How do you know which exercise to use when you have multiple exercises that appear to accomplish the same thing? This comes from Joseph. He's wondering what drives exercise selection, particularly when there are multiple means to a solution. How do you decide which exercise to program when tackling a goal based on table test selection? For instance, when creating a posterior concentric yielding strategy to the pelvis, can't a deadlift, front foot elevated split squat, or backward sled drag all provide the desired outcome? How do you decide which exercise you'll program? This is actually a really good question, and it's not as simple as it seems sometimes. I think that a lot of people are expecting some sort of cookbook kind of an answer. People are really uncomfortable in the gray, and what we have to recognize is that we have to have this overarching strategy of some sort. And then we have to have the tactics that we apply. And the way we're going to do that is we're going to divide this into three things that are going to help us narrow the probabilities because we're always playing with probabilities as to what will be successful and what may not. And so the three things that we're going to rely on are our model, our process, and then experience.

We have somebody that has this left posterior compressive strategy on the back of the pelvis and it's pushing that sacral base forward and maybe over to the right. And so now what I know is that from my assessment process that I'm going to need that yielding strategy on this left side of the sacral base. And so there's any number of ways that I can get this. So you mentioned in your questions a few exercises. So let's just say that, okay, I want to use either the Camperine Deadlift or the Front Foot Elevated Split Squat. Well, both of those are going to help me create that yielding strategy at the sacral base. So both of them appear to be on the table, but now we have to understand what the secondary consequences of each one of those are. And so if I'm using a Camperine Deadlift or I'm using a Front Foot Elevated split squat while I can certainly achieve that yielding position at the left sacral base, as I move out of those two exercises I have to create a concentric overcoming strategy which may actually reinforce the reasoning behind why this position existed in the first place and if I can't manage that strategy then all I'm doing is actually reinforcing what the limitation is. And so those are the secondary consequences that are associated with that type of an exercise. So let's just say that I can actually create an unloaded situation. So if I use a staggered stance or a side split squat with a cable chop, I'm actually moving into the same orientation of the pelvis where I'm capturing that yielding position. But now I'm doing it in a much more reduced load environment where I'm using the cable pull down to actually reduce gravity in my favor. So now I can actually capture the change and actually reduce the amount of concentric strategy that I'm going to have to use to get out of that. Now, let's just say that I have this additive in regards to my pelvic strategy that I've got this posterior pelvic compression. And so I immediately eliminate a few things, which would be the Camperine deadlift and the front foot elevated split squat, because that posterior pelvic compression is going to be interference. I may have to actually resolve that first. So now I'm thinking about a strategy where I might use like a heels elevated toe touch which is going to move me way back to that earlier propulsive strategy to help me reduce some of that posterior pelvic concentric activity in my world where I'm dealing with a lot of pain and people tell me that, oh, I have pain or discomfort in a standing activity that immediately tells me that, okay, I need to move you into a position where I have to reduce gravity.

So I might end up using something like a hook-lying activity under these circumstances to reduce that posterior lower strategy, knowing full well that if I stood them up, I have pain as interference, I have concentric muscle activity as interference. In the non-painful world, what you're gonna want to try to do is strategize them into the highest level of performance where they can still be successful. Let's just say that I worked somebody through multiple phases of interventions. I've reacquired the ability to stand effectively. And now I want to reintroduce a concentric strategy in that left posterior hip, but I need them to be able to control and manage it under those circumstances. Now maybe I start to introduce this with the backwards sled drag. So what the backwards sled drag will ask me to do is it allows me to grade the load on that concentric strategy. But as I move into the yielding strategy, the yielding strategy is entirely unloaded as I step backwards into that yielding strategy, so that might be a better way for me to start to reintroduce that. So as you can see, all of these activities can support the goal of acquiring the yielding strategy, but there are nuances associated with each one of those depending on what my findings are. And so that's why the representative model becomes so important. That's why following a process becomes so important. But ultimately, it's the investment in the repetitions. And when I say repetitions, I'm talking about experience here for you to gain the knowledge to understand the nuances of your interventions, to understand the subtleties of the presentations that your patients or clients bring to you. And then you can understand the secondary consequences. So let's mix this down into some simple rules. I have to understand what my starting conditions are on the representation that my client is bringing to me. So that is my archetypes. I have to recognize the strategy that they're presenting. And they also need to understand the strategy that I'm going to utilize to try to intervene to make the changes that are desired. And so that requires that I understand the nuances of the presentations, the nuances of the interventions that I'm going to be utilizing, so I need to understand where I would have secondary consequences that might actually be interference. Then it just comes down to my experimentation where I intervene, I observe what that outcome is, and then I intervene again. And so this is my repeated process until goals are achieved.

