“Play in the Gray”

We have all heard it from some family member, medical provider, online influencer, etc. Something definitive, extreme or final. “You can’t run after xxxx surgery”, “Deadlifting will hurt your back”, “Stop xxxx activity; it’s bad for you”. The reality is there are very FEW black & white issues when it comes to the human body.

Most of those black & white issues are related to severe life or death medical risk: Cancer/tumors, Spinal cord involvement, Heart/lung/brain. But even then, there is no consensus on one way to treat. We have recommended “best practices”, but those are (or at least should be) constantly changing and evolving. This is why sometimes it’s helpful to get second or third opinions on something more major. Sudden life-risking issues we have to do our best in the moment as providers and pray our training is enough to help. Sometimes it’s not. Thankfully, many times we as a medical society can make a difference and offer the opportunity for recovery.

Then, after an injury/illness you get to recovery- be it PT, post-op care, etc- and you hear any (or all) of those phrases above. Absolutes. Maybe you were a runner, now have some knee arthritis and are told you can’t run anymore. Maybe you are a dancer with chronic back/hip pain and told to just “stop dancing”. Maybe you are a post-partum mom with some leakage, being told “It’s normal” by your OB, or “I’ve had that since you were born” from your mom. Nothing is more disheartening than having an issue (pain, dysfunction, limitations) and being told it’s normal or a fact of life moving forward and to stop doing the things that bring you joy.

Let me make this clear: THIS IS NOT OKAY! The body is not built in absolutes. There are some more extreme cases where some of these recommendations may have at least partial validity. However, taking away a huge part of someone’s life comes with a cascade effect involvement of Mental/Emotional and Physical levels.

Let’s use the example of a runner who has been diagnosed with knee arthritis, told to stop running. After they stop, there is a loss of endorphins for stress relief, maybe they start sitting/eating more and gain weight. Then they get depressed at the condition of their body, stop going out as much or interacting with people from feeling ashamed. From here, more chronic health conditions develop (diabetes, heart issues) and more areas of pain which further limit mobility and participation in life.

Did that advice help that person? NOT ONE BIT. What would have been better? What about modifications to frequency/distance of running (maybe even just temporarily)? What about cross-training recommendations? What do we know about diet/hydration/sleep when it comes to cellular recovery- were those issues addressed? Could we have developed a program to improve mobility, strength, stamina, and endurance for this person to help balance loads/forces with running, thus allowing them to decrease pain and improve tolerance over time?

YES. A resounding YES. This is our role as medical providers. I get that Ortho’s cut, Sports Med docs often inject and Family Med docs are overloaded. But did you refer that person to the appropriate resources? Instead of take this pill and stop doing certain activities, gather a group of providers around you who specialize in different things: Personal & Fitness Trainers, Coaches, PT/OT/ATC, Nutritionists, Specialty niche providers (dancers, runners, pelvic health), Mental Health, Lifestyle/Wellness coaches, etc. Instead of thinking you have to be the one to do it all, what if you can offer your patients a team?

This is also where “Play in the Gray” comes in. As a PT, instead of giving my clients absolutes, I try to figure out where they are versus where they want to be, and what the path might look like to get there. There are many shades of GRAY in the world of movement. No movement is inherently bad. No pain is inherently bad. What if the body is just underprepared to control a certain movement or load? The answer isn’t to avoid it, but instead train the body towards success. This might come through exercises to build mobility, strength, control, stamina, etc. But this also might come from having a real discussion about overall health- mental/emotional issues, nutrition/hydration, and sleep/recovery. So often I find that these areas could use some work too, which will only mean we can maximize benefits of an exercise program. It’s also OK to feel pain sometimes. Not all pain is bad or a sign of damage. Sometimes pain is telling us we need to make an adjustment in order to move forward.

Going back to that runner. What if instead of “stop running”, the doc referred to a PT who discussed nutrition/hydration/sleep and provided some active strength exercises that didn’t provoke pain on visit one? Then on visit two, the PT began introducing more challenging load, adjusting for response. By visit 3-5, maybe its time to take a look at run mechanics to see if there are obvious imbalances in load patterns. What if that knee pain is actually a result of the big toe on the other side being stiff, not able to push well and thus landing extra hard? So we address that toe motion/strength, but also the leg strength to accept load. Or, what if the hip wasn’t extending well behind, leading to torque on the knee at push off… we address that hip motion and find a better way to create power.

Now, instead of a spiral into depression, weight gain, chronic health issues and loss of physical activity from an “absolute” answer, we have a person with knowledge of their own body. A person who has multi-dimensional training program and the ability to keep doing something they love, but in an even “healthier” way.

Play in the GRAY, folks. Play in the gray…