So I got an email from David who's having some shoulder pain with bench presses. He's doing a lot of ITY exercises, face pulls, rubber band exercises for rotator cuff strengthening, and he's still having a lot of shoulder pain. So I thought it'd be a good idea to come into the purple room, get a bigger representative model of what's going on in the rib cage, in the shoulder, in the scapula. So we have enlisted the assistance of Alfred here, and we'll talk our way through what may be going on. A lot of times shoulder pain is the result of a loss of range of motion that's associated with the inability to change the shape of the ribcage or change the position of the scapula as the arm moves through its arc of range of motion. So especially with compressive exercises like pressing, the exercise itself is going to promote a restriction in ranges of motion. If this is the case, then we need to make sure that we're doing enough work to maintain our ability to expand the thorax in the appropriate manner to allow us to maintain as much shoulder range motion as possible so we avoid the painful ranges of motion. So let's talk about how the shoulder actually moves through its range of motion and where we would expect to see this expansion and compressive strategy that allows us to move the arm through space. In the initial phase of raising my arm up away from my side, I need to make sure that I get expansion in this posterior lower aspect of the rib cage. This prevents the scapula from compressing against the rib cage too soon or moving too soon and I immediately lose range of motion under those circumstances. So maintaining this expansion of the posterior lower rib cage makes sure that I start from a good position. As I move the arm through this middle range of motion from about plus or minus 30 degrees from the horizontal, this is where the scapula actually moves the most. So this is what most people would term upward rotation, the scapula. And this promotes a compressive strategy in the upper back. This also pushes air forward and promotes an upward pump handle position of the sternum as I move the arm through this middle arc of range of motion. As I get to the top of an overhead reach, I need to expand again on this posterior aspect of the upper part of the rib cage. And if I can't do that, then I immediately have a deficit in my overhead reach. So what David's doing is a number of exercises that promote a lot of compressive strategy on the upper back, which is perfectly fine if that's what is needed.

However, if he's promoting compression below the level of the scapula, what you've already started to do is taken away the ability to externally rotate the shoulder and I'm beginning my upward reach in an internally rotated position. If that's the case, then as I pass through this middle arc where I should acquire internal rotation, I'm starting from internal rotation and then that can promote compression within the shoulder joint that gets uncomfortable. This may be why doing activities that are creating more and more compression in this posterior upper back area are not helpful and actually may be detrimental to the solution. So from a solution standpoint, what we want to make sure is that we get expansion in the posterior lower part of the rib cage, we want to then promote the compressive strategy in the upper back once we have this intact so we can get the expansion on the front side as we pass through this middle range of motion. And then once again, we want to make sure that we get expansion in the upper back as we acquire our overhead reach. So David, based on your email, what I would do is I would back off a little bit on the amount of rowing that you're doing, an amount of upper back work that you're doing with your I's, T's, Y's, face pulls, et cetera, that are actually increasing the compressive strategy here. What it sounds like is you need to reacquire some of this posterior expansion to allow you to start from a better position before you go into your pressing movements or active range of motion above shoulder level. So David, what I would do is I would spend more time working on expanding that posterior upper back and the posterior lower rib cage with activities such as this seated dorsal rostral expansion activity where I'm supinating, externally rotating the arms by pushing my hands apart, gently pushing down into the table and keeping my upper back expanded as I breathe in and fill that space in the upper back with air. These are the activities that I would probably try to emphasize more so than your I's, T's, and Y's, which actually compress that. David, if you go to my YouTube channel or the Instagram page, you'll also find a number of exercises that can be easily modified to help you maintain the expansive strategies that you're going to need to help maintain your shoulder range of motion and keep training. So David, thank you for your question. I think it's a really good question because I think a lot of people are also dealing with this. It's not that I's, T's, Y's, face pulls, rows are bad exercises; we just have to be a little bit more selective as to when we're implementing these exercises and have good reasoning behind them as a strategy to help us stay healthy and train.

