like, in in Halsteady in 19 fifties surgery, you just you'd fixed the thing.
Dr JJ Thomas:Yeah.
Dr. Alex Poor:And there are definitely clinics dotted over the world where they have a singular approach where they fix inguinal hernias a very specific way with an eye towards the anatomy, where I think they're doing wonderful things. And so sometimes people come to me to fix their hernias kind of because I understand the core and hopefully not gonna allow it to get buggered up in the process of fixing a hernia. And so that's the small part of my practice, but it's actually can be really fun because it's people who are usually doing a lot really kind of have this thing that just need to get behind them and then get back on track.
Dr JJ Thomas:And
Dr JJ Thomas:Yeah. So you get to watch. That that's Yeah. That's my favorite part of my job too. It's, like, watching watching this person be able to do the thing the the physical things that they weren't able to do prior to your intervention.
Dr. Alex Poor:Yeah. Yeah. So a lot of cyclists, golfers, and then, like, some baseball pitcher or somebody will come in with a hernia and they're just like, my mechanics cannot get messed up here.
Dr JJ Thomas:Yeah. Like, I have
Dr. Alex Poor:to get this thing taken care of because they're telling me I have to get it fixed. But can you just, like because a big sheet of mesh is kind of the alternative, and I have my opinions on mesh. Sometimes you need it, but if you can avoid it, especially down in the pelvic region, it's, it's worth avoiding.
Dr JJ Thomas:I love to hear that. Can we talk more about that? Yeah. So, yeah. Preferences.
Dr. Alex Poor:Yeah. So the thing about mesh is it's polyester. So it's No matter how thin the weave or lightweight, it's designed to kinda create scarring. And when it scars into place, you're just I mean, as someone who's in tuned to the fascial planes
Dr JJ Thomas:Yeah.
Dr. Alex Poor:You're just creating just havoc on that Yeah. By design. And that's what allows that fascial layer to become so strong that you're not gonna get a hernia again.
Dr JJ Thomas:Right.
Dr. Alex Poor:But what we've done in since the nineties is basically replace a 3 to 5 percent recurrence risk for hernias. That's gone down to, like, 1%. But then we've increased the risk of pain related to mesh.
Dr JJ Thomas:I've seen it.
Dr. Alex Poor:To, like, that's
Dr JJ Thomas:why I wanna hear more about it. Yeah. Yeah.
Dr. Alex Poor:And so if you if you go to any, like, large gathering of people, you can walk around for 5 minutes and you'll find at least one person who's like, yeah, I have a sheet of mesh in there. I don't love it, but it's there and it's okay. At least I don't have a hernia. And that's true. But I think there's an alternative to that, which is just kind of using your own tissue to repair the hole.
Dr JJ Thomas:That's great.
Dr. Alex Poor:And, again, mobilizing the muscle so there's no tension. The tension's distributed as evenly as possible. Yeah. Gives you the best chance to kinda get back doing your thing.
Dr JJ Thomas:So because what I also see we talk about treating the body as a system is that when people have had mesh, it it does it manifests on cross patterns. Right? It meant so for that pitcher, it probably plays a big role. But yeah. So that opposite shoulder, that sling
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:Will oftentimes be affected. That peck will pull in. And, yeah.
Dr. Alex Poor:Yeah. And I don't know how you mobilize it because it's plastered. And so I I think, like, you've probably had some success, but I think
Dr JJ Thomas:maybe that's doing, quite honestly, is I do the best I can soft tissue within that region, and then and then I I try to exactly what you're saying you do in surgery, actually, with needling. I needle outside. I try to take all the pressures from, the circumferential area around it. Yeah. And I just get them as loose as possible.
Dr JJ Thomas:Makes a lot of sense.
Dr JJ Thomas:But but it ends up oftentimes, as you say, being sort of a I'm I'm a little bit walking backwards up the escalator because, I do feel like it keeps pulling on them.
Dr. Alex Poor:Yeah. Yeah. It's a it's a you you're just not gonna win that fight.
Dr JJ Thomas:So do people ever take that out later? Like, is that
Dr JJ Thomas:Well, I
Dr. Alex Poor:end up taking it out, which is not my most
Dr JJ Thomas:I mean, people. I mean, I know. I'm sorry. But I've actually never had someone who said I'm gonna go I you know, people have fracture surgeries and they take the pins out. I've I've actually never had anyone tell me they took out the, but can they?