That's really good. So it's Tuesday, a very busy day. We're going to dig right into today's Q&A. It comes from Mike, and it seems like a very simple question, but we're going to stack some stuff on top of this and make it really interesting. Mike asks, can you walk me through the relative motions of the femur and the tibia and how different positions would limit knee flexion and/or extension? He gives an example of an internally rotated femur on an externally rotated tibia. Let's talk through this and see if we can simplify it to a certain degree. Then we'll look at some influences superimposed on the knee joint that might explain these issues so we can strategize our way out of them. One thing to recognize is that all joints move on helical angles. We tend to look at these in imaginary planar views, which complicates things. We see the knee and say it has sagittal motion, calling it flexion-extension. The reality is it's turning as it moves through space. As we extend the knee, the tibia externally rotates relative to the femur. As we flex, it internally rotates relative to the femur. We always talk about two strategies in one plane—the transverse plane. This is where the secret to the knee lies and needs to be respected. If we look at resources like Newman's kinesiology book, it discusses a 40-45 degree range of rotation with a 2:1 bias of external rotation over internal rotation. If we understand this rotation concept, we can ask what limits knee extension. If I need tibial external rotation for normal knee extension, anything that limits my ability to externally rotate the tibia becomes a restriction to extension. It could be as simple as fluid accumulation in the knee. A small amount of fluid, whether anterior-lateral or posterior-medial, would restrict my ability to externally rotate the tibia, leading to a lack of extension. This must be a consideration, especially for those who blame quad inhibition after knee surgery. I would look towards measures of fluid accumulation in the knee that keep the quadriceps eccentrically oriented, causing them to test weak or atrophy. In the opposing strategy, when we talk about tibial internal rotation, if we have anterior-medial or posterior-lateral fluid, we'll lack flexion because I won't be able to internally rotate the tibia effectively. For those experiencing posterior-lateral knee pain in deep squats and looking for a problematic structure, I can't rule that out. But if the knee checks out and the pain persists, what might be happening is that you're squatting with a tibia oriented more for extension. As you squat, you're sitting down on an area of fluid accumulation on the posterior-lateral side of the knee, compressing it and causing discomfort. Now let's consider what might promote these knee orientations. I don't think the knee is a very intelligent joint—it's more responsive to what goes on around it. So we have to talk about pelvis and foot orientation. The knee isn't very intelligent. Let's focus on tibiofemoral external rotation. With a fixed beam, the femur moves relatively. So it's externally rotated. Why does this orientation predominate? This tibiofemoral external rotation strategy is the system looking for internal rotation. I have a femur internally rotated on the tibia because I need to apply force to the ground to stay upright against gravity. Thinking about embryology and evolution, external rotation came first. We were swimmers before we were walkers. Coming to land required figuring out how to apply pressure into the ground through internal rotation for propulsion. If I've lost internal rotation anywhere in the system, I'll find a strategy to create it, often this tibiofemoral external rotation strategy. When we see terms like knee valgus or hyperextension, we're talking about someone using an internal rotation strategy. It's not true hyperextension; it's a lot of femoral internal rotation on the tibia. With valgus, we have a change in the center of gravity to an anterior-medial strategy, twisting the femur inward and the tibia outward to apply pressure down and forward through the knee. The pelvic orientation becomes crucial. An anterior pelvic orientation is me looking for an internal rotation strategy. That's why we lose external rotation of the hip when the pelvis anteriorly orients—we're seeking more internal rotation and sacrificing external rotation. This is why hip extension activities are vital for restoring normal knee excursion. I must establish external rotation first to delay propulsion and then recapture internal rotation. Looking at the foot, I might have a foot following the tibia into external rotation, creating an early propulsive foot. This means an externally rotated foot where I've lost internal rotation at the ankle and foot. Internal rotation at the ankle and foot is represented by my ability to dorsiflex and pronate. If I lose that strategy, I have to recapture it. My goal is to retrain the tibia to move through the full range of mid-propulsion, which recaptures dorsiflexion and, nicely, internal rotation up the chain into the hip, assuming I've managed the pelvic orientation. The bottom line, Mike, is we must stop seeing the knee as a hinge joint. We have to respect that it turns as it moves. Measurements like heel-to-butt flexion become hugely important because they represent my ability to fully internally rotate the tibia. Capturing 5-10 degrees of knee hyperextension, as defined in textbooks, represents my ability to recapture the external rotation of the tibia. We now have a simple way to look at the knee. If I don't have those excursions, nothing else about the knee matters until I can recapture them, as they represent the normal capabilities of my knees. Re-establish external rotation, re-establish internal rotation on top of external rotation. Get dorsiflexion back, and you'll save your knees from a world of hurt.

