The Beyond Pain Podcast

Episode 48: Running Through Pain with Vikash Sharma

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Summary

In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca welcome Vikash Sharma, a physical therapist and owner of Perfect Stride Physical Therapy. The conversation explores Vikash's journey into physical therapy, the impact of personal injuries on his practice philosophy, and the importance of setting patient expectations in rehabilitation. They discuss the mathematical approach to recovery, managing runners' training loads, and defining what constitutes an 'easy run' for recovery. The episode emphasizes the significance of movement, education, and individualized care in physical therapy. In this conversation, Vikash Sharma discusses the nuances of running training, particularly focusing on zone two training, the importance of varied workouts, and how to assess and progress individuals recovering from knee injuries. He emphasizes the need for a simple approach to training, the significance of maintaining activity levels during rehab, and the importance of understanding individual responses to training loads. The discussion also touches on personal insights, including Vikash's coffee preferences and reading recommendations.


Takeaways

  • Vikash Sharma's journey into physical therapy began with personal injuries.
  • The importance of setting patient expectations for rehabilitation success.
  • Movement and rehabilitation are powerful tools for recovery.
  • Individualized care is crucial in physical therapy practices.
  • Education is key, but patients must be willing to engage.
  • Managing runners requires understanding their training loads and limits.
  • Trial and error is often part of the learning process for patients.
  • Defining 'easy runs' varies based on the individual's experience and fitness level.
  • The role of technology, like Strava, in tracking patient progress.
  • Physical therapists are increasingly advocating for their value in patient care. Zone two training can include walking for novice runners.
  • It's essential to have varied workouts for effective training.
  • High days should be truly high, and low days truly low.
  • Strides and accelerations help introduce speed safely.
  • Assessing pain-free movement is crucial before progressing to running.
  • Maintaining activity levels during rehab is vital for recovery.
  • Modifications based on specific injuries are important.
  • Expectations around pain during rehab should be managed.
  • Strength training can improve running economy.
  • Personal preferences, like coffee, can reflect individual differences.

Joe Gambino (00:00.844)
Welcome back into the Beyond Pain podcast. am one of your hosts, Joe Gambino, and I'm here with the other host of the show, Joe LaVacca You can find us on Instagram. am at Joe Gambino DPT. LaVacca over there is at strength of motion underscore PT. You can find this podcast on Instagram as well. Beyond Pain podcast and on YouTube at cups of Joe PT or underscore PT rather. And we do have a very special guest today.

Vikash Sharma, is a physical therapist and the owner of Perfect Shrive Physical Therapy in Union Square in New York. It is where both Joe and I worked. And a while right before we came on this podcast, he let us know it's 13 years now that they've been in business, which is wild to us because that means I'm getting, or we're all getting a little bit old here. So this is where Cups With Joe, those YouTube videos started. So this is special episode. Welcome to the show, my friend.

Vikash Sharma (00:49.078)
with you.

Vikash Sharma (00:57.608)
thank you. Thank you for having me. I remember those days, man. The little back room, kind of filming some Cup of Joe's from there. Yeah.

Joe Gambino (01:04.772)
Hmm.

Joe LaVacca (01:05.797)
I have so many good memories from our time together there. that's really like Joe and I have talked about this. I think it's really where I grew as a therapist and got to know what I wanted to be and who I wanted to be in this field. And I was just, I was laughing the other day because I was thinking of when Joe first started, there wasn't really a perfect stride dress code. It was like, show up professional, but like,

Don't take advantage. then Joe Gambino comes out of school, sweatpants. He's got like one leg rolled up. Like just one leg though. You know, this baggy sweatshirt. I think he was maybe even wearing like a hat. You he looked like the Chappelle character, you know. And then like from that day on, Vikash was like, we got a dress code. And I was like, God damn it. Damn it, Joe Gambino. Like we were all getting, we were all really good here with a t-shirt and some like athletic pants. then Joe Gambino was the reason why we had a perfect stride dress code. So Joe Gambino.

Thanks, man. You made everything more professional at Perfect Strike.

Joe Gambino (02:05.24)
You're welcome. I always push those limits of dress codes. I always push those dress codes everywhere I was.

Vikash Sharma (02:08.253)
I'm sure this is a moment where you could put up a picture of like what you were describing, you know, and just flashed on the screen for a second.

Joe Gambino (02:15.348)
One day, well, if we can get a video editor, I would love to do that, because I think there's a few episodes where that would work perfectly.

Vikash Sharma (02:18.067)
you

Joe LaVacca (02:20.558)
Oh, it would be great. Yeah, we just got to find somebody and we can probably find someone pretty cheap down to it's a we can hire AI to

Joe Gambino (02:23.256)
Yeah. Yeah.

Vikash Sharma (02:27.687)
yeah, that the move for every industry right now, right? Just figure out how you can sprinkle some AI on it.

Joe LaVacca (02:34.997)
Yeah, for sure, for sure. Yeah, well, like we said, this is one of my favorite episodes I've been looking forward to. You know, there's not too many people that you get to call a friend and colleague at the same time. So Vikash, you're definitely one of those people for us. And I'm looking forward to where the show takes us today.

Joe Gambino (02:35.488)
There,

Vikash Sharma (02:51.869)
I appreciate that greatly. I Phil's I've been seeing a lot of lot of LaVacca So it feels I need to maybe like, you know, get some more Gambino in my life. I see, I see LaVacca like somewhat regularly now, you

Joe Gambino (02:52.868)
Well, I think this is the...

