Smart Athlete Podcast Ep. 112 - Maryke Louw - THE ONLINE PHYSIO

The key is to listen to your patient actually. Because there’s, I think I’m really a better physio now that I can’t touch my patients because it’s so easy, especially at the end of the day when you’re a bit tired to just go in and massage people.
Smart Athlete Podcast Ep. 112 - Maryke Louw - THE ONLINE PHYSIO

MARYKE: [00:00:00] The key is to listen to your patient actually. Because there’s, I think I’m really a better physio now that I can’t touch my patients because it’s so easy, especially at the end of the day when you’re a bit tired to just go in and massage people. But the way that you injure yourself, your mechanism of injury gives me about 80% already of what would be wrong there. And that’s why it also helps to be a bit old. I’ve done physio for nearly 20 years now so I’ve got quite a lot from experience listening to people.

[Intro Music]

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JESSE: [00:01:18] Welcome to the Smart Athlete Podcast. I’m your host, Jesse Funk. My guest today has her Master’s in Sports Injury Management. She has two different businesses or two websites where you can find her and her team; and started in 2014 and 2018, respectively. Currently, she’s also working with a German startup and they’re building an app for evidence-based rehab for sports injuries. Unfortunately for us, US and North American people, it’s not quite available here yet. But if you’re in the UK or Europe, you can check that out. Welcome to the show, Maryke Louw.

MARYKE: [00:01:55] Thank you very much.

JESSE: [00:01:57] Thanks for joining me, Maryke. And as with all my guests, working through technical issues sometimes we have; just dealing with all the — both perks and downsides of technology. You know, batteries die, connections die, we got to make adjustments. You mentioned you had listened to a couple of my episodes prior to coming on. I don’t know if you saw the one I did with Alyssa Clark. The only time this ever happened to me, I was interviewing her, we’re halfway through the interview, and storming outside, the power in my house just goes out completely.

So, then I ‘m like — And on her end, as I go — I watched back through the recording. What happened on her end is she’s telling me the story, everything goes dark on my screen, I freeze, she’s still talking to me. And then it cuts out and she’s like, “Where did — Are you still there?” And so I cut it and I got back on, on my laptop and I had just enough battery to get through the rest of the interview and like used what little light was coming through from outside as it’s storming outside. Anyway, my point being we make the best adjustments we can with whatever snafus happens.

MARYKE: [00:03:22] Well, the laptop’s now plugged in, so it shouldn’t die again.

JESSE: [00:03:26] Good. Well, and hopefully, I don’t think — You said you’re going to go out after we’re done here, so hopefully there’s no storms or anything that’s going to interrupt your situation like it did mine.

MARYKE: [00:03:39] The glorious thing about Greece in the summer is you have four months of no rain. Nada. Nothing. So, yeah, no.

JESSE: [00:03:47] Actually, that reminds me, I didn’t write this down, but I do want to ask you is that it’s become increasingly popular as COVID has kind of made people work from home and get really used to that situation. I think you were involved in this lifestyle well before then, but kind of — it sounds like you’re a little bit more of a — I’ll say digital nomad, but you’re free to move around, travel a bit more and not necessarily have a — I’m here 12 months of the year and I take one vacation kind of situation. Is that accurate?

MARYKE: [00:04:20] Yes. So, the all online physio thing for me like you mentioned started in 2014. And when I was creating the website at that point to deliver it, every single physio I spoke to thought I was nuts. Because they were — you can’t do that. Even — I mean, I still get the question of patients: “But how do you physio if you can’t touch people?” And it was literally, it was born from the — We were in Costa Rica for holiday and I just went I can’t stand the British winters anymore. Do we have to go back? And then you start thinking how can I do this that I don’t have to have a winter again? And yeah, so it was born out of necessity just to have a lifestyle where you can actually move around.

Actually, your story, sorry, about the power cut reminded me a few years back, my dad got ill. And the nice thing is I could pack my laptop and go to South Africa where they live, and be there to help out. But South Africa has power cuts permanent on a very regular basis. And I remember once having a session with an American patient, and just before it started, the power just went out.

And you know that it just was going to happen again. And I still don’t know what she must have thought when she came on that call and it was just candles everywhere. And it’s like, I’m not trying to be romantic, but this is all we can do at this point.

JESSE: [00:05:39] First thought in my head was candles everywhere, I was like — See, you went romantic, my head went now we’re like in a Buddhist monastery and you’re like, going to try to convert her into your cult. Like, come to South Africa. This is the place for healing, like this whole other situation happening.

MARYKE: [00:06:00] No.

JESSE: [00:06:03] Which obviously you don’t because you’re recording patient calls, you don’t do that. But I wish you had, like a photo of that situation because I want to see what that looked like.

MARYKE: [00:06:15] Oh, man. It’s — Yeah. And it’s — I mean, even my friends in Britain, sometimes you say something about growing up in South Africa or a country like that, where things don’t quite always work. And you can just see they go, no, you’re making that up, you know? But yeah, you appreciate it when things work again, when you’re back in places where things just go as it should.

JESSE: [00:06:37] Yeah. Well, and it’s like, we take these things for granted and it kind of happened when I interviewed Mangi Mosehle who’s a pro cricketer from South Africa. And it was like, just where he was it was like normally he had — I mean, everything was fine, but he had gone somewhere, I don’t know if it was a trip to a friend’s house or whatever and he’s on this call with me and just — the internet connection was just spotty.

