Rob Butler ’94 is the Director of Performance for the 2019 National League Central Division champions the St. Louis Cardinals. In this position, Butler oversees aspects of the athlete's physical health and rehabilitation in coordination with the Cardinals Head Athletic Trainer, as well as strength and conditioning, sports science, injury prevention, and athlete recovery and nutrition plans for the players across the various levels of the Cardinals organization. St. Andrew's Director of Athletics Al Wood visited Butler on site this summer. "We talked about the system of performance that Rob has implemented with the Cardinals," Wood recalls, "some of the science that drives that system, and how many of his approaches can be scaled to benefit St. Andrew's athletes."In 2017, Butler visited St. Andrew's to talk to students about the science behind his work, and we had the chance to sit down with Rob while he was in town to discuss the same.
Can you tell me more about your job title? What does a Director of Performance do, exactly?
Contrary to what Will Speers may say, I’m not a Crossfit trainer or a paramedic. Director of Performance is a title that’s been used a bit in Australia and in European professional sports organizations. It’s one that’s relatively new, probably in the past five to ten years, in the States. A Director of Performance oversees the continuum of player health and athletic performance [for a team]. The goal is to set up a process that allows for making systematic decisions about: how do we get players healthy? How do we work within a player’s health constraints? How do you make decisions about what exercises are done or not done? How should the athlete train to support the overall development of a player in a larger organization?
Historically, you’d have the medical side saying one thing, and you’d have the strength and conditioning side saying another thing [with regard to these decisions], all of which may or may not fall in line with the coach’s thought process. This would lead to mixed messages, or there just wouldn’t be a consistent process. As Director of Performance, we can create a more collaborative spirit between professionals and greater collective immersion into the issues limiting a player’s current status or long term development trajectory. In the end, we’re all there to serve the larger organization, and to support players so that they can play baseball at the highest level possible.
How did you get to where you are today? What was your career prior to this position?
I was an Assistant Professor in the School of Medicine at Duke University, in their Physical Therapy Division. I did research in the Michael W. Krzyzewski Human Performance Laboratory in the Orthopedics department’s Sports Medicine division. During that time, I was consulting with a couple of different professional teams—the Portland Timbers, Washington Wizards and the Toronto Blue Jays, and through that stumbled over into working with the Astros and the Red Sox as well. I got connected with the Blue Jays first, through some colleagues who thought I might be interested in integrating a data-driven approach into physical training and sports medicine care in a professional sports setting. Before that, the majority of what I knew about Toronto was my memory of sitting on Sherwood, watching Joe Carter put one over the fence to beat the Phillies [in the 1993 World Series], and Mitch Williams cursing in his glove. It’s kind of funny to connect that back around.
Anyway, I got connected with these teams, and through my work with them I began to see certain things about player health and training that connected logically, things that maybe weren’t on the cutting edge of science, but could take us down the path [toward recovery] a little bit further, a little bit faster. It was just a complete coincidence that I happened to be a consultant with the Blue Jays when Marcus Stroman tore his ACL. Marcus was a pitcher for the Toronto Blue Jays. He was going to be their number one starter until he tore his ACL, and at that point the majority of my research had been on ACL injuries and rehabilitation. He decided he wanted to do his recovery and finish up his degree at Duke [where he had studied sociology until being drafted in 2012]. So we worked with him at Duke and things turned out well for him—he returned to the mound in 169 days, and people had thought he’d be out for the year, which would have been the case if we had stuck with the traditional chronological timelines [of recovery and rehabilitation]. If we were giving Marcus the standard care, he would have come in three times a week for 45 minutes. That’s just what’s always been done—we assume it’s going to take 12 to 16 months to come back from this kind of injury. And there are plenty of horror stories of people going back to play at five months [after an ACL tear] who then retear or re-injure. Instead, we did 11 sessions a week with him, probably two hours a pop around his class schedule. We did PT [physical therapy] work in the morning, and then an additional sessions, usually strength training-focused, in the afternoons. It wasn’t about using all the fancy biomechanical tools, although we had access to them—it was more about having a consistent methodology that determines if appropriate progress had been made. There were three of us that worked together as a group, and the process that we used allowed for enough feedback loops to tell us when to push forward, or when to try something else, or when to do something less often or with less intensity. It allowed us to understand: are we going down the right pathway? If we get stuck one way, how do we supplement in other ways that don’t cause pain or deficits or extra muscle tension? How’s he sleeping? What’s his nutrition like? Those feedback loops allow for constant progress to happen. Our tissues get stronger with the appropriate amount of stress—not no stress. No stress is the only certain way to make our tissues weaker.