Joe Gambino (02:58.542)
Hahaha.

Well, I might be in New York soon, so if it does, I'll let you know. But yeah, I'll take the floor. Why don't you just let our listeners know a little bit more about you, your backstory and...

Vikash Sharma (03:04.405)
Thank you.

Vikash Sharma (03:12.213)
Yeah, no, a hundred percent. I mean, for me, um, I mean, not to kind of get way back into the, into the day, but, know, kind of one of those things where I knew I was going to be a physical therapist for, for quite a while, just with like, think a lot of other physical therapists too, right? You get injured a lot. You go to a PT clinic and you're kind of like, Hey, this is cool. I like this, you know? Um, so yeah, that was kind of like, you know, I had a very similar story to that. And then, you know, just kind of went to.

undergrad, did my anatomy cadaver lab, fell in love with the human body even more there where I just kind of got to learn the ins and outs of like, you know, the human body. and then, you know, out of PT school kind of started working at one of these like higher, higher volume practices, where I was getting burnt out probably like five to six months into practicing as a PT. You know, I was like thinking of outs already at that point, like, Hey, like this isn't what I signed up for, you know?

And that's when, you know, perfect stride kind of the ideas came, came about for perfect stride at that point. And, know, 2012. And then since then we've just been growing, you know, and it's kind of a, you know, there's, it's been a boom and kind of like, you know, the, the same model that we've had, right. That one-on-one cash base out of network. When, when we started back in the day in 2012, there was like a handful of people, you know, that I could name that we're doing it. Um, but now it's like, you know, it's kind of spreading like fire everywhere, which is, mean, awesome to see PTs are,

getting paid their value for what the services that we provide for people. So I think that's really, really awesome.

Joe LaVacca (04:38.978)
I think you're, bring up such a great point because it does seem that more and more people aren't waiting for like those stepping stones. used to be, you know, you, Joe and I came out of school. We had to do the grunt work. You know, we almost had to like take everything that we were given from the corporate model and say thank you at the same time. And it's really nice to sort of see like you're saying like,

people coming out of school now knowing like, no, I'm more valuable than this and I can give more and do more for clients. And I think it's creating a lot more avenues for success for people. you mentioned some of your injuries that you had to deal with. What were some of those, Makash, what was the toughest one that you had to deal with that kept you in PT the longest?

Vikash Sharma (05:27.862)
I feel bad for mama Sharma, know, just like, was just like, there was just like two, too many, you know? The first thing that got me into PT was a, like a gastroc, a calf tear that I had in outdoor track in middle school. And then it just kind of like, you know, just kind of went from there. You know, I think I used to skateboard when I was younger. So I had like a shoulder dislocation where I like came home one day and like my left arm was like dragging on the ground. And I was just like, mom, I think I did something to it.

And she's just like freaking out running me to the emergency room. And then I had a whole like kind of slew of shoulder dislocations after like I dislocated my shoulder 13 times, you know, and so there was strongly kind of recommending surgery and, you know, knock on wood through just very diligent rehab and PT. It's been like, you know, over a decade now, haven't had any problems with the shoulder whatsoever. So, you know, it's just one of those things where I've just like got to experience the power of just movement and rehab and like what it can do for people.

And I think that's part of the reason why I can just speak so highly of it, why I think there's so much power in it is just having experienced it firsthand as well.

Joe LaVacca (06:36.6)
Wow, that's really... I didn't know that either.

Joe Gambino (06:36.996)
I actually didn't know that about you, 13th locations. But it's crazy that you didn't have surgery either.

Vikash Sharma (06:41.461)
Yeah, I came out sleeping one time. Literally like went to put, like in my sleep, I just went to put my hand over my head and I just woke up in this like world of pain because my shoulder had just come out from doing that.

Joe LaVacca (06:41.805)
Yeah.

Wow!

Joe Gambino (06:52.13)
Mm-hmm. Yeah, that's

Joe LaVacca (06:52.61)
Now that is very interesting because I didn't know that either. you I would, don't know, Joe, about you, but I don't know my over under on shoulder dislocations might be nine, nine and a half before I decide for the surgery. So, I mean, for me, and this is, this is always why I love talking about people about their, injuries, because one of the cardinal signs I tell people to consider surgery is recurrent dislocations, but particularly if they start to happen in your sleep. So what was

Vikash Sharma (07:01.663)
I'm

Joe Gambino (07:02.144)
you

Joe LaVacca (07:18.83)
the thought in you or the PT that you working with or the doc that you were, someone convinced you otherwise. Who was able to do that?

Vikash Sharma (07:28.478)
I I think a large majority of it was just like my own stubbornness probably, right? Like I think I would see these like kind of like gains that I would make, right? I dislocate my shoulder. You'd have that period of like, hey, cool, I got to manage these symptoms. But then like every time it would kind of like get back, you know, and I would be like, okay, this is like, I get this. Like I can, you know, let it, let it recover, let the things calm down a little bit, build them back up again. And I can get back to bench pressing heavy. I can get back to like overhead pressing.

and then kind of like, I started learning more about PT, I started learning a little bit more about, like, you know, there's other like, you know, things that you may want to focus on. may want to focus on the stability of your shoulder a little bit. You may want to focus on like the mobility of the adjacent structures a little bit more as well too. Right. And then as I started doing those things, I started realizing, like, I was actually like getting better from a performance standpoint, even after having like these repetitive dislocations.