That always has to be a consideration, especially for you folks that want to blame the quads for being inhibited in things after a knee surgery, I would be looking towards like some measure of a fusion in the knee that is keeping that quadriceps eccentrically oriented and therefore it would test weak or it would atrophy under those circumstances. So in the opposing strategy then when we talk about tibial IR, if we have an anterior medial or posterior lateral then we're going to be lacking deflection because I won't be able to internally rotate the tibia effectively. So think about this for a second. So those of you that are complaining about a posterior lateral knee pain in your deep squat and you're looking for a structure that might be the problem. I can't rule out that structure is not a problem, but if the knee checks out okay, and you still have that posterior lateral knee pain, what you might be doing is you might be trying to squat with a tibia that is oriented better towards being an extended knee. So as you squat, you're actually sitting down and you've got an area of fluid accumulation on the posterior lateral side of the knee that you're trying to sit down on and you're just compressing that and then that results in the discomfort. Now let's consider some potential influences as far as what might be promoting these orientations in the knee that seem to be sticking it in a position. And the thing that I'm most fond of about talking about knees is I don't think that it's a very intelligent joint to put it mildly, I think it's more responsive to what goes on around it. So now we have to start talking about pelvis orientation. We talk about foot orientation. So if the knee is a pretty dumb joint and we're going to pick on this tibia femoral ER. So again, I have a fixed beam where I'm going to move it relatively as such. So it's externally rotated. And you say, well, why does this orientation predominate? And so there should be a picture right here. So you can kind of see what I'm talking about in a real knee. And this can happen on either side. So I can have this show up on the right knee, or I can have it show up on the left knee because what this orientation is, the tibial femoral ER orientation, is the system looking for internal rotation. And so what we have is a femur that is internally rotated on top of the tibia because I have to apply a force to the ground. I have to apply a propulsive force into the ground so I can stay upright against gravity, so I can walk and do all the cool things that humans do. And so when we think about embryology, when we think about evolution, external rotation came first. So you were a swimmer before you were a walker, you came up on land, and you had to figure out a way to put pressure into the ground, and that is through internal rotation. So again, that is our propulsion. So, if I have lost internal rotation anywhere in the system, I will find a strategy that will allow me to do so. And oftentimes, what we'll see is this tibial femoral ER strategy. We're going to turn the femur inward into internal rotation to create our downward force. So when we see terms like knee valgus, or we see situations of hyperextension of the knee, what we're actually talking about is we're talking about somebody that's utilizing an internal rotation strategy because that's what the resultant is going to be. So we don't really have a hyperextension. What we have is a lot of internal rotation of the femur on top of the tibia. When we have the valgus, what we have is a change in the center of gravity to an anterior medial strategy and then that twists the femur inward, turns the tibia outward and we will put pressure down and forward into the ground and so we have to do that through the knee. So the elephant in the room then becomes this pelvic orientation situation and so an anterior orientation of the pelvis is me looking for an internal rotation strategy. That's why we lose extra rotation of the hip when the pelvis anteriorly orients because I'm looking for more internal rotation and I have to sacrifice my ability to externally rotate. This is why hip extension activities then become very, very important when we're talking about restoring normal knee excursion because I have to establish my external rotations first so I can delay propulsion and then recapture internal rotation.