Dr JJ Thomas:If I have someone with that, can I send them to you? It's a big undertaking.
Dr. Alex Poor:Yeah. It's a lot. So just if if the mesh is this big, that means anywhere that the mesh is in contact, you have to carve it out.
Dr JJ Thomas:Pull the tissue away. Yeah.
Dr JJ Thomas:So you
Dr. Alex Poor:end up cutting
Dr JJ Thomas:a lot.
Dr. Alex Poor:And so there's nerves, there's blood vessels in the vicinity and all that. But I do get it. So there's another patient population that I see, which is people who have mesh that don't like it. Yeah. And very often, the mesh gets kinda knuckled, before it kinda freezes into place.
Dr. Alex Poor:And so if you just imagine taking, like, a towel, soaking it in water, and then putting it in the freezer Yeah. That's what's happening. Like, it gets stiffer and harder, and eventually, it's Yeah. That's what's happening. Like, it gets stiffer and harder and eventually it's rock hard.
Dr. Alex Poor:But in that process, if it kinda gets bubbled up a little bit, that little knuckle can just be poking you. And so sometimes we get away with just taking out
Dr JJ Thomas:the knuckle the
Dr. Alex Poor:knuckle Got it. And just moving the muscle around relative to the mesh. And so,
Dr JJ Thomas:the sounds like a compartment syndrome release. Like, it's just sort of like you're just like, sheesh, let me just make some pressure change here.
Dr. Alex Poor:Yeah. So, yeah, we'll we'll slice mesh. We'll, do a lot of that stuff. And we do that to the fascia a lot in the process of, you know, we talk about compartment compartment decompressions with respect to the rectus, abdominis, obliques and adductors. I mean, that's what we're doing all the time.
Dr. Alex Poor:That's where I'm talking about, like, loosening up that fascia. Yeah. And it's amazing when you get a lot of scarring either from injury or mesh or both. Yeah. You get a compartment center where that muscle just does does not have room radially to expand to accommodate a contraction, and so the muscle gets painful or inhibited or both.
Dr JJ Thomas:Yeah. That's really cool. Do you do injections and things also? Or do you
Dr. Alex Poor:Yes. Yeah. So, I know you had doctor Rodel on the on the show.
Dr JJ Thomas:I did.
Dr. Alex Poor:He's better than me, and I'll I'll admit it. But,
Dr JJ Thomas:He's pretty cool. Yeah.
Dr. Alex Poor:He's he's a winner.
Dr JJ Thomas:Better at core muscle surgery, though.
Dr. Alex Poor:Well, I don't know if he's ever tried, so we can't test that. Yeah. But so he does a lot of injections. He's just down the hall, and he's really busy, but he still is a great colleague and can sneak sneak patients in for me. And so if I need someone's hip injected or like a psoas or something that's tricky or potentially tricky
Dr JJ Thomas:under ultrasound.
Dr. Alex Poor:Yeah. Ask him to do it. I have an ultrasound probe and I do, so if I'm doing a lot of, like, needling to scarred up adductors Mhmm. I'll use the ultrasound and just make sure I'm I can visualize the vessels. But a lot of the stuff, I just do injections based on landmarks.
Dr. Alex Poor:And so because I'm operating on this part of the body all the time, I
Dr JJ Thomas:You know.
Dr. Alex Poor:Yeah. I don't know if I'm really doing much with the ultrasound,
Dr JJ Thomas:but I know.
Dr. Alex Poor:But steroids, and and local anesthetic injections kind of in the muscle surrounding where I do the repairs is big part of my practice as well. Okay. A lot for diagnostic purposes if we're trying to understand relative contributions of someone who has symptomatic femoroacetabular impingement and also has an obvious muscle injury.
Dr JJ Thomas:Mhmm.
Dr. Alex Poor:Are we trying to sequence out how we're going to fix it? Sometimes we do the hip surgery and the muscle repair at the same time. Sometimes we'll try one muscles muscle recovery. Most of these muscle injuries, you're back doing basically everything 2 to 3 months after surgery. Right.
Dr. Alex Poor:Hip surgery or
Dr JJ Thomas:It's not
Dr. Alex Poor:halfway there.