And then kind of learning more about the human body and being like, Hey, you know what, like, can really focus on building up these like muscles of the rotator cuff and like muscles that are surrounding the area a little bit more and make them more resilient. I can train my body to, you know, kind of like forget about these like, you know, past traumas that it's had by giving it successful experiences, setting more PRs. And through that whole process, just kind of realizing like, Hey, you know what, maybe this, you know,

in my practice philosophy, I do share that with people, but I let everybody know, hey, like, you know, I may be a very unique circumstance because I was somebody who like, you know, back in the day when, you know, you just get prescribed bands all the time and you're just sitting there doing like, you know, no monies and this and that. I would just have my just sitting right next to me and I'd be like watching TV, you know, like doing it. I'd be taking breaks in school, like in the library. And I'd be like working on just like, you know, strengthening things with my band. So, you know, there may be some different circumstances there, but I think

Joe LaVacca (09:07.501)
Yeah.

Vikash Sharma (09:20.233)
just kind of seeing that and going through that process was the thing for me where I was just like, Hey, you know, I don't necessarily know if I love a surgery. Cause even speaking to people who had had the surgery, like a few of them re dislocated their shoulder again too. Right. So I was kind of like, I think hearing that a couple of times from people, was like, I don't know if this is the route I want to go.

Joe LaVacca (09:32.046)
Thanks for having

Joe LaVacca (09:39.182)
Well, that's why I will never be successful, I think.

Joe Gambino (09:39.83)
That's pretty crazy.

Well, let me ask this, Vikash based on all that and that kind of journey that you went through, how has that kind of shaped what you do when you're treating your patients?

Vikash Sharma (09:58.207)
Yeah, no, I think that's a, yeah, I think it's taken like a, know, it has a very big impact on how I work with my patients. I think, you know, it's that setting those expectations from the beginning of like how powerful like movement and rehab is, but at the same time, it's like, it's a math equation. If the numbers, the work, the load is not being put in, that communication is not happening, you know, we're gonna get suboptimal results, right? I think that's where,

I think a lot of people have that expectation. They're just coming to us and like, hey, that's it. I'm good to go. I'm going to PT. I'm going through the motions. So I think really kind of like working to educate people upfront and just let them know that, like it's actually gonna take a lot of work and you coming here, it's great. Yeah, you're gonna get some coaching. You're gonna get some advice from us about what you need to do. But the key here is it's what you're gonna need to do.

it's gonna be a lifestyle modification for you, right? It's not just gonna be this like, hey, I'm gonna come in here, I'll do some exercises, like I'd go to the gym with a trainer and I'm good to go kind of scenario, right? So I think that's something from that experience that I've pulled and I've been really able to kind of go ahead and, know, implement in my own practice is just really, really kind of setting that expectation for people. And I think I'm really big on kind of like calling it, you know, like whether it's movement snacks or just being opportunistic about movement throughout the day.

I really try to drive that home with people, just kind of letting them know like, we gotta, regardless of how busy you are, Your cells do not care about that whatsoever. They need that communication, they need that stress, they need that load to grow and develop, and we gotta figure out a plan to make it work.

Joe Gambino (11:42.095)
I like that a lot. It's interesting because I think most of the time on this podcast, we talk a whole lot about, you know, with chronic pain, like how, you know, the stresses that play on it. But I think you're the first time that we mentioned where it's almost like a math equation where there's, you have to put in specific amount of inputs in your mind. I know you're probably going to say it varies, but do you have kind of like like a certain amount that you think of inputs that need to be

put in that actually would make a change for somebody? Like how does that work in your mind and how are you educating your patients around it?

Vikash Sharma (12:14.887)
You're very right to say it varies for sure. That's where my mind goes first, right? Each person will be different there for sure. But then, know, obviously I think you have to consider all those different things that go into it, right? Like where is that person right now on the spectrum of recovery, right? Like, is it something really acute? You know, they may just need some super, super minimal inputs at that point, right? Like we might even just be thinking about movements. We might even just be moving the other side, you know, like to...

you know, if we're on one end of the spectrum there. But then as we start to kind of like move up into folks that are getting a little bit more active, right? I think it's kind of like getting above their baseline, right? We kind of like have that envelope of function that sometimes we talk about, right? Like it's kind of going above and beyond that baseline to elicit a positive reaction and kind of an adaptation from those tissues. So I think that's another place, right? Whether in PT.

I think that's changing now, obviously. think there's a lot of change in the profession, which is awesome. But I think we were known as just, you know, being grossly under loading people like three sets of 10, here's a band like, you know, you, gave you three sets of 10, but you probably could have done like three sets of 75 and still probably not even like, you know, have been working that hard. Um, so I think we're getting much better about that, but yeah, finding that place where we're kind of like doing enough to elicit a change in their, in their anatomy.

Joe LaVacca (13:24.078)
you

Joe LaVacca (13:35.95)
So perfect stride specializes or emphasizes running, return to running, running injuries, right? That's a big part of the population that you guys still see, right? I know you guys see everything, but most of the time, like that's probably your highest amount of clientele. Yeah.

Vikash Sharma (13:52.553)
Yeah, almost definitely. If you have to pick one thing, runners 100%. Yep.