So, I ended up going back and it’s one of the few times that we really edited the episode because I don’t generally edit at all. Because it was like he’d say something but then instead of cutting out, it was like it elongated, like pause, it’d be like — The sentence to me would sound like this. So, it’d be like, “Maryke I… couldn’t believe that you could…” And it would just — It caught all the information, but it would like jam pauses in between things.

So, it was like, it reminded me of old school live weather reporting where the reporter’s speaking to the person on site, and there’s this big gap between like, how are you doing today? And then there’s like five seconds before they respond. So, it was — we were doing the best we could with the technology. And it’s one of those things that I mentioned sometimes on the podcast, and I do it to try to be grateful and appreciative of the things that we have and just realize that, like I am with you. Speaking to somebody halfway across the planet, like we live in the future, and I don’t think we appreciate that enough sometimes.

MARYKE: [00:08:24] Yeah. No. But you have to also spare thought for the people in Britain, because their internet is just as bad. I get better conversation like with you now, way further away from me. Whereas when you try with somebody rural in the UK, it’s like, nothing and it’s an island. It’s meant to be good.

JESSE: [00:08:44] Well, we’re — I mean, so where I am, we’re spoiled a little bit because we were the first city to have Google Fiber. So, that’s what I’ve got hooked up in my house. Yeah, so and I’m on a hard line. I’m not even on Wi-Fi with the desktop here. So, I’m straight in. There should be no lag at all, I hope. So, yeah we’re — at least here and the other cities in the US that have fiber internet are definitely spoiled at this point.

And you tend to forget, like what it was — I mean, I’m not particularly old, but I grew up with dial up and it’s like, that was ages ago, and you just forget. If you tried to exist on the internet with dial up now, you might as well just forget it. Yeah. But the point does remain that like what you do is enabled by the internet.

And so first, I have to ask, where were you like, four weeks ago? Because I could’ve use you when I like, I don’t know, I tweaked something in my back swimming. It was a rest week. I wasn’t even doing — It was the stupidest thing. And I kept being like, exactly what you do. I’m like, I wish there’s some way I could just call and be like, how do I fix this? So, first, thanks for offering such a service.

MARYKE: [00:10:10] It’s my pleasure.

JESSE: [00:10:11] Because it’s just — So, for you listening, I don’t know whether you were in college sports, but if you weren’t, for those of us that participated in college sports, we had at least a couple of years of time where you’ve got direct access to athletic trainers, if anything goes wrong immediately, without having to schedule an appointment or pay a copay or any of that. And so you get used to this something’s wrong, somebody can go look at it. Okay. This is our rehab plan, or this is — we’re going to tape it today, or just ice it or whatever it is. And then I’m 10 years post-graduation, and now it’s like, well, now what do I do?

MARYKE: [00:10:58] Yeah. Well, that’s actually the whole thing that got the founder of this app company that I’m working for thinking about building this app because he’s in Germany, he’s a runner, and he got injured. And he actually consulted me via the internet while I was in Thailand last year, beginning of the epidemic. And it frustrated him that he’d not been able to access medical health in Germany of all places where you should have it easily.

And he couldn’t get the right diagnosis and things. And then I managed to diagnose him, how far apart. And then he was working for a start up at that point and he chatted to a friend that they went, you know what would be cool, if we can build an app that can help people diagnose themselves immediately, and then get the rehab that they need? And yeah, it’s just transformed it.

Because I mean, also, with the online stuff, if you go on the website, you’ll see, oh, there’s people over the weekends, and I mean, because of the time differences. Americans love the UK times, because it means that they can get it after work, in the evenings, early, early morning, for instance, because there’s always a physio who’s got a slot somewhere along that. Whereas there’s no ways on Earth that your physio at home will be awake at six o’clock in the morning, or that you want to drive to your physio at six o’clock in the morning.

JESSE: [00:12:16] Yeah. So, it begs the question a little bit, you mentioned people saying you’re crazy when you were starting out, which I might add, generally, when you’re talking about entrepreneurship, if somebody calls you crazy, either, you in fact are crazy, or you’re on to something. It’s a coin toss. So, you know.

MARYKE: [00:12:39] I’ve gone from one to the other quite a lot in the last few years.

JESSE: [00:12:45] So, it begs the question, like, how do you — If you can’t actually touch and physically manipulate somebody, do you go, okay, like, how does this feel? Does this hurt? You know, that kind of typical way you would go through figuring out where exactly the pain points are, and what to do? How do you change that? Like, are we just talking about self-reporting of pain? Are you walking them through stuff?

MARYKE: [00:13:11] Yeah. So, the key is to listen to your patient, actually. Because there’s — I think I’m really a better physio now that I can’t touch my patients because it’s so easy, especially at the end of the day when you’re a bit tired to just go in and massage people. But the way that you injure yourself, your mechanism of injury gives me about 80% already of what would be wrong there.

And that’s why it also helps to be a bit old. I’ve done physio for nearly 20 years now so I’ve got quite a lot from experience listening to people. So, that gives you a good clue. And then you can make them do all the test movements that you would do in clinic, basically, in front of you in the camera. And that can give you a really good chunk of the rest of that knowledge. And yeah, most things you can diagnose pretty accurately like that.

But the key there is if you’re unsure about something, or you think the mechanism of injury makes it that you think, hmm, there can be something like a serious ligament injury or something, you need to refer. It’s not one of those things where you’re going to try and fix everything. But there’s certain things like muscle strains, tendinopathies, those things are pure rehab. If you’re doing massage or electrotherapy or something for that, you’re wasting the patient’s money because all the research shows that it doesn’t actually work. It needs graded strength training for it, and you can definitely do that via the internet.

