Dr. Kyler Brown on Injury Prevention, Rehab, and Performance for Longevity

In this episode of The Drive Podcast, host Peter Attia sits down with Dr. Kyler Brown, a sports rehab chiropractor specializing in sports injury, pre- and post-surgical rehabilitation, and bridging the gap from rehab to performance. Dr. Brown is also the co-founder, along with Peter Attia, of 10 Squared, an Austin-based training program focused on building exceptional muscle capacities for the "marginal decade." Originally recorded for the 10 Squared audience, this conversation delves into the core principles behind injury prevention, effective recovery strategies, and long-term performance optimization. Key topics include the nuances of movement dynamics that can lead to chronic issues, a framework for assessing and treating individuals, the importance of understanding functional asymmetries, personalized rehab approaches, and the crucial role of overcoming mental barriers in rehabilitation. This discussion is highly relevant for anyone interested in improving their physical well-being, recovering from injuries, optimizing their training for longevity, or understanding the sophisticated approach to health and performance championed by Peter Attia and Kyler Brown.

Key Insights

• Integrative and Proactive Rehabilitation: A collaborative approach involving surgeons and rehab professionals, emphasizing pre-habilitation (prehab) and aggressive, intelligent post-operative protocols, can dramatically improve recovery outcomes and long-term function, as exemplified by Peter Attia's own shoulder surgery experience. Early, controlled movement and targeted strengthening, even before surgery, set the stage for faster and more complete healing.
• Training for the "Marginal Decade": The concept of the "Centenarian Decathlon" underscores the importance of training with the physical demands of the final decade of life in mind. By preparing for these future challenges, individuals not only enhance their quality of life in older age but also significantly improve their current physical capabilities and resilience.
• Capacity and Precision in Training: Injuries often arise when the body's capacity for a specific movement or load is exceeded. Dr. Brown emphasizes that effective training must be precise, accounting for an individual’s unique biomechanics, movement patterns, injury history, and long-term goals, rather than solely focusing on short-term performance metrics or generic exercise programs.
• Addressing Root Causes, Not Just Symptoms: True rehabilitation extends beyond managing pain at the site of injury. It involves identifying and correcting underlying functional asymmetries and dysfunctional movement patterns (e.g., related to the "spinal engine" or pelvic mechanics), as localized pain is often a symptom of a problem elsewhere in the kinetic chain.
• The DNS Concept of Core Stability: Effective core stability, as understood through frameworks like Dynamic Neuromuscular Stabilization (DNS), is not merely about strong abdominal muscles. It encompasses the dynamic, three-dimensional control and pressurization of the trunk as a "cylinder," which is fundamental for efficient force transfer, injury prevention, and optimal movement.
• The Psychological Dimension of Recovery: Overcoming fear of movement and other mental barriers is as critical to successful rehabilitation as physical healing. Empowering patients with a clear understanding of their condition and a graded, confidence-building approach to movement is essential for a full return to activity.
• Holistic and Individualized Assessment: A comprehensive assessment, like that employed at 10 Squared, delves deeper than the immediate injury or complaint. It considers an individual’s entire history, demographic risks, detailed movement patterns (such as discrepancies between single-leg and double-leg function), and future aspirations to craft a truly personalized and effective training and rehabilitation plan.

The Genesis of 10 Squared: Peter's Shoulder Injury and the Marginal Decade

The conversation began with Peter Attia recounting his long-standing shoulder labrum tear, initially diagnosed in 2009. He had avoided surgery for years, fearing a trade-off between pain/instability and immobility. Upon meeting Kyler Brown, a new approach emerged. Peter's surgeon, Dr. Alton Barron, and Kyler collaborated closely, a partnership Peter highlighted as crucial. They implemented an eight-week "prehab" program before the surgery. Kyler explained that prehab focuses on making all muscles around the joint "awesome" without worsening the existing injury. This involved significant rotator cuff work, particularly strengthening the supraspinatus, and aggressive approaches to core stability and scapular interaction with the ribs. The goal was to create a robust support infrastructure so that post-surgery, the focus could be solely on the shoulder itself.

The post-operative plan was unconventional. Traditional recovery for such a severe labrum tear involves being in a sling for four to six weeks to ensure stability, often at the cost of future mobility. However, Dr. Barron, confident in the prehab work and Kyler's ongoing management, had Peter out of the sling in 24 hours. Kyler emphasized this was possible due to detailed pre-operative conditioning, precise surgical technique that didn't over-tighten the joint, and Peter's adherence to post-op instructions. Early efforts focused on range of motion without stressing the repair, using targeted isometrics to load tissues specifically. This experience, coupled with Peter's evolving thoughts on the "marginal decade"—the final ten years of life—led to the idea for 10 Squared. Peter noted that physical decline is a primary complaint impacting quality of life in this last decade, suggesting that training like an athlete for this period can significantly improve it.