So I hope everybody has a great Monday. I will see you guys tomorrow. It is Tuesday. I have neural coffee in hand and it is perfect. Okay. So yesterday I posted a video about shoulder impingement that's gaining in popularity on YouTube as well. But I got a bunch of comments on that. One of the comments was, hey, could you talk about forward head posture? Because a lot of us are dealing with that. And so I thought it would be a nice little tie into the shoulder. And so we'll just move up a level, so to speak. And we'll start talking about the neck and head position with this forward head. But let's be really, really clear about what we're talking about. So by traditional measures, what we're going to talk about is lower cervical flexion, upper cervical extension. And so the way we would describe this orientation from my perspective is that we've got concentric orientation of musculature on the posterior occiput going to the upper cervical spine. So that's concentric oriented. So if anything below that from C3 on down would be eccentrically oriented. If we turn things around, we look at things from the front, we're gonna use the hyoid bone as our representation of above and below. So below the level of the hyoid bone, we're gonna have concentric orientation of those infrahyoid muscles. And we have eccentric orientation of the musculature above the hyoid that goes to the mandible. The result of all of this is going to be a passive retrusion of the mandible. And these are the people that you're typically going to see excessive amounts of mandibular opening that would often be described as hypermobility. So they might have clicking with opening and closing, but they're also going to obviously see this magnified opening. And so that's a nice way to tell when you've made an adjustment of some sort or an effective change, that you'll see a reduction in this excessive opening. I think that the forward head posture has always been looked at in isolation and so the strategies that have been utilized have been somewhat ineffective because they're trying to do a piece work when this is a relationship problem that is a resultant of all of the things that happen below the head and the neck. So typically what you're gonna see with this traditional forward head posture is this is going to appear most often on people with narrow ISAs that lack the full breathing excursion. So we're gonna treat them as such. So we gotta think about the relationship of the axial skeleton to the neck, to the head, to the mandible when we're talking about how we're going to effectively work in this situation to try to restore as many movement options as possible.

When we're talking about moving towards an exercise strategy, the quadruped activities are a great place to start because we're going to get dorsal rostral compression under those circumstances, but we're going to get the up pump handle. The downward pump handle is typically going to be associated with this forward head posture as well as the compressive strategy that we'll see on the posterior aspect of the rib cage below the scapula. Quadruped fits really well because we get expansion in both of those areas that are typically compressed. So your forward reaches also fall into this. There's a whole series of arm bar activities that would be effective in the gym. Your cable reaches are going to be effective in the gym. And so again, we don't have to throw people on the ground and turn them into rehab clients. This is a little counterintuitive. So we think about the strategies associated with the narrow ISAs and where we're going to see those compressive strategies. If I bring up my model again, we're going to see compression from the scapula down into the lower posterior rib cage. We're also going to see the compressive strategy in the lower part of the pelvis. Hinging activities are now on the table as far as helping us to restore movement options. What we're looking to do is we're trying to restore a normal exhalation strategy without compensation. So now, if we can teach somebody to hinge effectively, that posterior lower aspect of the pelvis will move from its concentric to eccentric orientation. If we can effectively maintain position in the thorax under those circumstances as well, then we're going to get the lower posterior rib cage to expand as well. So we can actually use deadlifts to help us restore normal movement options in these cases of forward head posture. That's actually pretty cool when you think about it because we rarely talk about deadlifts being useful in restoring movement options because of their compressive nature. The thing that we have to consider in these circumstances is: do I have any other superficial compressive strategies that would preclude me from using a deadlift under these circumstances? So there's a lot of variations that we can use. We could use like a kettlebell deadlift, which would help us promote the expansive capabilities. A snatch grip RDL is actually very effective in keeping the lower posterior rib cage expanded with the appropriate instructions. Again, there's a lot of how you do things in influencing this as well. But like I said, the really cool thing about this is we can use our hinging activities. And once we've actually restored our movement capabilities, now we can actually keep some of these activities in the training program. So now you've got your kettlebell swings that are back on the table. And like I said, all of your deadlift variations as well. So we don't have to look at this forward head thing in isolation as it would typically be prescribed. We have to look at this as a relationship problem and the forward head posture is merely the result.