Joe LaVacca (13:56.578)
Right. So hearing you talk about the math equations and the inputs, I would imagine this can go two ways. And I think for my population that I'm seeing, it's getting people to do more, right? To buy in for your population. And this is just, you know, the stigma of runners. They seem to like to do too much. So how do you pitch this to them on this envelope of function?

on keeping them active, but not doing too much. Do you have a system? Do you have a way of tracking their runs or like you throw a spike into their shoe or something? Like it's on a timer switch if they go too far. How are you maintaining these athletes that you guys see?

Vikash Sharma (14:44.477)
No, hundred percent. mean, I think this is a big one. We talk about it in the clinic a lot too, cause there's always these like, you you get these personalities that come in and you kind of have to figure out how to, how to negotiate it. So I think, you know, part of it is like, you know, initially I said setting the expectation from the beginning, like really kind of trying to drive that home on day one as much as possible. And sometimes it's the point where the person is just like, like, okay, I get it, right? Like I get it, but then they'll come back at the next visit and they don't get it. Right. Like.

that happens way too, way too often, you know, and I've been noticing my experience, but it's like, know, you can provide all the education, but if it's going on deaf ears, it's, it's tough. And that's where sometimes people honestly just have to learn with trial by error. You know, there's, there are those personalities where it's just like, they have to figure it out the hard way. You can literally do everything right. Send them like little, even I'll schedule, send emails to people to remind them like, Hey, today's run was scheduled. You told me you're doing it in the morning. So this is going out before your run.

Remember, this is truly easy pace. Like we do not want to go above this pace, right? Like, and somehow, you know, hey, I was feeling great, you know, and like, just like, kind of didn't realize it and just kind of hit this downhill. And next thing, you know, I was going like a minute mile faster than you told me to go, or like the sun was out today and you know, I was supposed to do three, but I did eight, you know, and it just, happens, you know.

And that that's, you know, that's, that'll be the lesson that kind of gets them back more on board with rehab is right. Having that failure and being like, maybe this person does understand what they're saying. so I think that that is a big part of it too, for sure. Sometimes like, you know, just pulling up people's Strava's accounts, just having them literally be like, Hey, let me, let me look at your Strava. Like, you know, I'll, do that fairly regularly with most people, but you know, sometimes we'll just have to do that, like not take their word for it. You know, like when sometimes the math isn't math thing, we'll have to just like.

get into the weeds a little bit more and like, yeah, look at the paces, look at the elevation, look at their mileage, look at their frequency a little bit more to see kind of like what's going on there. Because like I said, a lot of times with running, it just comes down to kind of controlling for those variables. And then obviously, like I know, like a lot of the stuff that you guys are talking about in the podcast, chronic pain, that kind of does sometimes throw a little bit of a different wrench into the equation that you have to solve for.

Vikash Sharma (17:02.997)
But that's an important thing. And then also understanding that there's certain guidelines that we'll kind of put on people, right? Like I'm sure, talked about it quite a bit, like pain guidelines, right? We'll kind of give some sort of pain guidelines around running that we'll kind of work with our people on to kind of control for some of those variables, giving them cross training, right? So it's kind of just like understanding like, hey, maybe we'll be running this much, but out of those like 70 miles a week, you're running right now.

know, X percentage is gonna need to be some form of cross training until we allow this to recover a little bit more as well too.

Joe LaVacca (17:39.758)
I really like that you look at the Strava because you know no one's running without putting it in the Garmin or the Strava. They're not leaving that watch at home. There's no way. They're always going to get credit for the the one of the four accounts. So that's a that's a good idea. 100 % I do it. I do it too.

Joe Gambino (17:40.108)
Yeah.

Vikash Sharma (17:51.038)
A hundred percent. Right. Even if it's like that little like 0.2 mile run to the gym or something. Yeah. It's, it's going to be in there.

Joe Gambino (17:58.468)
That's funny.

Vikash Sharma (17:59.893)
I think I'm one of the few people who doesn't like, I'm not a big Strava person. I'm just not like a huge, huge social media person. So I think you're the only person on Garmin Connect that like I actually like follow. So I think sometimes I'll just like like your workouts on Garmin Connect.

Joe LaVacca (18:12.59)
I have been doing a little bit more indoor running just because I have the new gym downstairs. So it's like, it's a little cold today. And I was like, but I have a treadmill now. it's a little rainy today. I have a treadmill now. So every excuse that I used to have to not go run, especially for this easy stuff. I'm like, well, now I don't have any excuse. I literally created an environment where I walk downstairs. I'm in the gym.

Joe Gambino (18:35.534)
You

Joe LaVacca (18:41.486)
and I have a treadmill staring at me saying, what are you gonna do now? I did have one question though, just because you mentioned the easy, easy pace. And I've heard so many things about this from so many people, zone two, paying attention to heart rate, paying attention to respiratory rate or a talk test, just your subjective rating of easy, maybe going off a percentage of your race pace. What have you found to be most reliable when guiding your runners who are

turning from injury on what an easy run actually is.

Joe LaVacca (19:23.51)
I we lost, Vikash. So, Vikash, you mentioned the easy runs for clients. And I've heard so many different things about easy runs. The zone to the heart rate, staying at a certain heart rate, the talk test, being able to have a conversation. So just subjective rating, what is easy to even some people recommending, well, what's your race pace and taking like percentages off of that. And then that should be your easy pace. What have you found to be

most reliable to guide your clients recovering from injury back to what an easy run actually is.