JESSE: [00:14:33] I think it’s pretty groundbreaking that you just listen to people, and that’s the key, listen to what they’re saying. Like who would have thought you had to listen to what somebody was telling you.

MARYKE: [00:14:46] You know what, it drives me nuts because the number of patients that I get who come to me that says well, they’ve just had an injection for plantar fasciitis, for instance, and it didn’t work. — [crosstalk]

JESSE: [00:14:55 Like a cortisol injection or something?

MARYKE: [00:14:58] Yeah. And you see them and you go, “Okay. Where is your pain?” And they point to their Achilles. And you go, “But that’s never going to be plantar fasciitis, that’s under the foot if your pain is on the Achilles tendon.” And then he goes, “Well, I told the doctor that.” Just didn’t listen to their patient, did they? They heard foot pain and they just went with what they kind of heard.

JESSE: [00:15:20] They heard foot pain, runner, that must be it.

MARYKE: [00:15:24] Yeah. So, and it’s — I know it sounds — Uh, that’s not it, but honestly, there’s so many cases like that.

JESSE: [00:15:37] That is frustrating. And I think part of like, my personal frustration sometimes is that I almost just will avoid going someplace — Like, unless it’s something major. I ended up actually having a stress fracture in one of my metatarsals earlier this year because I — there’s this big push to do all these like lighter and lighter cushier shoes, and just — I was wearing some of those.

Frankly, they’re just too soft and it was just like — we weren’t building mileage too fast, but that’s the only thing I can break it down to is that — I even ran on it for three weeks. And I was just like, yeah, my foot’s a little sore. But then they came to be a couple runs I was like, no something’s wrong. So, I went and got it X-rayed and it was like, yeah, that’s — you should be healed in a couple of weeks. This has been injured that way for several weeks now. Like, oh, okay.

But I only went to this guy because my coach recommended it and like this particular doctor does triathlons, is an endurance athlete, is familiar with the culture. It seems like, at least growing up, and my parents would do the best for me if — this is pre-college, like high school. Just take me to a general practitioner, it’s like we wouldn’t get very good answers or like, they’d be like, I don’t know — I don’t know what’s going on. It’s like, well, that’s not helpful. Can you send me to somebody who actually knows what — And even specialists sometimes if they didn’t have — it seemed like for whatever reason, if they didn’t have any grounding in like, oh, this guy runs 40-50 miles a week, it’s probably related to that.

MARYKE: [00:17:20] Yeah. Well, to be honest, I will never forget, when I started working with the doctor that I worked with last in the UK, he was absolutely brilliant. He started out as really, really sporty himself, he was in the, I’m going to get this wrong now, the Air Force, I think. But then he broke his neck playing rugby, and that — when he woke up in the hospital, he couldn’t move anything below his neck, and that obviously changed his life. But he is an amazing person so he did get some function back and he could kind of walk afterwards, but needed the wheelchair and stuff.

And he went on to become one of the top sports physicians in the UK. But that experience, I truly believe, made him a better doctor as well. But also because he understood sports. And so many times I had people tell me about how when they went to see a doctor, like in the 80s, or something, and they would say, top runner, I get pain when I run over this, they would just say, well, don’t run that much. [crosstalk]

Yeah, that’s not really going to happen, is it? Because also as a runner, I know, some people will often ask me, can I run if I still have some discomfort or something? And I know for a fact that I have done that in the past, I can tell you exactly what, if you’ve got [inaudible 00:18:39] tendinopathy, just choose the right side of the road that the foot can’t roll in, you can probably go for a jog stall.

So, yeah, it definitely helps that you need a sporty background yourself or just liking sports. I mean, I’m not particularly good at it, at any of it. I just enjoy doing it. But yeah, if you’ve got a sports injury, I would always say look for somebody who actually specializes in it. I mean, my general practitioner, I want them to pick up if my heart’s going to have a problem, or I’m going to have a serious thing. And I don’t necessarily need them to know about sports injuries, all of that, but I definitely would like them to be able to refer me to somebody that knows about the right things. So, yeah, who you see makes a big difference.

JESSE: [00:19:24] Well, it’s like I often — So, I’ll run this by you since I’m not a physio. But my general rule of thumb, because I also do a show on running where I just talk about my experience and thoughts on coaching running and how to be a better runner and stuff. And sometimes people ask questions about injuries and I try to give my best advice, but also often hedge that with, I’m not a doctor, if it hurts a lot, go see a doctor.

Because people want to be like, well, you’re the running guy. It’s like yeah, but I’m not certified to consult you physically. So, my general rule of thumb with injuries is, if it doesn’t alter the way you run, you’re probably fine. But as soon as it does, that’s a good signal to one, stop, and then two, see somebody, is that a fair bit of advice?

MARYKE: [00:20:20] Kind of. Also, if — because you’ve got to also remember, long distance athletes and endurance athletes can tolerate a lot of pain before they take note of it. So, you ran with a fracture in your foot for quite a while by the sounds of it. [crosstalk]

JESSE: [00:20:38] Yeah. Like three weeks, but I guess it just felt like my foot was sore. It wasn’t even like a sharp pain. So, it felt more like a muscle or a tendon issue than it was a stress fracture.

MARYKE: [00:20:52] And it is an interesting thing though because I’m busy doing a series of videos on stress fractures, covering them all from the top to bottom. And it’s amazing how many people report that. And how the intensity of the pain cannot tell you whether it is a full on fracture, which it sounds if you actually had one that they could see it on X-ray. [crosstalk] It was just a stress reaction.