Dr JJ Thomas:Yeah. Yeah.
Dr. Alex Poor:Yeah. So sometimes we'll try to get away with it. And so we'll numb
Dr JJ Thomas:up the hip or we'll numb up
Dr. Alex Poor:the muscles and depending on the response, helps helps us gauge Yeah. Relative contribution.
Dr JJ Thomas:It's great. It's a very low invasive way of making a clinical decision. Again, one of the reasons we love you.
Dr. Alex Poor:Yeah. And then Johannes makes it all really easy, but he's busy. So sometimes I have to do it myself.
Dr JJ Thomas:No. That's good. That's cool.
Dr. Alex Poor:I wanna know clinically how you've seen PRP affect your patients' practice.
Dr JJ Thomas:Oh, good question. Yeah. And and all can I do all around? Because I probably have seen wait. You're doing research on PRP, are you?
Dr. Alex Poor:We published a paper in January showing our retrospective experience where,
Dr JJ Thomas:I just threw that
Dr JJ Thomas:question right back at
Dr. Alex Poor:your time.
Dr JJ Thomas:I can answer
Dr JJ Thomas:it still. I'm sorry. I wanna
Dr. Alex Poor:hear your answer, but yeah. The the the 10,000 foot summary is basically we had, starting in 2012, patients showing up who had had prior PRP
Dr JJ Thomas:Uh-huh.
Dr. Alex Poor:Mostly at the, like, NFL and, like, elite level, and then it very quickly trickled down to weekend warriors Yeah. To now where it's everywhere. And in the same window, we started seeing people with, like, full on bone growing in their adductors.
Dr JJ Thomas:And Interesting.
Dr. Alex Poor:That you know, we we call it heterotopic ossification. You can call it myositis, ossificans, whatever. It's a phenomenon that happens in trauma. So, like, if you get hit in the quad over and over as a running back, you can have a ball of calcium there.
Dr JJ Thomas:Right. Like, was it incidental and they already had it in the population you were working with?
Dr. Alex Poor:Right. So we were kinda curious. So we started tracking it. And it turned out that, like, over 3 years, everybody who had a bone or calcified scar tissue in their adductors had had PRP. So then we started tracking it prospectively.
Dr. Alex Poor:And, basically, we had we had the NFL players.
Dr JJ Thomas:Yeah.
Dr. Alex Poor:And what was cool about it is I think it was 31 patients came to us over the course of 2 seasons. So then we got on the horn and we called every head athletic trainer and team doc for all the teams, and we just said, like, okay. In the last two seasons, how many players had groin injuries? And how many of those patients do you think you treated with PRP? And it was really, really rough.
Dr JJ Thomas:Right.
Dr. Alex Poor:But what's cool is if you added up all the numbers, it was just about 30, 35 patients. So we think we saw most Yeah. Of the patients that had PRP
Dr JJ Thomas:Great.
Dr. Alex Poor:Injected during that time frame, and 50% of them had calcium deposition in their Wow. In their adductors, which basically for me, I can I can tell someone that's considering it, there's maybe a 50% chance you're gonna get calcifications there? I don't think it's gonna be effective because I think we see most people who who who would be coming to us if it doesn't work. It seemed like most of them end up coming to us anyway. Yeah.
Dr. Alex Poor:But the other thing is when we looked at the eventual post op outcomes, healing was slower because we had to do more and also everything was a little more fibrotic or a lot more fibrotic in some cases, but they did okay. Like, the end results at, like,
Dr JJ Thomas:3 6 months. Because I do feel like on the clinical side, when I most of the patients I've seen that have had PRP, it's either it's been hip it's been hip cuff. It's been like glute med min
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:Rotator cuff, and then knee. I'll say because knee the knee seems to be like sometimes it's like it seems like it's been everywhere in the knee, to be honest. Yes. Clinically, patients seem to respond really well.
Dr JJ Thomas:Okay.
Dr JJ Thomas:So I wonder how much is like, on one hand, I now that you're saying that, I'm like, I wonder how much I think placebo is a very strong event. Mhmm. And it does give people confidence, to go through the rehab, and they've also invested however much money in this procedure that, you know, if you need that to be committed, then great. But Yeah. I was 100% calling it the PRP because, and recommending it quite honestly.