In the end, it just turned out that we had a driven athlete and a bunch of people that wanted to communicate with each other and to give Marcus everything we had to support his goal of pitching in September. So I think that experience pulled me into discussions with different teams about how this kind of work could potentially fit in Major League Baseball, which is probably the last of the four to five major professional sports to integrate a more holistic model for player care and performance training.
Do you think this model works if the patient isn’t a professional athlete, and maybe isn’t as motivated to engage in fitness?
I think about how we train fundamental reading and writing. When my kids were first going to school and learning how to read, they took a test and then they got a book that correlated with their testing results.There’s a book group that’s harder and a book group that’s easier, and a middle book group, and if the children are provided the right level the process allows for simple error detection and self-correction and understanding, that in turn allows for a consistent development of the reading process. I’ve found it completely surprising that we didn’t have a similar model to develop and progress systematically toward movement and musculoskeletal health the way we do for reading and writing, which are far more complex constructs. But, fundamentally, whatever it is, if it’s reading, math, exercise—no one wants to be in the “easy” group, right? No one wants to be in the easy exercise group. Everyone wants to be in the “hard” exercise group because we’re bad-ass and we’re going to punch through it. And yet, when people aren’t good at one thing, they go do something else. When the harder books are too hard, the kids get stressed out and don’t want to read and then just get away from reading all together. So there’s got to be a way to pull you in. You’ve got to be engaged or anchored somehow to create an environment that allows for growth and development.
However, like most things in life, it isn’t just as simple as the process being right—it’s also how the process is communicated. The words that are utilized to describe the process play an integral role in optimizing an individual’s potential. The language and the terms we use are just as relevant as the data we use. Some people don’t like their data. I don’t like looking at my checkbook. I don’t like looking at the scale on a daily basis. How do we change that to have a positive spin on it? The last thing you want someone do with their information is to have it hurt progress. So we really engage the patient and let them know that whatever is going on with them, it isn’t a limitation like they think it is, and it doesn’t mean they’re not as good as they think they are, and it doesn’t mean that they’re done with their process. The data is just a representation of where they are at this current point in time, and by going through this consistent training and testing process, we will understand how close they have come to how far they can go.
How did you get interested in physical therapy and biomechanics in the first place?
My PhD was in biomechanics at Delaware. I graduated in 2005, and did a post-doc at Chapel Hill, and that was where I started getting interested in arthritis pathways, in understanding more about how knee injuries are associated with early arthritis in young adults. It didn’t make a lot of sense to me that, after you finished recovering after your ACL surgery, you’re likely going to develop knee osteoarthritis at a really young age. How does that connect? I thought, We’ve got to be able to do better than that. I just started unwinding the story of why this is the current medical expectation and asking, Where is the point that we all agree upon is unacceptable, where we can get some standards in place? And I quickly realized that in the musculoskeletal care world, we don’t agree on a lot of things, whether it’s how much a joint should move, how strong muscles should be, whether someone should be in pain, how functional people should be, how fit they should be—all of which are different factors related to whether or not someone is healthy or stays healthy in the long run.
During my time at Duke, I was lucky enough to collaborate with an oncology research group at UNC-Chapel Hill, at the Lineberger Cancer Center, and if you compare what is standard practice from the musculoskeletal standpoint to what is standard practice from an oncology standpoint, it’s night and day—you don’t leave an oncology unit until your numbers are where they are expected to be for you to be able to live when you return home. But for musculoskeletal treatment, it’s like, “Well, do you still have pain?” “Yeah, a little bit.” And we send you on your way—typically stating that the symptoms will resolve over time, or that you should follow a pharmaceutical regimen. We don’t even agree on some of the fundamental biomarkers that create success and health and wellness after a surgery.
The one thing I always struggled with as a biomechanist was the fact that it’s not really an accessible technology. You have smartphones and you can take videos, but there’s still issues related to how our bodies move three-dimensionally in space that are only accessible—and only reimbursable—at certain biomechanics labs around the country. You can go to one of these locations and pay them $1,000 and they can do whatever tests on you, but what does that mean? How do you train based off of that, and what does that lead to? I don’t know that we have a good idea of how biomechanical information connects to some kind of individualized plan down the road. This limited knowledge base drove me to undergo training to receive a doctorate in physical therapy while working full-time as a professor [at the University of Evansville in Indiana]. That allowed me to begin to understand why we are not translating our research into clinics effectively.