Vikash Sharma (19:59.32)
Yeah, and that's, you know, once again, kind of going back to that, you know, it varies situation. I think it had a lot of gross, like kind of like variation between people on that, depending upon like, you know, if you're a more seasoned runner, if you're more novice runner, like right, your efficiency and heart rate might be sitting in different places as a result of that. So I think it really comes down to that individual. But in all honesty, like, yeah, like kind of just getting to that understanding, like, hey, can you, can you generally have a conversation with somebody while you're running? Right.

Like if you had a friend with you and you guys were just like, know, talking up a storm, would you be fine? I think is a good starting place to go. And then, you know, reinforcing that with a little like rating of perceived exertion scale, right? Like on a zero to 10, are you in that like four-ish ballpark, would you say? You know, I think if you kind of like use both of those, that can be a really, really good starting point. You know, and an understanding that, you know, like I was mentioning, if you're a more novice runner, that you're just not efficient.

Right? Your like body just hasn't, your physiologist hasn't become efficient to that stress yet. So a lot of times I'll have to recognize that with like, you know, that population, there's going to be some walking involved a hundred percent. Like I think people grossly miss, you know, misinterpret like what that zone to sometimes can be. And you know, if you're not, if you're not that like skilled at it, your body hasn't become efficient, you're going to be walking a little bit to maintain yourself in that kind of a, in that zone, in that range that we want you in.

If it's really hot out, same thing, even if you are a little bit more seasoned, like, you you get some of these really hot summer days, like, I don't care who you are. Like, you know, if you're really trying to stay in that zone two range of easy running, you're probably going to need to stop at some point just to kind of like, you know, let your body recalibrate to that. If you really want to try to keep that effort easy and kind of like, you know, make sure that you're keeping your training week kind of a, you know, going according to how you want those stresses to be working out throughout the week.

Joe LaVacca (21:51.15)
Thank you for confirming that walking is a zone two activity for me. That's where I'm at right now.

Joe Gambino (21:51.97)
No. That's all that's all Joe heard. So I think this is interesting. I think people will find I feel like zone to work has become like very, popular these days. So can you maybe elaborate on like the different zones, what they may be used for and potentially how they might be cycled in someone's training program?

Vikash Sharma (22:18.872)
Yeah, no, 100%. You know, I think for me, I generally always err on the side of like, keep it simple. And then those folks that like, you know, just really want to get into the weeds, well, we'll get into the weeds. But I think for like, you know, 90 something percent of the people I work with, just like having like a keeping it simple approach just, you know, is more than sufficient. So the way, you know, usually I'll break it down a lot of my runners is like, you know,

you kind of want to have different workouts for a lot of reasons. But I think like, you know, one of the big ones that I always tell people is because, you know, novice runners, I think the biggest mistake that they'll make is it'll be that idea of like each run, I need to run out my door without warming up, run as hard as I can for as long as I can. And, you know, that's my workout, you know? And I think kind of that goes into that education piece of like, letting them know like, hey, why does that not truly make sense? And why do we need to run slow?

And I think one of the biggest reasons is like, you gotta have your, you gotta let your high days truly be high days. I'm sorry, your low days truly be low days so that your high days can be truly high days in training as well. Right? From just a physiology standpoint, if every day is hard, every day really isn't going to be your best effort, right? It's going to be what you perceive it to be your best effort, but you're just being hindered by the fact that you haven't recovered fully. So I think that's where some of those like easier days come in really, really handy. And that's why you need them.

along with just kind of like the physiological benefits that come from it, right? There's a lot of things that happened at the cellular level where your mitochondrial density builds, like their mitochondria stores increased, your capillary beds get denser, which just makes you more efficient as a runner. So when people are starting off, that's where we'll go. All your runs will be slow. It'll be your base building phase. We're just going to get you kind of like more efficient, get your physiology on board with it, get your, you know, all your tissue structure is a little bit more adapted to running.

And then that's where I start to talk about, like now we need to kind of incorporate some variability, right? To kind of like let your body be stressed differently and grow differently. It's kind of like the equivalent, you know, starting to run faster and running is kind of like throwing some more weights on the bar, right? Like we're kind of trying to push it a little bit more now and we're trying to kind of like, you know, get you to build different skill sets. So then we'll talk about kind of like, hey, how do we want to start introducing speed into people's workouts?

Vikash Sharma (24:41.014)
I love the idea of strides and accelerations, right? They're just like this really easy kind of like thing that you can implement that people can get started with and you can control them really well. So what I'll usually do is I'll say, once we're done with our base building, hey, we're gonna start introducing our speed work and it's gonna be in the form of strides. So before your workout, we're gonna take, you know, whatever distance you want, whether it's hundred yards, 200 yards, and we're gonna kind of start from a standstill and we're gonna kind of like just ramp it up. You're gonna start running and you're gonna start running at like,

20%, 40%, 60%. Maybe somebody that like, you the beginning part, that's where we cap them off at. And then you're gonna come back down that ramp. It's gonna kind of work up. You're gonna hit the top end and then you're gonna come back up and you're gonna go back down to a standing kind of standstill. And then we'll turn back around and we'll do it again. And that's just a great way to kind of get the legs turning over and the tissues starting to get exposed to some faster paces.