Dr JJ Thomas:Yeah. Now I tend to recommend, again, certain doctors because I do feel like I've had experience with some doctors who are just sort of haphazardly putting a whole ton of stuff in there.
Dr. Alex Poor:Mhmm.
Dr JJ Thomas:Now hearing that because you guys were doing these injections. Right? So I'm sure you guys were very deliberate about what you were doing.
Dr. Alex Poor:Well, I've I've Oh, no.
Dr JJ Thomas:They just tried to figure. Yeah.
Dr. Alex Poor:Yeah.
Dr JJ Thomas:It would be cool to do a study where the control is, you know, the type of PRP, the right? Because I Johannes did a little talk here on his PRP stuff, and so we we learned about, you know, we learned about the deliberate thought process you can make about the type of, solution you're mixing with the, plasma. And, anyway, so it'd be really cool to have a study where it that part is controlled. Yep. Because I imagine, for me, I agree.
Dr JJ Thomas:HO is like a trauma response and so heterotopic acidification. So if if it was a ton of needle a ton of 10otomy and a ton of substance in there and the body was already under duress, then I would it would make sense to me that it would form bone. But
Dr. Alex Poor:I think, intra articular is probably safer Okay. Because there's it's it's in a confined space. Yeah. And I also don't know enough about it, but basically one very, oh, gross oversimplification, I hope you don't get bombarded with comments on this, but is like leukoreduced, like, so filtering out the white blood cells
Dr JJ Thomas:are hot.
Dr. Alex Poor:And that's, like, just one branch point when you're fine tuning the mixture that really matters. And so I've seen, I think, more of a fibrotic calcific response with leukocyte rich PRP, and I think that's fallen out of favor with a lot of clinicians that at least I talked to.
Dr JJ Thomas:Okay.
Dr. Alex Poor:And so I think perhaps leukocyte depleted PRP is gonna be less of a problem. But we didn't we didn't have the procedural notes for the majority of the patients in our study. So that's one thing that we talked about in the discussion where we don't know. Clearly, the technology is getting fine tuned.
Dr JJ Thomas:Yeah.
Dr. Alex Poor:And, you know, at one point, people were worried, like, well, should we not draw PRP from someone who's sick? Is that gonna change the constitution of the plasma too too much? And I think a lot of that's kind of been ironed out by people that know more about it than I do. But I would never hesitate to put PRP in the knee or hip joint just because I think you know whatever's gonna happen. It's a it's a fairly unique environment.
Dr JJ Thomas:Mhmm.
Dr. Alex Poor:What I think the issue is around the pubic bone is that these are little microevulsions. Mhmm. And so you've probably got little flecks of cartilage and bone
Dr JJ Thomas:In there.
Dr. Alex Poor:Sitting in there already.
Dr JJ Thomas:Yeah. And then Yeah.
Dr. Alex Poor:It's like a crystal. So you got a seed crystal, put the right environment around it, and it will just kinda grow.
Dr JJ Thomas:That makes sense.
Dr. Alex Poor:I'm not sure that applies to other places, but maybe these partial evulsions, chronic evulsions, that might be where I'd be a little
Dr JJ Thomas:more hesitant. It's less common in, like, gluteum in men even because those attachments are less likely to evolve as much. Right?
Dr. Alex Poor:That's fair. Yeah. I mean, I think that they're just super tight. Yeah. And I don't think that's I don't think the pathology
Dr JJ Thomas:is super tight. I've probably seen the most glute bead men PRP injections, and I haven't, I mean, I haven't felt that that was happening in any of them. And I am needle you know, not I don't needle. So I usually talk with doc about when, when and if to needle, but I usually wait in an area of PRP for, like, 6 weeks
Dr JJ Thomas:Yeah.
Dr JJ Thomas:Honestly. So but after that, I will needle it if I'm trying to get muscle recruitment.
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:And I would think I would I've felt HO before in patients through needling, you know, populating and then rate. I'm like, oh, you know, but I I haven't felt that with my PRP patients yet.
Dr. Alex Poor:Okay.
Dr JJ Thomas:So it'd be interesting to see.
Dr. Alex Poor:Yeah. I think also the glute med pathology is so frustrating for people.
Dr JJ Thomas:Yeah.