JESSE: [00:21:14] Right. It was on X-ray after it because it’d already been healing so he could see the section healing.

MARYKE: [00:21:21] Yeah, yeah. So, my thing with aches and pains is if it — Well, if you’re not injured, and you’re getting a niggle of some sorts, I would say, go for — do a easy session. Definitely not a hard running session if you’ve got some sort of a niggle, but then check how it reacts afterwards. If it’s kind of okay and it’s not worse by the next morning, then it shows that it’s okay. But check that delayed response.

Because often it will be — things like tendinopathy is and injuries like those will be absolutely fine while you run. You may even feel that oh running’s doing it well, because the pain is disappearing. But then the next morning, you wake up and you go, oh, that’s quite stiff, especially at the beginning, it’ll be a little bit of stiffness that goes away quite quickly, but then that will start to build. So, it’s about — Yeah, it’s what you’ve said — described there. If it’s not going away, and it’s staying there for a while, then I would, and especially if it’s getting more intense, then you need to get it checked.

JESSE: [00:22:21] This is kind of a call back to the interview you did on the Run Smarter Podcast, talking about runners being impatient, which is a little bit funny to me, because, I mean, as an endurance athlete, it’s like, your whole goal is to be patient, basically. Like you’ve got to — You can’t sprint out and then die off. Like you’ve got to be patient for a long period of time. And to get better, you got to be patient. But then — like when it comes to injuries, we get very impatient very quickly. It’s like, Maryke, I ruptured my hamstring yesterday, I need you to fix me today because I’ve got a race this weekend. Like, make it happen. But it just doesn’t happen. So, how do we or how do you coach more patience into your clients that have that need to go faster?

MARYKE: [00:23:23] Yeah. So, to be honest, that’s where I’ve been told I communicate like a German. I’m very direct. It’s the South African part of me, I think. I tend to not beat around the bush anymore. I give people all their information in the beginning. And I educate because I believe if somebody understands what the injury process is that got them there in the first place, and then understands how the body actually heals this thing, and how long it takes for that process.

Now, I tell them that the first session, it never goes in. Two weeks later, they inevitably kind of go, it’s still sore. So, I get them to mark on a calendar where the time is that we’re looking for it to be better so that they can — Because you know how it is if you’ve been injured for three days, it feels like four months, you kind of lose perspective in it. Yeah, it’s about education and it’s about — Also, there’s no fast rules in these things.

So, if somebody really wants to get back to being, I’ll give them okay, well test this. Let’s see how it goes. And often if they’ve tested it and gone, okay, no, it’s not great, it’s not ready yet, then they’re quite happy to sit back and — But I’m also a little bit lucky in the sense that by the time somebody has gone on YouTube and searched for solutions for their problem, they’ve already usually seen about three four other clinicians or they’ve had an injury for several months.

So, then they’ve gone through the whole I’m angry with this injury. I haven’t got patience, they’ve gone through the grieving and they’re in their acceptance phase, which makes life a lot easier because then if you’ve had something for so long, you don’t want to mess it up. So, then sometimes it’s more about going. No, honestly, you can start running again. Just start again, please.

JESSE: [00:25:07] Yeah. Yeah, there’s that hesitation because you’re like, you’ve been through it, you’ve been through the roller coaster of emotions, and all those kinds of things and you just — you don’t know what to do. So, then you finally get to that point where you go, okay, maybe I’ll try it a little bit. Maybe it’ll be okay. You know, I know, my wife’s gone through that. She had surgery for a labral tear, and she’s like, slowly gotten back into running.

She doesn’t run that much, but it was like, she’s taking it — Like, she’s been super patient. Just like, way more patient than I would have ever been like, building up from like, I’ll run for 30 seconds, and then walk for a minute and then I’ll run for 30 — And like, building up to — Now, it’s like, okay, I’ll run for five minutes and then walk. I mean, it’s been months. Because she doesn’t want to go through that again. It was such a horrible, horrible time. And it’s like that avoidance is more important than getting back to performance.

MARYKE: [00:26:23] To be honest, she’s being really clever about it as well, because I so many times meet people who say no, I can’t run again, because I just keep on getting injured. And usually, when you look at how they’re going about it, they have the mindset, a fitness mindset when they’re trying to do it. So, they have the same thing of I’ve just not trained for a while, I’m just going to ramp it up. And I can push through it, all of that. But what they don’t understand is that part that you’re injured, that tissue’s capacity is now reduced. So, it doesn’t have the capacity to cope with all the load from running. Because in that sense, running is a strength training stimulus.

So, for her with her labral tear, every time she goes for a run, that labrum will get some micro damage because we get micro damage all over the body when we run, and it’s when the body repairs it that we get stronger. But that repair, after all her rehab, her muscles and stuff will be brilliant and strong, cartilage will have strengthened a bit. But every run she does act as a strengthening stimulus for that repair. So, she’s doing the safest option by going that slowly. And if you’ve got an injury that just does not allow you to run, then it’s likely because you’re trying too hard to go in too quick and ramp it up too quickly.

JESSE: [00:27:37] So, thinking about what my wife’s doing, trying to get back into all of her running and workout routines and everything, should she — her hip gets a little bit sore after runs and she’s running twice a week and doing, like strength work the other two days, and she works out to try to make sure she doesn’t end up back under a surgeon’s knife so to speak. Although it was not that kind of surgery. So, with that, like kind of long term outlook, I think on the other podcast, you’d done, the Run Smarter Podcast, talking about timelines for change, not necessarily even recovery. But I think you mentioned something about eight weeks for muscles, but at least 12 weeks for tendons?