So part of the spirit of all these questions I was having was realizing that [as healthcare professionals] we almost have to prove deficits as opposed to assume deficits [in a patient]. The more we enable a person to be an athlete, to be athletic, to be fit, to exercise, the closer they’ll get to healthy—as opposed to putting some sort of disability or limitation on them. Unfortunately, for most of the country, we support individuals when they are not healthy, but there are no models to financially support actually being healthy. For me, the fundamental question gets down to this: how can we figure out how to pull in data to enable performance, as opposed to disable performance ?
Is there something about baseball in particular that lends itself to your areas of research?
Baseball just drew me in. It forces you not to solve a problem at one level—you’ve got to solve the problem across nine different locations, with all different levels of athletes, who have different dialects and different backgrounds and different histories and different abilities. Some players are drafted from college, some are drafted at 16. Some grew up on rice and beans, some are vegan, some haven’t figured out how to eat like adults yet. So how do you systematically make decisions on a larger sale to maximize the athleticism and the performance and maintain the health of of each individual on the team? Baseball is an opportunity to examine a microcosm of some of the issues facing our healthcare system in general. It’s easy to take a pill. It’s easy not to engage. It’s easy to be passive. At times I think that may be why, right now, musculoskeletal injuries and diseases are the number-two leading healthcare cost. You wouldn’t think that—you’d think oncology has to be second after cardiovascular disease, right? Well, number two is musculoskeletal injuries: back pain, knees, ankles, everything. When you go get a physical, everyone gets their blood pressure checked, we test your eyes, we test your blood, and that’s covered by insurance. But we don’t really ask [about musculoskeletal health]. We generally tell you, “Oh, just go exercise.”
We continue to make money, as a health care industry, off of more sickness, not more health. The goal is wellness, but we make a lot of money off of sickness and disabilities. As far as the healthcare industry is concerned, it’s very counter to what are our needs are as a country. How we treat people is still a volume thing. Insurance dictates that. A lot of your cost comes in the first fifteen minutes of seeing an individual, and at the same time, once you get your volume to a certain level, there’s almost a cap on what can be reimbursed. The majority of the time we spent on Marcus’s therapy was not “on the book” or done on billable hours. It was just a matter of trying to get it right, which didn’t make a lot of money for anyone. It was just three or four people who said, “This is the goal, and we should do what we can to support that goal.” How that level of care could be scaled to the masses is a work in progress, but it is not impossible.
What would advice would you give to the average person who wants to maintain or improve their musculoskeletal health?
Let’s be clear: the majority of musculoskeletal injuries can be taken care of by one thing: exercise. But what we do to promote exercise? We talk about it, but there’s really no benefit to doing it other than just being healthy, right? It gets down to a time factor. What do you with your free time? Do you use that as a time to get outside and be active? We don’t have a lot of engaged outdoor environments for adults—there’s no play areas or monkey bars. Fitness is all videos on the internet. You get into a sport as a kid, and then you grow up and realize there’s no place that has crew shells in your area. So what do you do? You pick up running. But then you don’t have time to go out and do 60 minutes of running. But when you do 16 minutes of high interval training, it’s far better than 60 minutes of running—it’s less stress on your joints, which leads to a more healthy overall individual. But you think, there’s no way that 16 [minutes of exercise] can be better than 60, because we assume more exercise is always better, and anyway, you‘ve always had back pain and tight hamstrings and none of that can be changed, right? Unless we allow ourselves to be open to change. Too often we think we need 60 minutes to run and 15 minutes to change into the right clothes, another 15 minutes to warm up and then 30 minutes to cool down. These were really amazing delusions of time utilization for me in grad school. However, now there are jobs and kids and school and cars with flat tires and dogs that are randomly vomiting on the carpet, the idea of 120 minutes of uninterrupted athletic activity is likely difficult to carve out of the day. So the goal is not 120—the number needs to be more obtainable. Eight minutes of something is better than zero minutes of additional resting behavior, particularly if your eight minutes are balanced between high intensity work in an appropriate functional range combined with intermittent rest periods.
There’s a strong argument that, as opposed to taking away the arts and the physical education that kids get in school, they should get more of that, in balance with some of the time associated with the core education, in order to create a more robust, learning human. Kids act out in class, but we take away the one thing they likely need, which is movement and engaging with the outside environment. That’s one of the things that’s so great about St. Andrew’s—the three-sport model. I still remember—it was my third year here, and I wanted to do an IP one season that was basically me playing more soccer. But John O’Brien said, “Yes, we could sign off on you doing that, but that’s not what’s going to allow for you to really develop. More soccer is not the answer.” Which we know now is true—the better athletes are the ones who were engaged in more than one sport to develop their athleticism, while still working on particular skills. In the end, that diversity of experience tends to make you more resilient as a professional athlete, and it’s no different even if your “sport” is maintaining your health amid all of the other events that fill your days.
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