Dr. Alex Poor:And you really only have percutaneous options. Yeah. So even if you get some a little bit of, you know, like, fibrosis or whatever, if if it's functional at all, I mean, I'll be happy with that. So
Dr JJ Thomas:So I remembered remember earlier, I was like, I forgot. I know what I just thought of. I wanted to bring this up to you clinically. I often see a pattern a movement pattern where, especially in runners or athletes that run, which is almost all of them
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:The side of, like, a sports hernia, it's like the opposite hip is often even sometimes more dysfunctional tighter. And I think, you know, in my mind, it's that pelvic drop causing that torque on the
Dr JJ Thomas:on the
Dr JJ Thomas:adductor side.
Dr JJ Thomas:And is
Dr JJ Thomas:that something you notice too clinically? Okay.
Dr. Alex Poor:Yeah. So I mean, going back to your knee analogy, I I like to think about the rectus abdominis and adductors as like the ACL. So it's really a central stabilizer. Yeah. And I think the next thing that happens once that's off, you get some instability there, is basically everything else just tightens up to try to protect.
Dr. Alex Poor:And I think as a result, that's often when, like, QL glute on the contralateral side Yes. Just get, like, incredibly tight and get, like, the hitch.
Dr JJ Thomas:And so I have a
Dr. Alex Poor:lot of people who walk in being, like, I'm okay. And then you watch them run and it's like No. I don't think that's how you're supposed to run.
Dr JJ Thomas:But I
Dr JJ Thomas:always it's funny. I'm glad you said that because I always take it as the core muscle injury happened because of that tightness on the opposite side. That's right. Like, it's you know what I mean? So it's kind of I mean, either way, we have to treat them both.
Dr. Alex Poor:Yeah. Yeah. Same thing with, like, the hip FAI. That most people's bones kind of were determined before their muscles noticed that there was a problem. Yeah.
Dr. Alex Poor:So I think, like, the chicken and egg thing, I give the hip guys credit. They're treating the underlying pathology more often than I am. But, like, you can't you can't have these compensatory patterns without things kinda falling apart.
Dr JJ Thomas:Mhmm.
Dr. Alex Poor:And so, yeah, very often by the time if you train at a high level, if you run 50 miles a week, if you Right. Play varsity sport yeah. Sure. Right. Like, it's there's a repetitive stress.
Dr. Alex Poor:It does not take long for, like, multiple systems to to kinda show wear and tear.
Dr JJ Thomas:Yeah. Really cool. This has been awesome. Thank you so much.
Dr. Alex Poor:Yeah. Absolutely.
Dr JJ Thomas:I I don't think I have any more questions. Do you have any more questions for me?
Dr. Alex Poor:Well, I
Dr JJ Thomas:Shoot. We got that.
Dr. Alex Poor:I could talk about this stuff all day. But the Tell
Dr JJ Thomas:me.
Dr. Alex Poor:The things that I would like to understand from your perspective
Dr JJ Thomas:Yeah.
Dr. Alex Poor:Are, what is maybe the most useful variable from your perspective to tell someone to go consult with the surgeon?
Dr JJ Thomas:Oh, I'm so glad you said that. I actually had intended to bring that up. So I'm glad you I was just talking about this with, I think, another clinician. I think umbilical and personally, I've always found umbilical hernias are very easy to spot. Mhmm.
Dr JJ Thomas:Sports hernias are not as easy. And I always felt for a long for many years, I I hated saying that out loud. Like, I felt like I should just be able to feel it. I every doc I ask, they're like, you just feel it. I'm like, I can still feel it.
Dr JJ Thomas:I don't know if I feel it. So so I would love if you have any tidbits on our end. But when do I usually I give myself I usually give myself 4 to successions with them Okay. And I try to make a change. Yeah.
Dr JJ Thomas:And if I can't and if I can make a change in terms of their function and their symptoms and their unless it's ginormous. Like, there are ones, especially umbilical hernias where I'm like, you know, it's like 3 fingers and I'm like, for and for patients that don't know what I'm talking about, sometimes we measure the amount of separation by our finger breaths. And so it's like 2 to 3 fingers, usually 3, and I'm like, okay. Just call doctor Poore and still come back, and we're still gonna treat you. But that way, it gives them a little bit of push on it.
Dr JJ Thomas:Yeah. But, yeah, more clinical presentations. So 4 to 6 sessions change, and I'm looking for a symptom change, movement change. Like, a lot of times they will lock down.