MARYKE: [00:28:34] Oh, yeah. To be honest, I think it’s even longer for tendons. I’ve changed my mind since then. I’ve seen so many now. Yeah. So, again, it’s useful to think about the structures that’s involved. So, if we think of cartilage, it takes months and months and months and months for cartilage to get full strength. If we think of just — actually, so most of the research into wound healing has been done with cosmetic surgery because their wound healing is really, really important.

But what they’ve shown is that the scar tissue of a cosmetic surgery wound actually takes up to a year and a half to fully turn over and settle back into normal kind of tissue. So, I don’t know if you’ve ever had a significant scar, you know, where you’ve just cut yourself or something like that, and it has that weird purple color for a long time. And then — [crosstalk]

JESSE: [00:29:24] Yeah, this guy — Gosh, I don’t know what it was. I was on a gravel bike trail and I went over the front of the handlebars and the gravel like tore it all up and there’s this chunk right here, it was just like, black purple for a long time.

MARYKE: [00:29:40] Yeah, you kind of think oh, okay, that’s my weird looking elbow now for the rest of my life. And then because it happened to be on my leg and just one day you kind of look at it, you go, oh, it’s normal color now. When did that happen? And it literally, it takes nearly 18 months just for that to happen. And this is again skin is something that heals quite quickly, although it’s also a lot of collagen in it. So, the main thing with this type of surgery and for knee meniscus injuries as well is people underestimate how long it takes for that tissue to really fully recover.

So, for her, I’m glad to hear she’s just running twice a week, because I think that — if she’s still getting sore after that, that’s probably the perfect kind of volume for her at the moment. And then the other important thing with that, because it’s a joint, yes, fine, she’s doing the strength training, so she’s giving it loads of support from the outside. But joints are interesting in a sense, and I never appreciated this when I was younger. Now that I’m getting older, my joints are not pristine. You know how when you sit still for a long period, and then get to move you go, oh, everything’s stiff. That’s basically because joints don’t have arteries and veins going in and out of them.

So, if you’re sitting still, and they’re not getting movement, there’s no change in what’s happening inside them. So, they need movement to get the nutrients in and out, to get the inflammatory stuff out. So, for any type of joint issue, if she — I don’t know how she feels about things like swimming, or cycling, but doing a type of sport, where there’s a lot of movement, but not a lot of impact, can be brilliant for joints, and really, really help to feed them. But I know that some runners really hate cycling, so it will depend on what she prefers to do. But if she can do it, and it’s pain free to do, then it’s something to swallow like a pill, basically two to three times a week, it can be really useful.

JESSE: [00:31:32] Okay. I’ll definitely pass it on. I know, she’d like to get a bike. And we’ve got the perfect kind of environment to do that around here. So, she’ll probably use that, use your advices, like more — we need to go get me a bike. So, now I know what we’re doing this weekend.

MARYKE: [00:31:49] Yeah. And what she may find is if she does have the bike, and she does regular bike rides, she may find that actually, the reaction after running is not as much. Or if she is left with some stiffness after the run, getting on the bike and just going for an easy ride should be able to ease that then.

JESSE: [00:32:05] So, this is probably a duh question, but for clarification sake, because I like to keep everything straight in my head as I was having a conversation with somebody else the other day, I’m a jack of all trades, master of none kind of person, so I need straightening out from time to time. So, because of the joint situation, I know, like when I talk about running, getting ready for races, it’s like you want to warm up, a part of that is lubricating your joints. Is that the purpose of that — like you’d have to go through those gentle motions to get all of the stuff in and out of the joints at that point; is that —

MARYKE: [00:32:40] Yeah, so it’s shocking when I really only at what point in my career, I only went: what does a warm up actually do, and looked into it. Because the truth is, when I studied physio early 2000s, we were pretending to be sports physios, but there was very little sports related stuff in there. It was all about disease and things. So, yeah, warm ups are amazing things. So, it depends also on what you’ve done for the rest of the day, kind of what you’ve already been up to.

But if you, for instance, like most of us, you either get up out of bed to go for your run, or you’re sitting and working all day, and then you get up to go for a run. So, in both scenarios, everything would have stiffened up a bit. So, you’re lubricating your joints with the warm ups, you’re getting that range of motion through it so that things don’t suddenly have to stretch when you go.

Because you’ve also got to remember you’ve got a capsule around that joint, which is like ligament type stuff. And if that’s been stalled for hours and hours and hours, it’s not quite as flexible. So, you’re improving the flexibility of all of those things along with it. And then there’s obviously that you’re actually waking up your nervous system. So, I always kind of smile when people go, oh, I’m doing activation exercises. All exercises are activation exercises. If you’re contracting muscles, you’re activating them. So, yeah, and I mean, if — especially something that I see a lot with my patients who work from home and who ends up sitting a lot before they go out for a run, they can literally cut the injury rates in half if they just get into the mindset of even if it’s an easy run, I need to do something to get my hips moving because they’ve been stuck in flexion all day.

JESSE: [00:34:23] It’s something I’ve kind of recently adopted. I think when I was younger, I could get away with it more just like heading out the door and go — like using the run as a warm up. It’s like, okay, but as you’re getting a little bit older, again, I’m not old yet, I’m early 30s, but you’re starting to feel it a little bit. And it’s this advice from Jason Fitzgerald, who’s a big kind of running advice guy, he has a blog on YouTube. He’s been on the podcast, and he’s big into like strength training for injury prevention. But one of the things he does is he has kind of a routine of like, strength work, so to speak, prior to going out to run.