And like I said, all of your deadlift variations as well. So we don't have to look at this forward head thing in isolation as it would typically be prescribed. We have to look at this as a relationship problem and the forward head posture is merely the result. So hopefully that sheds a little light on this forward head posture thing. Hope it's useful. If it's not, please ask another question and we can go deeper into detail as we need to.

So the differences between the wide and the narrow as they approach the end strategy are all strategies that we're superimposing on top of these archetypes are exhalation strategies. So they're very concentric orientation heavy stuff. So they're squeezing, squeezing, squeezing to try to hold position against gravity. And so what you're looking at, Matt, is the wide at the very end. So let's look at a pelvis to show us what we mean by that. So when we look at a wide ISA, they're gonna have the IR iliums and a nutated sacrum. So the sacrum's gonna be forward and the iliums gonna be IR, which means that I'm gonna have a sacrum that kinda looks like that. So I'm exaggerating for effect, but that's the nutated position of the sacrum. At end game, the last superficial strategy that they'll have is to actually bend the apex of the sacrum down and underneath them. So this is a really hard IR or ER force against the sacrum. And so the difference is that you're gonna see with the wide and the narrow. So the narrow is already gonna be compressed in this scenario. So these are the ones that look like the true sway back. So you're gonna see something that looks kind of like that where the pelvis is sort of ahead of the femur here. With the wide, it's because this is the last compressive strategy, what you're gonna see is they're gonna kind of push through the hip. They're going to push straight through the hip, and so they end up with this really kind of hard ER position. So they'll stand almost in what looks like a sway back, but their butts are going to be clenched really, really tight. They're going to stand in a little bit of knee flexion because of the orientation of the femur at the tibia, puts them in a little bit of a tibial IR. So they're standing in deflection and where the narrows may be pronated in this position, your wides might look a little supinated because what they're actually doing as they're driving this hard ER through the pelvis, they actually claw the ground, especially with the lateral two toes, they'll claw the ground. So it looks like their toes got kind of chopped off at the end. The forefoot will look a little short under the circumstances because they are really grabbing the ground and pulling themselves forward in this compressive strategy. As far as the anterior thorax goes, they're still going to be pulling the sternum down with rectus. They're going to try to pull up on the pubis. But because of the orientation of the pelvis, it's not going to sway underneath like it would for the narrow. But again, Matt, you're still dealing with a massive compressive strategy here. So gravity is not your friend.

This would be somebody that if you could get them in a pool to move around, they're probably going to love that because it's going to help them decompress everything. I love the fact that you're going sideline because it does help eliminate a lot of the gravitational influences that they're going to be dealing with. But you got to think really, really kinder and gentler. So the side planking might even be too aggressive because there's still going to be some breathing difficulties here. When you're driving breathing on these people, it has to be the gentlest of breath. It's not about hard exhales. It's not about being aggressive at all. It is a calm, relaxed, just movement of airflow. You want minimal energy output under these circumstances. Very low effort movement, you're gonna try to start to restore some gentle rotation. So you might even just start with head turns inside line. You're gonna start with some thorax shifting inside line, some hip shifting inside line. What those hip shifts and thorax shifts are is a subtle rotation through the axial skeleton. So it's a great place to start. That's why I like to use the Scapier PNF or pelvic PNF patterns in these because we can actually help guide these people into rotation again. And then just like I said, gently guiding the breath because again, if you try to breathe aggressively under these circumstances, all you're gonna do is kick on the superficial strategies again. Once you get them to a place where you're starting to see the restoration of rotation, then you can start to flip them over onto their back and start to work on like ipsilateral connects, re-bringing same side elbow to same side knee. So now we're starting to get a compression and expansion almost laterally. It's still rotation, but again, we're trying to induce as much of this compression expansion as we can. But again, it's got to be this kinder, gentler kind of strategy. Once you do the ipsilateral connection, we work towards cross connects, and then once you start to do that, then you can start to use some leading resistance. So now we can bring resistance back into the game, where we can get some reaching activities in here, where you're going to compress one side, expand the other. So I hope that gives you a little bit of strategy on this one, Matt. These are the toughest ones to use.