So you were a swimmer before you were a walker, you came up on land, and you had to figure out a way to put pressure into the ground, and that is through internal rotation. So, again, that is our propulsion. So, if I have lost internal rotation anywhere in the system, I will find a strategy that will allow me to do so. And oftentimes, what we'll see is this tibial femoral ER strategy. We're going to turn the femur inward into internal rotation to create our downward force. So when we see terms like knee valgus, or we see situations of hyperextension of the knee, what we're actually talking about is we're talking about somebody that's utilizing an internal rotation strategy because that's what the resultant is going to be. So we don't really have a hyperextension. What we have is a lot of internal rotation of the femur on top of the tibia. When we have the valgus, what we have is a change in the center of gravity to an anterior medial strategy and then that twists the femur inward, turns the tibia outward and we will put pressure down and forward into the ground and so we have to do that through the knee. So the elephant in the room then becomes this pelvic orientation situation and so an anterior orientation of the pelvis is me looking for an internal rotation strategy. That's why we lose extra rotation of the hip when the pelvis anteriorly orients because I'm looking for more internal rotation and I have to sacrifice my ability to externally rotate. So this is why hip extension extension activities then become very, very important when we're talking about restoring normal knee excursion because I have to establish my external rotations first so I can delay propulsion and then recapture internal rotation. If we go all the way down to the foot, now we're talking about a situation where I might have a foot that's following that tibia into external rotation. Under those circumstances, I'll have an early propulsive foot. That means that I'm going to have an externally rotated foot I've lost inter rotation at the ankle and foot. Inter rotation at the ankle and foot is represented by my ability to dorsiflex and pronate. And so if I lose that strategy, now I'm going to have to recapture that. So my goal then is to retrain my tibia to be able to move through the full excursion of middle propulsion. and that's where I recapture that dorsiflexion, and nicely I capture interrotation all the way up the chain into the hip, assuming I have managed that pelvic orientation. So the bottom line here, Mike, is we have to stop looking at the knee as some sort of hinge joint. We have to respect the fact that it turns as it moves. And so measurements like heel to butt flexion become hugely important because it represents my ability to internally rotate that tibia fully. Capturing my five to ten degrees of knee hyperextension by definition in textbooks is my representation of my ability to recapture the extra rotation of the tibia. So now we have a really, really simple way to look at this knee. If I don't have those excursions, I don't care about anything else about that knee until I can recapture those things because they represent the normal representation of what my knees should be capable of. So, re-establish ER, re-establish IR on top of the ER. Get your dorsiflexion back and you're gonna save your knees a world of hurt.

So we have a really, really simple way to look at this knee. If I don't have those excursions, I don't care about anything else about that knee until I can recapture those things because they represent the normal representation of what my knees should be capable of. So, re-establish ER, re-establish IR on top of the ER. Get your dorsiflexion back and you're gonna save your knees a world of hurt. I hope that's helpful.