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:So we do whole body movement assessments with all of our patients. And a lot of times we'll see with core muscle injuries, we'll see, just like we said earlier, tightness in the hips, but, a multi segmental rotation limitation or, even half kneel. Like, a lot of times I'll analyze these people in a half kneel position and their their hike will their hip hike will be way up on one side or their drop will be way very significant on the other side. So if I get them in a very regressed half kneel posture and their positioning is very poor and their balance is poor, then I may also tell them to go right away, but 46 visits.
Dr. Alex Poor:That makes sense.
Dr JJ Thomas:That's great.
Dr. Alex Poor:Yeah. I mean, I think for me, the way to kinda feel these things Yeah. It's it's if you can feel it, it's a big one.
Dr JJ Thomas:You know?
Dr. Alex Poor:So I I wouldn't beat yourself up over that.
Dr JJ Thomas:Yeah. Because I'm like, I miss I think I
Dr JJ Thomas:was sleepy that day in PT school. I used to tell myself.
Dr. Alex Poor:No. It's it's not. It's because these things are tricky because it even if you evulse a huge segment of the adductors, the fascia, the over like, fascia lata,
Dr JJ Thomas:feet,
Dr. Alex Poor:that stays intact in the majority of cases. When that rips, you can see it from across the room. Yeah. But a lot of times people have an avulsion and even surgically, you dissect down to the superficial fashion and everything's still intact. Yeah.
Dr. Alex Poor:Then you incise that and there's a big hematoma.
Dr JJ Thomas:Wow. Okay.
Dr. Alex Poor:From the outside, it's I think you can feel bogginess. You can feel swelling. Yeah. But you're not gonna feel discontinuity like you would with other things.
Dr JJ Thomas:That's great to hear.
Dr. Alex Poor:But pain and weakness are the 2 things that really can guide the exam. Yeah. And so if it's all kind of like bringing you back to the pubic bone
Dr JJ Thomas:Mhmm.
Dr. Alex Poor:Then that's usually
Dr JJ Thomas:A good indication. Yeah. Yeah. Yeah.
Dr. Alex Poor:And so I the trick, the one that's kinda mean that I don't really recommend, but if I need like, I have patients come in and they're like, it's like when you bring the car to the shop, it won't make the noise. Yeah. Totally. So if
Dr JJ Thomas:I'm trying
Dr. Alex Poor:to let them feel the thing that brought them in, if you have them do either, like,
Dr JJ Thomas:a v sit up or just a crunch and you apply some pressure on the lateral edge of the rectus right
Dr. Alex Poor:at the pubis Yeah. That will that's mean. That would be fairly provocative for people with an injury. If you can slam on that and they can hold a crunch position and they have no symptoms, then They're
Dr JJ Thomas:totally fine.
Dr. Alex Poor:Probably don't have an injury.
Dr JJ Thomas:Sometimes I feel like these injuries have a subtle like, they have a referral more here
Dr JJ Thomas:Mhmm.
Dr JJ Thomas:Too. Do you?
Dr. Alex Poor:I think it's hard to localize for people. Yeah. There's 2 things. 1 is once once it's below the belly button, people a lot of times are just kinda like it's somewhere down there. Yeah.
Dr. Alex Poor:And so they'll often point way more lateral. And when we get into it, it's right along that linea semiglinaris. The other thing is that the nerve ending or all the nerves in the lower part of the rectus kinda enter in that area where the posterior sheath drops off. That's a third of the way down from the belly button. Thank you to that motorcyclist.
Dr. Alex Poor:Yeah. The so the anatomy there is important. And so when all these nerves enter the rectus abdominis muscle compartment, just below where that rectus sheath stops, very often we have pain at that spot. And so people will be a little confused as to why they have kinda upper abdominal pain, and they'll, you know, get checked for appendicitis. Yeah.
Dr. Alex Poor:It's just it's just the way the anatomy of the nerves is laid out.
Dr JJ Thomas:Cool. Thank you. Yeah. That was very helpful. Yeah.
Dr JJ Thomas:What about you? I think you told me you like yoga too.
Dr JJ Thomas:So my aunt Ant. Yeah.
Dr. Alex Poor:Was a a yoga instructor in Hawaii.
Dr JJ Thomas:Oh, wow.