But if we look at sort of the end game situation where they're pulling the sternum down and pulling up on the pubis, what we have is an orientation of the head forward. So this is not a traditional forward head where we have the lower cervical extension, upper cervical extension. The orientation of the cervical spine really doesn't change a whole lot. It's just the fact that the head is going to be shifting forward. What you're going to see though because we've got an actively retreated mandible in these circumstances is the mandible is going to get pulled back and so they're going to stand and they're going to be mouth breathers. They'll stand with their mouth open. You'll see the retreated mandible and then the head actually just shifts forward. So we're getting actually more of a compressive strategy of the cranium down on top of the cervical spine. So again, not really a traditional forward head scenario and probably a little bit more compressive than what we would see with the traditional forward head. So you're going to see a lot of limitation in the upper cervical spine under those circumstances because you've got concentric on concentric all day long there because the hyoid bone gets pulled up. You've got concentric muscle activity pulling the mandible back. You've got concentric activity coming from the upper trapezius grabbing the cranium and pulling down. So we got a lot of limitations here, which is why we have to use this kinder, gentler approach with these people to work their way out of these things.

Okay. So that right there put us a little behind the eight ball as far as how we got things started. So we were basically flying by the seat of our pants. We were trying to figure things out as we went. So the thing that you want to think about, Nikki, is like you say, okay, what am I best at? What am I really good at? And what do I want to do? And then you, you take all the other stuff that goes along with that and you have two choices. Either you sacrifice your ability to do that other stuff that you like to do. Um, and you try to be better at the other stuff, knowing full well that you never will be because it's not interesting. It's not exciting. And it's not what you, what you came here for, right? Or you find other people. So, so Mike and I have like the world's greatest accountant. And then we have a business coach, Pat Ricksby. If I can mention Pat's name, I don't think he's afraid to have us mention his name. Um, Pat's amazing. We've worked with Pat from the early stages of our fast, thankfully. He has been savior on many occasions to help us out. And we have evolved. There are certain things that we now understand and do better as business people. But if I had my way, I would be the technician. I'd be the teacher. I would be that guy all the time rather than having to worry about paying bills and managing the finances, because there are certain aspects of that that we still have to do ourselves. One of the strategies that is very, very helpful when you're trying to coach or observe or understand what someone is doing is to imitate them. Totally underrated. You know, students always ask, they go, well, I want to learn about gate. It's like, OK, what do you want to learn about gate? Well, I want to understand what they're doing. It's like, OK, do exactly what they're doing. Like, imitate them, and you will feel what they're doing. And it's like instantaneous, and then the light bulbs go off. And then they go, oh, now I get it. So if you're ever questioning something as to what's really going on, Just imitate. So break the whole propulsive cycle into three phases.

And so, that right there put us a little bit behind the eight ball as far as how we got things started. We were basically flying by the seat of our pants, trying to figure things out as we went. So the thing you want to think about, Nikki, is like you say, okay, what am I best at? What am I really good at? And what do I want to do? Then you take all the other stuff that goes along with that and you have two choices. Either you sacrifice your ability to do that other stuff that you like to do and try to be better at the other stuff, knowing full well that you never will be because it's not interesting, exciting, or what you came here for. Or you find other people. So Mike and I have like the world's greatest accountant, and we have a business coach, Pat Rigsby. If I can mention Pat's name, I don't think he's afraid to have us mention his name. Pat's amazing. We've worked with Pat from the early stages of our business, thankfully. He has been a savior on many occasions to help us out, and we have evolved. There are certain things that we now understand and do better as business people. But if I had my way, I would be the technician, the teacher, that guy all the time rather than having to worry about paying bills and managing finances, because there are certain aspects of that that we still have to do ourselves. One strategy that is very helpful when you're trying to coach or observe or understand what someone is doing is to imitate them. Totally underrated. Students always ask, 'I want to learn about gait.' 'Okay, what do you want to learn about gait?' 'I want to understand what they're doing.' 'Okay, do exactly what they're doing. Imitate them, and you will feel what they're doing.' It's instantaneous, then the light bulbs go off, and they say, 'Oh, now I get it.' So if you're ever questioning something as to what's really going on, just imitate. So break the whole propulsive cycle into three phases.