And same thing coming off an injury. That's like, once again, it's like a great way to kind of like, you know, get people that small exposure so we can see, hey, how does that hamstring start responding to this a little bit more? You know, after we've gone through our battery and checklist of other things that we want to check off in the clinic and we're starting to get you back to running, we've done our slow running. We know that faster running is really what strains that hamstring a little bit more. How do we kind of like make sure we're not giving it too much volume and just kind of checking off another box along that ladder of recovery?

So that's where I'll kind of start is with some strides. And the goal of that is just like, it's not meant to be aerobic. So I'll tell people just to kind of like pause after each stride, let your heart rate recover and then kind of go right into your workout afterwards. And then from there, we'll kind of build out, right? We'll kind of get into some tempo runs. We'll kind of get into like speed work on hills. We'll kind of get into some track workouts where we're doing intervals, whether it's like, you

miles, 800s, 400s, 200s, ladder pyramid workouts and things of that nature. But then like I say, know, like we always kind of have to structure it in that point, going back to like those slow miles of having those peaks in your week, which are like those high days and then using some of that, like, you know, slower pace running to kind of have some more mileage in the week where you can kind of keep gaining some physiological adaptations, but you're still allowing your body to recover and kind of make sure that you're ready for those like.

Vikash Sharma (26:57.164)
you know, top end workouts that you're gonna have.

Joe Gambino (27:02.552)
That was well said. Nicely concise there. Yeah.

Joe LaVacca (27:02.734)
of that. Yeah, very good. In that regard, then, Vikash, as you're progressing people, Joe and I have been talking a little bit more about knee pain the last few weeks. Knee pain, as I understand it, is one of the more or most common injuries with running. Is that fair? that right? Yeah. Okay. Yeah. Right. Right. So

Vikash Sharma (27:25.036)
Yeah, yeah, no, stuff, right? Runner's knee, right? There's like that whole like, you know, runner's knee out there.

Joe LaVacca (27:31.114)
We'll keep it there because I'm sure there's a million assessments that you could be doing with people. For someone recovering from a knee injury, knee pain, runner's knee, whatever the case is, are there specific assessments you would like to see or have them achieve before you clear them for, let's say, a stride work, a speed work, or like progression in this capacity?

Or is it just like better to just gave their load tolerance and you know as you were so wonderfully putting it before it is a little trial by error in some cases

Vikash Sharma (28:03.5)
Yeah, no, a hundred percent. know, I think as much as like we, you know, we want to have the science and the exact formula behind it. We know a lot of what we do in rehab is, is an art form, right? Like it's, it's understanding that individual. It's understanding how they're going to respond based off of past patterns that we've seen with other individuals as well too. So I think there, you there is like that kind of like weaving the, the worlds of like, know, like, you know, the art and the science together a little bit when it, when it comes to this.

So yeah, have all of our kind of like objective measures that we wanna make sure that we're kind of screening for. We'll use some dynamometers in the clinic to see like, what's our force output looking like, right? Like if we're just doing some knee extension and flexion and we're doing it maximally, like, hey, are you getting some pain with it? And then, hey, are we like relatively in the same ballpark here? Like some people would argue even if you're not, yeah, you can maybe still.

kind of get back to running, right? Your body will adapt to it a little bit. It'll figure out the equation itself, but you know, we try to get people like definitely within 10%. We like to say, can we get even within 5 % of like the other side to kind of check that box off a little bit. You know, then like just there's a simple things that come along the way, right? Like, can you walk pain-free? You know, like are you walking pain-free unrestricted, right? If the answer is no to that, like, I mean, you know, you'll be so surprised how many people will still ask like, can I run? You know, it's like,

you're not walking pain-free, like, you know, let's think about this. Like, you know, what's the logical answer here, right? So that's, you know, that's something along the way. And then thinking about all those other things, right? Like, hey, how's our like hinge pattern? How are we squatting? You know, are those pain-free, right? That's going to give us a lot of good information too. And then kind of like moving more towards things in that bucket of that things that look like running, right? Like once we kind of go through like some of our patterns of like hinging, squatting, you know,

How is that looking, single leg squatting? Are we able to work through those? How is like a hop looking, right? Like how is a double leg pogo hop looking? How is a double leg forward progression pogo hop looking? And I like to kind of gear those on like, sorry, I'd like to base those on like gears, like right, like a low, middle, high gear effort, right? Like, are you able to work through those? We'll start with low, we'll go to middle, we'll go to high, we'll go to forward progression, we'll go to zigzag, we'll go to single leg.

Joe LaVacca (30:12.046)
Mm-hmm.

Vikash Sharma (30:21.388)
then we'll even kind of go into like running in place, right? I'll use that because that's going to be a little bit less stress, but it'll be similar. And then you can kind of like work into, you know, getting people to kind of like move into either hopping on the treadmill, doing some like, you know, jog walk cycles or even this, this notion. I think that was like popularized a long time ago by one of like the OGs of like running rehab, this guy, Bruce Wilk out of Miami. And he called it like gliding. It was just this like,

Like idea of like, you're kind of like in this middle zone of walking and running. You're kind of like doing this, like, you know, maybe it's like a high four or low five kind of on the treadmill and just playing in that area a little bit and seeing kind of like, Hey, how do you respond to that? So I'll kind of even have sometimes depending on the person, I might, that's my beer. That's where we might go with those people too.