We would see this naturally in just about any rotational athlete at some point in time during their performance where we would see a sharper turn, we're going to see this representation of the asymmetrical presentation through the thorax and through the pelvis. Again, this is not something unusual. Again, we're probably looking at a change in yielding strategy. If I magnify the overcoming strategy on one side, if I magnify the yielding strategy on the other side, I get a bigger turn. So essentially what I've done is I've moved myself further away from the dead center of middle propulsion. So I'm moving one side towards a later propulsive strategy. I'm moving the other side towards an earlier propulsive strategy. And so now what we have to say is okay, what's the goal? Are we trying to increase the degree of adaptability? Am I trying to raise performance and then what is the interference? And so this just becomes basic training. We have to identify what constraints are the limiting factors. How am I going to address those? And so when we talk about, well, do I need to work on symmetry first? I think the question that we first ask is, is symmetry even important under the circumstances? Or am I just trying to capture enough adaptability to alleviate pain? Am I trying to encourage adaptability to achieve a goal? Am I trying to raise some measure of performance? And so like I said, it just becomes a training process. Here is presentation A, the goal is presentation B, and then I train to close the gap. So however it's necessary for me to expand the available strategies, I have to just decide, it's like, okay, do I need to just unbalance this program to achieve those goals to become more adaptable or to raise the performance? And so then we have to just decide, okay, how much of this do I need to do? How often my frequency, my intensities to maintain this favorable change to achieve the desired outcome? So the big takeaway here is that the principles do not change. It's just a representation, like I said, of the greater turn. So we identify the presentation just like we normally would. We determine what our intention is, what is the goal, we identify the limiting factors these become our key performance indicators that we're going to track over time as we train we determine the best approach and the way we do this is we this person becomes their own experiment just like every other person that we read a training program for is we identify what we think we see, we intervene, and then we monitor for the changes and we track our KPIs to determine that we're on the right process and we're moving towards the desired goal. So just adapt the program to the individual. So it's always going to come down to those principles.

They don't change no matter what our presentation is. So Carl, I hope that is helpful for you. Everybody have a terrific Wednesday. I'll see you guys tomorrow morning on the Coffee and Coaches Conference call. Have a great day. Oh, if you have any questions, ask Bill Hartman at gmail.com. Happy Thursday.

When we do inverted exercises, like hip elevated inversion exercises, or hanging exercises, my question is, if I'm trying to achieve posterior expansion, but I have my arms extended overhead—either inverted or hanging—I'm not sure if that might slightly close off the posterior thorax. I wasn't sure, like, if there's a better way or how that is working.

So what you have to understand is where the greatest compression is as you move the arm through any range of motion. So as you elevate, you're going to be moving through that space where the dorsal rostrum is that space between the scapula. So as I move through the middle range, so if you held your arm straight out in front you at 90 degrees of traditional shoulder flexion, plus or minus 30. Through that range is where you're gonna get some of the most, like the strongest compression in that upper back area. And that's not a bad thing. It's not a bad thing. It just means that it's concentric muscle activity to be able to hold the scapula in that position. So there will be some more compression there, but that's a good thing because then it gives you an opportunity to create expansion elsewhere. So anything below that range that would typically be expanded has potential for expansion. When I do move through that range, because I'm creating the compressive strategy on the backside, I am more likely to create expansion on the front side. So when we talk about the anterior thorax expansion, so we talk about pump handle and things that from a breathing standpoint, moving through this range gives me that opportunity to emphasize that. The thing that you always wanna recognize, is that it's not this black and white kind of a thing. It's a bias. So I always say, I always use the word bias because what I want you to understand is that both things are happening at the same time. So when I have a compressive strategy somewhere, I'll have an expansive strategy somewhere, but that doesn't mean that the area that's being compressed does not expand at all. It does, right? We have connected tissues that behave a certain way based on the way that tissues are loaded. So you hear me say things like concentric yielding. What that means is that the concentric muscle activity is such that it creates a position of the body. And then the yielding action is the response of the connective tissues to the loading strategy. So when I load tissues slowly, they yield, they give way. When I load them quickly, they get very, very stiff and then become resistant.