Dr. Alex Poor:And so I went to Germantown Academy, a great prep school in the area. And one of the things that is amazing about that place, and I hope they still do it, is they take the seniors and they kick them off for 2 months and have them go to an internship just so they let everyone else study.
Dr JJ Thomas:That's awesome.
Dr. Alex Poor:So I went out to Hawaii and lived with my aunt in Kona and went to her yoga classes, you know, lived
Dr JJ Thomas:That's great.
Dr. Alex Poor:Just like learned how to surf. Just had like a great time, but, she was a massage therapist and yoga instructor and really believed in what she was doing to help people.
Dr JJ Thomas:And she
Dr. Alex Poor:had a couple patients with like pancreatic cancer and, you know Wow. Suffered trauma and car crashes. And she was like trying to show me what she could do and I never understood it. Yeah. But then it was really fun when I went to medical school.
Dr. Alex Poor:We'd talk on the phone and I'd be like, hey, I think I know that thing you were trying to show me.
Dr JJ Thomas:Yeah.
Dr. Alex Poor:It's blah
Dr JJ Thomas:blah blah.
Dr. Alex Poor:And she'd be like, nah, that's that's meh, it's not quite you know, she'd be like not really down with western medicine and meditation.
Dr JJ Thomas:But it stuck with you.
Dr. Alex Poor:But it was there was enough crosstalk that we kinda aligned. And so I, yeah, I think that finding a way to activate muscles can be really hard in a dynamic setting.
Dr JJ Thomas:Mhmm. So
Dr. Alex Poor:if you just hold still
Dr JJ Thomas:Mhmm.
Dr. Alex Poor:And just try to activate a muscle, that can be really helpful. But, like, I I don't know. You need a context for that because it just feels weird just to kinda lie on your back and try to fire muscles. I'm sure you have people do it all the time, but it's hard.
Dr JJ Thomas:No. No. It's very hard. Yeah. No.
Dr JJ Thomas:It's input output. Like, that's what we teach in here. It's input output. That patients are like, well, what I'm like, look, from the minute you walk in the door, it's input. Like, if somebody doesn't make eye contact with you right away, that's poor input.
Dr. Alex Poor:Sure.
Dr JJ Thomas:You know? So it's and down to me touching you, down to me needling you, down to you you doing an exercise. So but I think with something like yoga and other exercises that give good input, like you said, just laying flat, they're not gonna have the input.
Dr JJ Thomas:Right.
Dr JJ Thomas:But now if you connect that chain and you do, you know, a twisted warrior where your elbow is connected and you're twisting and and they're gonna have that input.
Dr. Alex Poor:Yeah.
Dr JJ Thomas:So that's cool. I I was impressed that you, that you mentioned the yoga. I think it was through text. But Yeah. It's cool.
Dr. Alex Poor:I've I find people who can't help but cheat or they are too weak to do rep 1 of set 1, getting into a place where you can hold a position Mhmm. That's using that same muscle, but it just a little less provocative or a little bit easier to actually do it the right way Yeah. Has been helpful. But it really comes down to having somebody who can really guide you through it, which I don't know. It's not not everybody really kinda wants to Yeah.
Dr. Alex Poor:Focus on the the core muscles in a way that can be helpful.
Dr JJ Thomas:Yeah. Awesome. Thank you so much.
Dr. Alex Poor:Yeah. Absolutely.
Dr JJ Thomas:I hope this helped all of you guys. I know it helped me tremendously. I feel like, I feel relieved that I don't have to always feel that the sports hernias that I can just I can use this, I can use just palpation and and a little bit of a meanness every now and then if necessary. And it was really cool hearing about all the updates and how you progress surgery, PRP talk. Yeah.
Dr JJ Thomas:Thank you so much.
Dr. Alex Poor:Hey. Well, thanks for having me. This is a lot of fun.
Dr JJ Thomas:You guys, if you wanna know more about what doctor Alex Poor does, or you heard us talking and maybe some of these symptoms were like, oh, god. Maybe I need to get checked out. Check him out at the Vincero Institute. He's easy to find online. He's, as I said, very active, engaged professional in the community.
Dr JJ Thomas:So, and that's it for today. If you have any questions that I can answer, feel free to always drop a note in the discussion, and don't forget to hit subscribe so you don't miss out on future episodes.