Joe LaVacca (30:55.982)
I'm

Joe LaVacca (31:10.99)
I think I heard Thomas showed talk about that gliding idea where it's like, yeah, not quite one, not quite the other, but I really like what you said there. So objectively, I know, or some places I've seen recommend like, you're not putting people through a rigor of like, hey, you need to squat one and a half times your body weight. I like that dynamometer idea. I use the dynamometer too. I think it's really, really valuable.

But have you found anything like squatting one and a half times your body weight, even in research makes you less likely to have running injuries or deadlifting or hinging as you're saying twice your body weight makes you more resilient for running injuries. Does any data like that actually exist?

Vikash Sharma (31:51.384)
In that respect, no. I mean, think there is data out there about like, you know, if you are strength training, you know, like they talk about the idea of like strength training coupled with plyometric training can help improve your running economy. So I think there is definitely some good data out there about, you know, talking about how that can help more on like the performance side of things a little bit more. But at the end of the day, I think, you know, kind of just the idea of like, yeah, if you're having some pain with squatting, you know, like that.

how are we gonna fare with running? Sometimes it carries over and sometimes it doesn't, you know, right? Your knee's not going through the same ranges of motion. It's not really, you know, doing the same exact things as it would be when you're squatting. So that's where I think like getting things that are more specific to the task at hand can make a little bit more sense, 100%, you know, like you're gonna be a little bit more cautious and that like, you know, yellow flag is gonna be back of your head. I love to get people cleared on all sorts of different movements before I get them back to running, cause that.

will kind of like, you know, allow me to have more confidence in like, you know, saying that, yeah, like, you know, you're, you're not having knee pain with anything we're doing. So we're probably going to be a little bit more confident that you're going to get back to running. But, know, if somebody is able to, you know, get through some jump squats and they're able to get through Pogo hops, they're able to get through some like box jumps and some box drops, right. And they're able to get through some jump roping and running in place, you know, probably going to have like a good indicator that, like maybe you're not able to squat your body weight, but you're doing all these things.

we probably have a little bit of freedom here to kind of start that process, right? Cause I think that goes into that idea of like, you know, one of the biggest myths around running might just be, I think a lot of people will be like, I have pain, I can't run, right? So I think that's where that education process comes in where like, Hey, there are times when you can have some pain and we can kind of start working into running and seeing how you respond to that a little.

Joe LaVacca (33:44.248)
Well, that answered one of our other questions. So that was great. Thank you, Vikash

Vikash Sharma (33:48.28)
I try man, I try.

Joe LaVacca (33:50.51)
I'm sorry.

What do you think, Joe, you think you time for like one or two more questions? Because I just want to be respectful of your time as well.

Vikash Sharma (34:00.12)
yeah, it's up to you guys. Yeah, if you guys got some time, I got some time.

Joe LaVacca (34:02.53)
Good. All right. And Joe, we do have something very important we have to ask Vikash before we get off that we did not ask to start. But I think I know why. I think I know why we didn't ask it. But we're going to we'll bring it back around. You know what I'm talking about, right?

Vikash Sharma (34:16.416)
scared.

Joe Gambino (34:19.3)
I got you, man. Yeah, we have to ask you. Maybe we'll do one more question. We'll ask those questions and then I know you have some other, you know, we have our finishing questions. So.

Joe LaVacca (34:26.57)
All right, cool. Makash, what do you think are the three most important things for runners to consider when they're going through their rehab?

Vikash Sharma (34:38.904)
Yeah, so I mean, think there's obviously, yeah, there's a lot there. Every person, once again, going back that, it's gonna be different. But if we're thinking about it from a general standpoint, I think one of the biggest things is maintaining that highest level of activity and fitness that you can, right? I think that's just super, super important, especially when somebody's in a training block, right? And they're trying to of peak for a certain day for a certain performance that they have.

it just becomes so vital to kind of figure out how can we keep this individual as, you know, active, as resilient, as strong as possible. So I think that's a big thing is to kind of really make sure that we're kind of pulling all the levers to make sure that we're kind of keeping them as active as possible. So I think that's really, really important. And, you know, like we talked about cross-training is a big part of that sometimes, you know, depending on the person, might be like, Hey, if we can do, you know, some method of cross-training, let's try to kind of get the same amount of minutes that we would

planned in our running workout at the same level of intensity. So that way we can kind of like, you know, keep stressing certain systems at that point similarly-ish to what our plan was while we were, you know, while we were in our running kind of a regimen and then leaning into maybe some strength training even more so we can kind of just keep putting some positive adaptations into the body as well. So I think that is really, really important.

And then just modifications that you can make, right? Based on their specific injury, I think is really, really important too. You know, whether it's like, hey, we can still keep running. Some volume might need to be reduced. You know, do we need to eliminate like, you know, hills? Do we need to change up your footwear a little bit to allow you to kind of be successful? Do we need to get you on or off the treadmill to help supplement during this time? I think that's like, kind of like some important things to consider in terms of like modifications that you can make.

And then kind of going back to the expectations thing too, right? I think that's really, really important for people to just kind of like understand and know. Like I think just like, hey, this is gonna be a really important part of your rehab. We know that, hey, like let's say with like a tendon based pathology, like we're gonna have some pain and it's gonna be okay, right? If it's kind of like, if it warms up, it cleans up a little bit, we're respecting these pain guidelines and like, know, following this framework, we can still work through this a little bit.

Vikash Sharma (37:00.888)
I think things like that are really, really important to kind of like, you know, make sure that you're discussing with each person.