Training for Longevity: The Centenarian Decathlon and Risk-Reward Assessment

Peter Attia's "Centenarian Decathlon" concept involves identifying 10 physical activities one wishes to be capable of during their marginal decade. Kyler shared his own examples, such as wrestling with his grandkids, rucking (hiking with a weighted pack – aiming for 20 lbs for 4-6 miles on varied terrain), and playing sports with his kids. The underlying principle is that preparing for these future demands inherently makes one more capable in the present. Peter used an archery analogy: training to be accurate at 100 yards makes 50-yard shots seem easy. Similarly, being exceptionally fit in one's 90s is a far more demanding (and rewarding) feat than being fit at 50.

The discussion highlighted how the risk-reward calculus of exercise changes with age. Younger individuals often possess better tissue quality and can tolerate imperfect movement patterns. However, as Kyler pointed out, "injury doesn't show up out of nowhere." It's often a result of the body being unprepared for a specific load or movement. Peter shared his own experience of reintroducing jumping after decades of non-impact activities, realizing he'd lost significant tissue pliability. Kyler stressed that many people lose capacity for activities like jumping or reactive movements because they cease doing them. He advised observing children, who naturally engage in varied, playful, and reactive movements, as a model for maintaining tissue health and neuroplasticity. The conversation underscored that training for the Centenarian Decathlon isn't just about old age; it enhances one's capabilities and resilience throughout life.

The 10 Squared Approach: Bridging Rehab and Performance

Peter and Kyler then discussed the philosophy behind 10 Squared, their joint venture designed to integrate rehabilitation principles with strength and conditioning to train individuals for their marginal decade. Kyler explained his role involves extensive two-day assessments that go "under the hood" to identify not just existing pain points or past injuries, but also underlying weaknesses and potential risk factors. For example, a client who loves surfing might require uniquely robust shoulder strengthening in specific ranges of motion different from traditional swimming. A key principle is to "bake in" corrective exercises and gap-filling movements into the overall strength program, making it functional and sustainable, rather than assigning a long list of tedious, isolated rehab drills that people rarely adhere to.

Kyler critiqued common pitfalls in the conventional rehabilitation world, such as "cookie-cutter" approaches where multiple clients receive generic, often insurance-driven, protocols (like passive modalities and basic exercises) without individualized attention or a clear plan to build capacity. He stressed the rarity and importance of communication and collaboration between orthopedic surgeons and rehab professionals. Even in professional sports, Kyler noted, care can be fragmented due to multiple "cooks in the kitchen" and time constraints. 10 Squared aims to provide a more integrated, long-term oversight, focusing on building a "crazy robust foundation" rather than chasing short-term fixes or the latest techniques.

Understanding and Addressing Complex Injuries: Case Studies and Principles

The conversation delved into specific case studies to illustrate these principles. Peter's wife, Jill, an endurance runner, presented with knee pain that Kyler identified as stemming from a proximal hamstring tendinopathy on the opposite leg. Kyler explained the concept of the "spinal engine," where running involves unilateral (single-leg) rotational propulsion. Jill's slight scoliosis and compensatory movement patterns, exacerbated by increased training volume (two marathons in short succession), led her to overload her right knee due to issues with her left hamstring and pelvic rotation. This highlighted the principle that pain often manifests at a site different from the root cause. The discussion also touched upon the significant biomechanical changes women experience post-pregnancy, such as altered pelvic mechanics and foot structure due to the hormone relaxin, and the general lack of robust post-partum rehabilitation protocols.

Another crucial concept discussed was core stability, viewed through the lens of Dynamic Neuromuscular Stabilization (DNS). Kyler emphasized that true core stability isn't about a "six-pack" (rectus abdominis) but about the deep stabilization system creating a pressurized "canister" involving the diaphragm, pelvic floor, and deep spinal muscles (like multifidi). This system must function dynamically to allow for controlled movement in multiple planes. When this deep system is dysfunctional, superficial muscles (like the QL or biceps in the case of shoulder instability) compensate, leading to tightness, restricted movement, and pain. Kyler shared an example of a client whose glute minimus trigger point mimicked radicular nerve pain, underscoring how muscular issues can masquerade as more serious spinal problems.