So, like I’ve added that in [inaudible 00:35:07] on top of doing the mobility stuff, leg swings and hip circles and that kind of stuff, doing some squats and calf raises, and like trying to activate all those muscles and get all those things warmed up a little bit before I even head out the door. And it’s like, that was the big, I’ll say big nugget, which is kind of an oxymoron, I took away from him is that’s something I probably could have been doing for a long time to lower injury.

MARYKE: [00:35:38] Don’t you also just then suddenly feel, you know, how you can sometimes just feel heavy when you go out. But when you do that type of thing, then you just feel as if oh, I can actually balance, you know?

JESSE: [00:35:49] Yeah, the starts have been much better.

MARYKE: [00:35:51] Yeah. No, you’re definitely immediately ready. And there’s — So, the main research about injury prevention through proper warm up has been done with football, because I mean, they’re forever trying to figure out how to get fewer injuries there. So, talking about soccer, that type of football. And they’ve shown that — they created this warm up plan, which consisted of all of those exercises, you’ve just said; squats, balancing stuff, bridges, what else was in there? Lots of adductors, just hands, but all like planks and things that you would think — that’s strength training. And the injury rates just fell dramatically. Then they started applying it to different sports. And one of the most interesting findings with that is that in rugby, it even cut the concussion rates.

So, for some reason, either it’s because the neck muscles are woken up better that there’s less force going through there, or people are just more alert. But yeah, they surprisingly found concussion even went down. And that’s now been rolled out to all kind of — or validated in all types of sports. So, it’s definitely worth adopting something like that.

JESSE: [00:36:58] Because I’m more familiar with runners I’ll say runners, but maybe this happens with other other sports. Do you ever have to convince people that it is actually going to positively affect them, it’s not going to negatively affect them like where it’s like, oh, if I do all these squats, I’m going to be tired, and then I’m not going to go run.

MARYKE: [00:37:17] Well, that’s a very important thing. You cannot take your mate who’s a really fit club runner who does spring training regularly, if you do the same warm up as then you’re going to be knackered if you’re not that fit. So, active warm up is brilliant at activating things and getting you ready. But what they’ve shown is there’s definitely a kind of Goldilocks number of things to do. And that is relative to you.

So, if you’re not that fit, then doing 10 squats is enough. If you’re going to do three sets of 10, you’re going to be slow and sluggish and it’s just not going to work. So, it doesn’t have to be many, but it just needs to be something that gets all the movements that you need, or the range of motion and the muscles that you need for the run.

JESSE: [00:37:59] Yeah. That’s something — you think about picking the right number, and then coupling it with patience, like my run this morning, I knew it’s kind of early-ish for me as far as like, the things I have to do for the day to talk with you. And I was like, okay, I’ve got to go run eight miles, that’s going to take me, after I get done and do strides and cooldown and do the warm up, and we’re — hour 10 or so.

And there’s this like anxiety mindset almost where it’s like, I’ll just skip the warm up, I’ll just go run. It’s like, no, slow down. Like, it’s five minutes. If five minutes is going to make or break you, like you didn’t start early enough. And I think getting over that mentality has been probably more of a challenge than actually doing the right thing for me. Because it’s like, you want to go faster, you want to get done sooner.

Same thing with — I still have to coach myself through and I talked about this with other people, like going slower on your long runs. Like you don’t need to fly out the door and try to hammer your every long run, or even most long runs. And you think about it like nowadays I’m running 07:00 to 07:15 pace per mile. I can’t remember what my kilometer pace would be so I apologize, I don’t have the conversion off the top of my head.

But I think about okay, so if I go hammer and I go 06:50 pace, so 20 seconds per mile faster, what did I accomplish? So, then I’m — oh, I’m like three minutes faster over the entire run, but I increase my injury rate like high ‘cause I’m doing [inaudible 00:39:47] It’s like, just sit and think about it for a second. You’re not really helping yourself by doing that.

MARYKE: [00:39:55] But it’s also you kind of — I find with me in any case as well and I see it a little bit in my patients as well is you kind of have to hit your head a few times against that same wall before it goes into your skull that it’s not worth it. So, I’ve just — I don’t want to jinx it now, but I’m making a comeback from a year long injury, which I’m hoping is not going to — So, at the beginning, when COVID just started, so that was — what was that? Beginning of 2019? I can’t even remember now.

JESSE: [00:40:29] It’s been a weird memory lost year.

MARYKE: [00:40:32] We had just traveled to Thailand for this big change in lifestyle. And, of course, suddenly, it was really hot. And I just started walking around in flip flops and walked miles and miles and miles in. I thought Birkenstocks are good for you, but I forgot that I’m used to really lovely cushioned shoes. So, after doing that for two months, my metatarsals went, yeah, we don’t love you anymore. Then, of course, lockdown happened in Thailand.

Plus, you can’t really access things like podiatrists easily because of the language barriers and stuff. So, I couldn’t get orthotics again, because I obviously was a bit stupid and threw mine away at some point, because I thought, oh, I have an easy lifestyle. Don’t need these things. And yeah, it just — it dragged on. The left side recovered quite quickly, lovely. Right side would not settle. And I had to do the same thing that your wife did was, I did make a comeback in December and then I got ahead of myself, because I hate running slow. And then I paid the price. So, this time around 30 seconds, on 30 seconds off five times. That was all that I start with. I’m on 2.5 kilometres now, so that’s good, but slow.