So early, mid, late?

Early, mid, and late. Knowing full well that there's a point where propulsion becomes maximum, which is in that middle area, right? When the heel breaks the ground, you're at max propulsion, okay? But let's leave that off the table. Let's just make it early, mid, and late for the sake of argument, right? You've got basically then three foot shapes to deal with. But when you're, so if you're walking straight ahead, knowing full well that I have segments that rotate into ER and IR. When you get through that middle range, that would be that point where you have the greatest differential in opposite directions because they have to cancel each other out so you can go in that direction. Otherwise, if I don't have the opposing ERs and IRs through that middle range, I have to go off course. And you have to make a course correction somewhere. And people do this all the time. So the people that I see in the purple room tend to have a lack of relative motion somewhere. And then they compensate for that. So when you can see, your vision corrects your direction quite a bit when you walk. And so whenever you see if you walk across the room, you go, wow, that looks kind of weird. It's like they're making a constant course correction with every step because they probably lack some relative motion somewhere. And if it gets bad enough, then it might hurt. So through that middle range is that point where you're going to have the traditionally described closed chain pronation. So you're going to have the eversion of the calcaneus and the adduction plantar flexion of the talus through that middle range. If we're looking at the subtaler position. And that allows the tibia to go straight over the foot so you can again, it looks like you're walking in a straight line. So you have to pass through that pronated position, otherwise your tibia stays behind you. You would get stuck in early propulsion if you didn't pronate. So the talus has to move. So if the talus is still dorsiflexed and abducted as you pass over the foot, you will use a late propulsive foot position to try to pass through the middle propulsive phase, which is, again, tends to be problematic for a lot of people, because that means that they have to make a twist somewhere else to stay straight, but understand that the foot is going to behave just like all the other structures above it. So when you have an internal rotation position, which is that propulsion strategy in the foot, so is the hip, so is the pelvis. They go together because that's where the maximum push is. And so I have to have this coherent strategy up the chain because if I have an early or a late propulsive strategy in the pelvis where I should have a maximum propulsive strategy in the pelvis, now I have a problem because now I have too much relative motion occurring where I should not have relative motion, right? Then I can't produce forces the way I want to. And now I got to distribute it differently. And then that might cause a problem. So either I lack performance, I can't push hard enough, or it becomes a point of discomfort.

where I should have a maximum propulsive strategy in the pelvis. Now I have a problem because now I have too much relative motion occurring where I should not have relative motion. Then I can't produce forces the way I want to. And now I got to distribute it differently. And then that might cause a problem. So either I lack performance, I can't push hard enough, or it becomes a point of discomfort.

So would you kind of define early propulsion as from initial contact to flat foot in I guess quote unquote classical terms or just the phase in which the entire foot is going through that wave of pronation from the rear foot through the midfoot to the forefoot.

So let's assume we have normal relative motion. If we had to make a division once the talus starts to move towards the internally rotated position, so plantarflexion, adduction. Once that starts to move in that direction, you're moving towards the middle phase. Because theoretically, and again, this is totally theoretical, when the heel strikes the ground and the foot goes to flat, before you would load it, before you would put any weight on that foot, the talus is still kind of dorsiflexed and abducted. Got it.

So when it starts to plantar flex and abduct is when you start to go into mid propulsion.

Yeah. But see again, it's like we're just throwing out a theoretical point in time to have a discussion. It's not very meaningful. The idea is, when I take a snapshot in time, what's moving? Does everything move the way I need it to accomplish the task without putting stress or strain on anything in particular? If that's the goal. Because cutting off of a foot and walking straight ahead are not the same thing due to the changes in constraint at the ankle and foot. I intentionally limit motion between bones in the foot when I'm pushing off in another direction because I have to create a turn. So the compensation through the extremity is to make that turn and to drive the thorax and so forth off of the foot. Whereas if I'm going straight ahead, I have to cancel out forces or I can't go in that direction.