Practical Application: Movement Assessment, Stiffness, and Plyometrics

Peter introduced his race car analogy to explain dynamic stability: a stiff chassis and suspension in a race car allow for efficient power transfer to the tires, similar to how a stable human body can transmit and receive force effectively. This kinetic stability is key for complex movements like throwing a fastball. Kyler elaborated on assessing an individual's readiness for dynamic movements, stating "the exercise is the test." At 10 Squared, they use a combination of qualitative observation and quantitative data (from motion capture, force plates) to evaluate movements like wall squats, and particularly note discrepancies between double-leg and single-leg performance, which can reveal underlying balance and control issues.

Regarding clients with limited training history, the initial focus is on building habits, mitigating injury risks, and then prioritizing based on medical risks (e.g., poor cardiovascular markers from a CPET test) or significant functional deficits (e.g., very weak calves indicating a fall risk). For someone with weak calves and poor balance, a running program would be contraindicated initially; instead, cardio would be programmed around these limitations while strength work targets the deficits.

The discussion also covered foot reactivity. To maintain this, Kyler advocated for training in three-dimensional space (e.g., multi-directional lunges) and using either very heavy loads or very fast movements to recruit type II muscle fibers. This often involves a progression: starting with long-hold isometrics (like an isometric mid-thigh pull against an immovable bar) to prepare tendons, then moving to deloaded plyometrics (e.g., band-assisted pogos to train speed without full bodyweight impact), and finally progressing to full bodyweight and beyond. Peter shared his own foot/ankle issues, stemming from his highly mobile "swimmer's feet" lacking multi-positional stiffness. His pogo-stick misadventure caused a tendon flare-up. Kyler explained exercises like the front foot hover in a split squat (elevating the front heel while lunging) are designed to load tendons at different lengths and build strength and control, particularly for issues related to "toe-off" mechanics during gait.

The Psychological Aspect of Injury and the Future of Rehab

A significant portion of the discussion focused on the psychological aspects of injury, particularly fear of movement. Kyler explained that when the brain perceives a threat (due to past injury, pain, or even hearing about others' injuries), the nervous system heightens sensitivity to pain. He emphasized that "pain does not always mean injury"; it's often a protective signal. For instance, imaging like MRIs often shows age-related wear and tear that isn't necessarily the cause of pain or a "death sentence." Emotional and mental stress can also significantly exacerbate physical pain. The key to overcoming this, Kyler stated, is empowerment through education, providing rational explanations for pain, and a carefully graded plan to reintroduce movement and build confidence.

When assessing low back pain, Kyler looks for "red flags" like neurological weakness (motor deficits, loss of bowel/bladder function), which warrant immediate surgical consultation. For mechanical low back pain or even some disc issues without weakness, interventions like the McKinsey Protocol (specific movements to centralize pain and decompress discs) can be highly effective. Peter shared a profound personal experience where severe acute low back pain was resolved within an hour through specific DNS-based isometric loading, illustrating how targeted exercises can "reprogram" the nervous system and alleviate pain by mechanisms like reciprocal inhibition.

Looking to the future, Kyler acknowledged the potential of AI and video recognition software for movement analysis but cautioned that the nuanced understanding of individual responses and the art of coaching remain critical. He reiterated his "degree agnostic" stance, valuing the skill set and approach of a practitioner (whether chiropractor, PT, or strength coach) over their specific title. The ideal practitioner possesses a diverse "tool belt" of techniques (manual therapy, adjustments, needling, taping) but uses them to create a window of opportunity for the most crucial element: active rehabilitation and strength building. These passive modalities, Kyler and Peter agreed, should serve the ultimate goal of enabling the individual to perform the work needed to retrain movement patterns and increase strength safely and effectively.

Conclusion

This episode with Dr. Kyler Brown offers a deep dive into a sophisticated, proactive, and individualized approach to physical health, injury management, and long-term performance. The core message emphasizes that by understanding our bodies, addressing the root causes of dysfunction rather than just symptoms, and training with intention—particularly for the demands of our later years through concepts like the "Centenarian Decathlon"—we can build remarkable resilience and maintain a high quality of life. Peter Attia and Kyler Brown's work at 10 Squared, and the principles discussed, provide a powerful framework for anyone seeking to move beyond generic fitness advice and truly optimize their physical well-being for both the present and the future. The conversation highlights that effective rehabilitation and training require a blend of scientific understanding, precise application, and a keen awareness of the interconnectedness of the body's systems and the mind-body connection.