JESSE: [00:41:49] Yeah. Well, in her it was such a — Like, she wasn’t even — I was writing her workout schedule previously, this was several years ago. And we were working out — I mean, we were working out pretty slowly. And it was just, she wasn’t even up to like running five kilometers yet. Like, we’re still pretty low mileage and it was just, she started out and just something snapped. And it was just such a freak situation.

So, but thinking about the number of injuries that people go through, and you’re talking about earlier what do we do, we go to YouTube, and we’re like, what’s wrong with me? And I do this too. My go-to actually is, okay, this is my pain. Let’s look at like, an anatomical model of muscles, and like trying to figure out like, which muscle is the problem, and then how do we address it? But it’s still self-diagnosis. So, I want to ask, how much trouble are we getting ourselves into by trying to self-diagnose and self-treat instead of just calling you up and getting professional advice?

MARYKE: [00:43:04] Well, to be honest, patients are sometimes surprisingly accurate with their diagnosis of things. Because a lot of things are literally if it hurts on the tendon, it’s likely the tendon. The problem comes in with the treatment part to it. So, take Achilles tendons, for instance, if you Google on the internet, how to treat an Achilles tendon, you’ll get loads of exercises and things out there. But the problem is that there is no recipe, there is no one size fits all. It depends on how strong your tendon was to start with, it depends on how long you ignored it for; how strong you are now, you know, how much running you’ve done in the past where you start.

So, sometimes I’ll see patients read — because when you look for tendons, for instance, you’ll get the message that you need to do heavy strength training. So, bless them, then they jump in with this really painful tendon, start with really heavy strength training, and then, lo and behold, it’s really painful. So, I would say diagnosis wise, I would never discourage people to go and look for what it could be.

But if you want to know what treatment to do, do speak to a professional because they can just guide you as to where the right place is to start and how you need to progress it because that’s where the wheels come off quite often. What I would also say is, if you’re not getting better as expected, because the person you see needs to kind of give you a timeline for this is what’s wrong, this is how long we need to kind of do things before we’ll see an improvement.

If that’s not happening, don’t just keep on going back and back and back if there’s no improvement happening. Do read up about things, see if people can be wrong. Anybody can make a mistake. I know for myself in the days where I had to see loads and loads of patients in one day, you get tired so you miss things. So, if you feel something’s not right, or you’re — don’t just assume the person in charge of your care should know what it is. Have a frank discussion with them. But yeah, do you look at Google, because it can help if you go, but don’t you think it could be this or could be that? It is really annoying as a physio when a patient does that, but it is useful sometimes.

JESSE: [00:45:10] Yeah. Well, that’s the, I think the tough thing, because I have friends who are doctors now and it’s like, we have this tendency to, especially when we’re talking about like, actual illness versus injury. It’s like, there’s a reason that people go through years and years of school and specialization to diagnose those things, because just a Google search, you have like a runny nose, and you Google it and it’s like, oh, I’ve got nose cancer, it’s — [crosstalk] Right, right.

So, it’s like, no, you just have seasonal allergies here. Like, here’s a Claritin, you’re going to be fine. So, that’s where I wonder — whether it was that kind of scenario, where it’s like, we’re getting ourselves in over our head. And I know, like you said, trying to design the rehab routine is very difficult. Because without somebody like you saying, okay, this is where you are now, this is how we figure out where you are now, it’s hard to say, okay, I shouldn’t go lift weights. What I should start with is like, standing up out of a chair.

MARYKE: [00:46:28] Yes, exactly. Exactly. So, and it was interesting, because in this process of designing the rehab programs for the app, you kind of go, how do I do this? How do I know when a patient can start or what a patient can do? When do I decide they’re ready to progress to the next thing? And then you realize, oh, oh, no, there’s definitely set targets that I’ve learned through the years. You know, if somebody can’t do that yet, then they can’t do that. So, for instance, with the Achilles again, we’ve just learned that if you want to get back to your running, you have to pretty much build up to doing your exercises with weights, that’s equal to about 20% of your body weight.

If you’re not at that level, and you go back to running, you may be okay for a week or two, and then the wheels come off. So, there’s definitely things like that. But yeah, I would say it’s a mixed thing. I like that people can be more informed these days about things. And I like the fact that patients ask me, can you just write down what it is that I have, because I know they’re going to go read up about it. Because I feel if you — You have to understand the condition to understand how long it will take and not rush things, and get better at the best rate then.

JESSE: [00:47:41] The timeline thing, I thought about this earlier. I can’t remember whether — I think it was pre-recording we were talking about I had spoken to Lwandiswa Zuma, who is another pro cricketer from South Africa. And early on, he was like 18-19, he had what he believed at the time to be a career-ending back injury. And it was like 18-19 months before he started bowling again. And because it took so long, he really thought things are done before he’s got started. And it’s like one of the things I talked about with him. And I’ve kind of come to this place too where it’s like, don’t set a timeline on it, just be with it. Like, continue the process and you’ll get there when you get there. Because if you set, like I asked you earlier about eight weeks, 12 weeks, it’s like yeah, but…

MARYKE: Yeah, exactly.

JESSE: If you get to that eight week point, or that 12 week point, or whatever it is, and you’re not better, then there’s this source of frustration of like what am I doing wrong? And then you’ve got to go through this whole emotional turmoil instead of just being like, am I there yet? No. What’s the next step, and continuing forward.