They'll go off this foot conversation and you're talking about the people that are making course corrections. I'm almost thinking of like a classic waddling gait. That would that be along the lines because that would almost be more of like an open chain pronated position where they're very just getting pushed from side to side.

They're cutting, right? So their foot tends to stay towards that later propulsive strategy, right? So chances are their center of gravity is already forward, right? They can't turn. And so, yeah, so it becomes this, right? Push off, push off, push off. So they're literally doing like a slalom you know, jump from foot to foot as they walk.

Can you say the name of those books that you showed us again?

Nope. Um, I would, Michelle, I would get that one.

Okay. Who's it by?

Michelle. We must see Michelle. As far as description goes, it's better. It's a nice place to start to develop your framework reference.

Okay.

We must see Michelle. As far as description goes, it's better. It's better. So it's a nice place to start to develop your framework reference. OK.

Thank you.

And after this, then you can start to superimpose some specificity on there so you can get something like Baxter has running stuff in it. This is more of like, you can actually see it says in sport. So it's got a little bit more specificity in there in regards to some of these things that we talk about. But again, I think they tend to look at great detail because I mean, it's a textbook about the foot, right? So all of the detail is just like, you know, kind of overwhelming at times.

Thank you.

Yeah, but if you start to look at the foot in its segments versus the whole foot, you can talk about the gliding of the medial cuneiform with the navicular if you want to, but the reality is you have to try to segment this thing and make it a little bit simpler. And you can, in my opinion, make it look very familiar to you if you know how to flip things around in your head. But the end result they wanted was the extension. It doesn't address the rotations. So again, you have to look at the mechanics of the knee. It's like, okay, how do you get the extension? Why do you have to have tibial ER? Do you have tibial ER? So again, those questions need to be addressed. Do I have a position at the pelvis that negatively influences the knee? Do I have a position at the foot that negatively influences the knee? So all of these mechanics come into play when you're trying to address, and we're talking about knees, but this is any joint—there are influences that will limit joint excursion. Again, is the person using a compensatory strategy to move through space that does not allow them to access their full knee excursion?

However, if we get this upper dorsal rostral compressive strategy, we're going to see concerted orientation in the posterior scalene. We'll see it in the elevator scapulae. We'll see it in the upper trapezius. We're not going to see this normal counter rotation mechanism occurring. And so we want to make sure that we can restore this. So what we have to do is we have to capture eccentric orientations again in all of this posterior musculature. There's some easy ways to do it. And there's also some tells to let you know that you do have this compressive strategy going on. So let's go over those tells first. So as we look at Alfred here on the table, one of the things that we can actually look at from a structural standpoint is this angle between the spine of the scapula and the clavicle. And we refer to that affectionately as the Campereen angle named after the late great Mike Camperein. One of the things that we want to look at is we want to make sure that that angle is about 60 degrees. That would be a normal representation. More often than not though, when we have this upper dorsal rostral compression, this angle is actually going to be less than 60 degrees. So right away we have a visual representation of this compression and what's happening here basically is we have the narrowing of the angle and so the scapula actually just rides up this posterior rib cage as the upper trapezius will pick up its concentric orientation. Now it can certainly try to assess the lower cervical spine manually to determine whether it can turn or not, but actually a better test is looking at end range shoulder flexion. So as I flex the shoulder, what I should see as a posterior tilt of the scapula is that upper dorsal rostral expands. But what I should also see is that ipsilateral or same side lower cervical rotation. So if my shoulder flexion is limited, I kind of know that I've got this upper dorsal rostral compressive strategy in play. If you've got some manual therapy skills, I've got a couple videos on YouTube that will show you how you can manually restore the expansion of this Campereen angle by depressing the scapula and rotating the cervical spine. If you don't, then you're going to have to use some exercise related strategies which we can cover out in the gym. Now before we head out into the gym, I want to go through a couple mechanical issues that we might need to attend to as we go through some of these exercises. So let me give you an example for someone that might have a wide infrastructural angle that would have a representation in the neck of lower cervical extension, upper cervical flexion. So under those circumstances, I'll have a lot of upper cervical rotation available to me with very limited lower cervical rotation.