Joe Gambino (37:07.49)
Yeah, I like that. think, you know, I always describe to people like a risk reward cycle. know, you mentioned someone preparing for a race and they have like a performance, you know, they're trying to perform at a certain level to me. like, okay, well, what's the risk reward if there's only a minimal pain, right? Like, sure. You know, go work for your race, as long as it's not going to cause a major setback. And then on the opposite end, if someone has nothing, it's like,

What's the risk reward here, right? Like we can make things worse. We can do this yo-yo thing. But if you take a, you know, give us a month or so, two months, right. And if we can get you back to running where you can just be full speed and not have to worry about it, right. What makes the most sense here? So I really kind of like how you, how you laid that out. Um, we'll shift to that question, Vikas, that you're now scared of. And the question is, how do you take your coffee?

Vikash Sharma (37:45.378)
exactly.

Joe LaVacca (37:51.973)
And I know the answer.

Vikash Sharma (37:54.048)
God, you guys aren't gonna love this.

Joe Gambino (37:55.78)
This is this is a no judgment zone Pekash

Joe LaVacca (37:55.886)
I know, that's why I said, I skipped it.

Vikash Sharma (37:59.992)
I don't take it. I think that's why you guys might not like the answer, you know? I think I've had the equivalent of maybe one full cup of coffee over my entire life.

Joe LaVacca (38:04.172)
Right.

Joe LaVacca (38:10.786)
I knew it. That's why I said I was like, I knew that there was something in my mind where it's like, don't ask about coffee. Alright, so Vikash, when Joe and I are drinking coffee, what is your go to substitute then? And is it tea? Is it something else? What are we drinking?

Vikash Sharma (38:26.54)
Yeah, I'll be right next to you guys having a cup of green tea for sure. Yeah, yeah.

Joe LaVacca (38:29.486)
Green tea. All right. We doctor it up. We put some milk or sugar or honey, anything like that in it.

Vikash Sharma (38:35.478)
Nah, I'm pretty simple man, just straight up. I feel as if I was a coffee drinker, that's probably what I'd be too, was just like, you know, like straight up black coffee as well. Yeah.

Joe Gambino (38:45.887)
And there we have it.

Joe LaVacca (38:46.188)
I knew it. knew it. All right. All right. There we go. Vakashi, are you reading, listening, or watching anything intriguing that we should put on our radar?

Vikash Sharma (38:58.584)
I'm trying to think right now. Reading a couple things. I just finished a Peter Galloway book. What was that one called? It's like right over here somewhere. where I put it. The Algebra of Wealth. Yeah, I just finished reading that. He's like an NYU Stern business professor, just kind of breaking down the ins and outs of finances and the economy. Just reading through that and then reading

Dan Martell, who's like this business coach, he has this book called, kinda called Buy Back Your Time. So reading that at the moment as well. And then there's, I think there's a few others that are just sitting on the back shelf. But right, yeah, and I think my next one is gonna be to kinda get into something a little bit more on the running and the rehab front, because I've been reading a lot of other kind of books at the moment. yeah, yeah. How about you guys? You guys got anything good going on right now?

Joe LaVacca (39:54.446)
What am I reading? I'm reading some philosophy book about pain and I'm actually finishing up the book that you recommended, Never Lose a Customer Again. So I actually have, yeah, I've had those two going as well. And I'm about 30 minutes away from finishing Severance. So that was amplified by this week when I was literally laying on the couch for the last two and a half days. So got a lot of Severance watching it.

Vikash Sharma (40:06.347)
okay.

Vikash Sharma (40:23.469)
I'm almost there, I two episodes to go as well. What about you Gambino?

Joe Gambino (40:27.796)
I actually just started reading the science is stuck. Well, girlfriend, cause we just had her on the podcast. I decided to jump in. I'm like two chapters in now. So been enjoying it so far. And then watch them wise. actually started watching the pit. I don't know if you've seen it. think it's, I know what it's on. It might be on like HBO max, but it's, it's, it's pretty good. So we've been enjoying that. And I think there's one more episode left next week. So that'll be, that'll be the end of that once we're there.

Vikash Sharma (40:39.091)
nice.

Joe LaVacca (40:44.94)
yeah.

Vikash Sharma (40:46.166)
I've been hearing a lot of good things.

Joe LaVacca (40:57.134)
I saw a meme the other day about that show.

Joe Gambino (40:57.602)
I feel like it's so hard to find shows, so I'm gonna have look into The Severance, because we haven't watched it yet.

Joe LaVacca (41:01.976)
Severance was decent, man. You gotta just give it like a couple episodes and then it kinda gets you going. But I saw a meme the other day where it was like, no matter how bad you think your day is, it's not as bad as Noah Wiley's on the pit. So just keep thinking about his day on the pit. So I gotta watch it now, because I'm intrigued. I'm like, well, what could be a worse day than the worst day? All right, Joe, you got anything else for our boy?

Joe Gambino (41:13.294)
Yeah, it's good.

Vikash Sharma (41:21.996)
Yeah, same here.

Joe Gambino (41:26.462)
That's it my friend, take us home.

Joe LaVacca (41:28.558)
All right. Well, Prakash, we love you, man. Thank you for joining us. This is very special. Joe, love you. Listeners, we love you. And don't forget to come back next week for another episode of the Beyond Pain podcast.

Vikash Sharma (41:43.224)
Thank you guys.