MARYKE: [00:49:10] And that is the hardest, hardest part. So, the first thing to know is that I have not seen an injury that hasn’t healed. Not meaning myself personally. But I mean, every single injury that a person gets, can get better. So, yes, some of them of course, if it’s like severe trauma, you will have adjustments to make, but if it’s a knee injury, if it’s an Achilles injury, all of those things can get better. So, I often get people when something is really painful that they just can’t see that they’re going to get back to their sport. And the best thing is to, like you said, do not focus on how far you are away from that but the small steps. And it’s difficult when something takes that long.

High hamstring tendinopathy is one of those things and it upsets your whole life because when you have that condition, you can’t even sit. So, you can’t go out for food with your friends or anything like that, because you can’t actually — it just frustrates you. And it’s about just keeping people that they keep track of where they were and where — and checking in with yourself again. Okay, fine. I can’t run 5K yet. But you know what? I ran 30 seconds this week, and I couldn’t walk two kilometers five weeks ago, something like that. If you’re not going to keep goals like that, and keep reminding yourself of it, then you’re going to — Yeah, you’re going to lose it.

JESSE: [00:50:31] Before we run out of time, I want to shift gears a little hard here because I want to ask you about this. I saw — You posted this on your Twitter, I think, thinking about genetic testing for kids and sports potential. Like I said, we’re shifting hard gears here, but I wanted to ask before we run out of time. So, are we really trying to — Have you seen the film Gattaca? Do you know what I’m talking about?

MARYKE: [00:50:57] It’s ringing a bell, but yeah, that you engineer.

JESSE: [00:51:00] Yeah, like engineering kids to be whatever and it’s like, this kid is not engineered. And he’s like, trying to become an astronaut, and trying to do all these things to get through and fake it basically, and showing like the will of the human spirit as a determiner. It sort of reminds me of that, but like, are we really at the point where we’re like, are parents so obsessive, I guess, that they’re like, is my kid going to be an Olympian? I need to know and I’ll pay to know right now. Are we there? Is that happening?

MARYKE: [00:51:34] There’s definitely crazy research going on about that, and there’s companies claiming that they can tell you things like that. And it’s important to understand that there is no one or two genes that decides that you’re going to be sporty or not. It’s such an interaction of things. And the little bit that I understand of it is you still got epigenetics in there as well, which means there are loads of genes that’s asleep, and they can turn on or turn off, depending on what else happens in life there.

So, yeah, I would say, from a personal point of view, I know you need a standard of genetics, which I missed, to be fast and have explosive speed. But if you take people within that range, there’s a lot of different things, and it’s a lot of mindset that goes into who then makes it or doesn’t make it, and whether they even want to make it. But yeah, I just — I feel it’s sad when things get to that point where people try and control things that much because it takes the fun out of the sport. It just — yeah. Why then?

JESSE: [00:52:35] I don’t know. I just don’t — This is one thing I think my parents did well with me is like — and maybe it’s because I was so motivated myself, but just like, they didn’t push me to do anything. It was just like, if you want to do it, like you’re going to do it, and they kind of let me be. And so I think maybe it’s impart because that’s my personal experience, but just, I don’t get the culture of like, we’re going to make you into this world class, you’re going to college, you’re going to play in the NFL. Just like, why are you putting so much pressure on kids?

And some of them make it and I think maybe that exacerbates the thought process. But I know from having spoken to a number of Olympians now that it’s like, they often played multiple sports and didn’t specialize in — Like, didn’t start this like super crazy training early on. It’s like, can you look at the evidence and say chill out? It’s going to be okay.

MARYKE: [00:53:54] And I mean, if you think quickly about injury management and kids, the main injuries they get during those growing years is growth related because they’re just doing too much intensity. So, they’ve shown that it’s much better for development if you want a strong athlete when they’re late teens or early 20s, you need to give them variation. Because if they’re doing just the same thing — Interesting with football, again, they’ve shown that actually kids who are exposed to lots and lots of hours of high intensity football in a week, their hips, the bones actually shape change shape to the type of bone that we know or the shape that causes early arthritis in hips because they’re soft. So, yeah, no, I’m definitely there with you. If you want a strong child who can really perform later on, then give them variation.

JESSE: [00:54:35] Yeah. Maryke, as we’re winding down on time, the question I’m asking everybody this year, so I can get a kind of cross sectional response is: How do you stay motivated after failing to reach a goal?

MARYKE: [00:54:51] Oh, yeah. I guess — Yeah, I’m quite easy on myself when it comes to exercise goals, I usually just go eat a chocolate or something like that. So, I’m not — My goals are more [inaudible 00:55:07] related to the other things, but I think also, I’m not too hard on — I always look at what I’ve learned from it. So, there’s always something you learn from what you do. And if it doesn’t come out exactly like you wanted it, it’s something you take with you. And often the goals you don’t achieve turns out to be ones that you didn’t really want to achieve in the end that much.

JESSE: [00:55:33] That’s fair. Maryke, where can people find you, get in touch, see what you’re doing, if they need help, all that kind of stuff?

MARYKE: [00:55:41] Yeah. So, you’re welcome to either look at the website But you can also find me on LinkedIn, Maryke Louw, and yeah, there’s — I think if you want to get in contact on social media, probably my Instagram handle is the most — the one that I keep an eye on most because the rest — and I need to remind myself now as we speak, what that is, which is Online.Physio.Maryke.

JESSE: [00:56:12] And those are — if you’re on YouTube, those are on the screen. If you’re not, they’re down in the description, so you should be able to click on those and get straight to them. So, Maryke, thank you for hanging out with me today.

MARYKE: [00:56:25] Thank you for having me. It was fun.

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