Bill, can you go more into yielding and overcoming strategies and when you use one versus the other?

Yes. Oh, did you want me to expand on that?

I thought you were just capable. Some examples and what you find on the table.

I will. I must say something though, Nate. I appreciate your facial expressions. Thank you. It lets me know that I'm not a total idiot when I try to make a joke. So do you understand what the difference is, what they are?

Overcoming, trying to approximate some of the tissues and then giving away.

Have you seen my silly putty example?

I don't think so.

Okay, hang on. Guess what? So something to learn really quickly. There's a lot of toys out there for kids that are all physics based, that they are great. My purple room is like a kid's dream. I have slinkies and balls and hoberman spears and all sorts of stuff. So you know what silly putty is, Dan?

Oh, yeah.

OK, so silly putty. OK, so this is viscoelastic. So you're 99% water and 1% stuff, and your 1% stuff is all viscoelastic tissue, except for the mesenchymal stuff, but we don't talk about that. So when I pull on this slowly, it stretches, right? And then when I pull it really fast, it snaps clean, OK? And so what that means is that something that's viscoelastic has different mechanics depending on the forces that are applied and how they are applied. So what I just demonstrated was a rate dependent response of the viscoelastic tissues. When you pull on a viscoelastic tissue, it gives way slowly, right? Which means it can absorb the force.

Is that change permanent or relatively?

I hope not.

OK.

OK. They are adaptable. They change over time. But again, the hope is that we maintain the normal resiliency of those tissues. So when I push on it gradually and it can absorb the force, that would be a yielding action. It is the connective tissues that are yielding in humans. It is not the muscles from a modeling standpoint. Don't confuse the two. Okay. When I yank on it really, really fast and it snaps, that's an increase in the rate of the force applied. So if the rate increases, it makes viscoelastic tissues behave stiffer. When they are stiffer, they don't stretch as much. It's very, very difficult to deform them. And then they don't absorb and release energy like the yielding strategy does. So depending on the response that I need to produce whatever action that I'm doing, I need to have the ability to access the two different behaviors that I demonstrated. Okay. So if I have to, let me give you two examples and I'm challenging you here. Okay. So you're on the spot. So don't screw it up. Okay.

Yes. I don't perform well on the spot.

If I jump, what I want you to do is I want you to tell me which activity loads the system faster between I'm going to jump off a 36 inch box onto the floor or I'm going to perform a 98% of my 1RM max effort squat. Which one loads faster?

I would say the first. The jump? Assuming you're not just like collapsing down.

Okay, so we're not collapsing down. So you're saying that the tissues are loaded faster if I jump off the box, is that correct? Yeah, and you just like land on the ground. Yeah, it's just a normal, just jump off the box and land, stick it. Perfectly, like great technique, the whole thing. My argument would be that it's actually the exact opposite because the minute I have that weight on my back, I'm loaded. It's instantaneous. Are you saying when you unrack it and then you're standing, you've got the weight on your back and you initiate the squat. Okay, the tissues are instantaneously loaded; the rate of loading is instantaneous. It's already there. As you jump, so what I want you to do is I want you to look at the two activities in slow motion in your head. As you jump off the box and I make the initial contact. Okay, I make the initial contact. The tissues are loading over a longer period of time. It's not a long period of time. It's just a longer period of time. The back squat example, the load is already there. It's instantaneous. The jump off the box, the tissues elongate over a longer period of time. That's actually a yielding action because I have to store the energy in those connective tissues. If I'm loaded from an instantaneous standpoint in the back squat, I need an overcoming action because if I would yield, you're accelerating towards the ground.

Yeah, and you just land on the ground.