I have neuro coffee in hand and it is perfect. All right. A busy Monday coming up. A little housekeeping item. Ifast University members, we have a call at 1 p.m. Eastern Standard Time. If you are not a member of Ifast University, please go to IfastUniversity.com. Get yourself signed up. And then you can join us for that Q and A. Again, 1 p.m. Eastern Standard Time. Link will be on the Facebook group page. Okay. Taking in today's Q and A. This was Steven. Steven's dealing with a client that has some medial knee pain. And based on this description, it appears that this person has to use a very, very wide stance squat because of the lack of available space. And so we discussed how we're going to reacquire that ER space so we can start to drop inter-orientation a little bit closer to midline, because chances are what we have here is an exaggeration of the ER representation. And that allows us to apply the inter-orientation into the ground in that space. Unfortunately, we're probably using a knee compensation under those circumstances and then applying the internal rotation. That way, that's the medial knee pain because you've got a knee orientation that is better represented as a knee that should be straight and we're bending it in a squat circumstance. A little assist from Manuel near the end of the call where we talk about some of the mobilizations that I presented recently on some other videos that will allow us to actually mobilize the lower extremity into internal rotation. So a nice little combination of contributions there from the guys, Steven and Manuel. So thank you guys. Truly appreciate it. Everybody have an outstanding Monday. I'll see you tomorrow.

Good morning, Bill. Greetings. I've got a question for you on what I believe is a Patellar tracking issue. I've got a 30-year-old male who loves to play soccer and lifts a lot. He has about 75 degrees of external rotation in the hips bilaterally, and only about 10 degrees of internal rotation. He's very strong. His shoulders have a similar presentation or orientation, with significant external rotation. His feet are also significantly externally rotated. When he squats, he's very far out everywhere in his body. So what I'm thinking is that he doesn't have the space to move through internal rotation or... well, okay.

So the reason he has to go wide is because there's no space front to back. He's moving into the space he does have, which is all external rotation. So it's all away from the middle. He tries to go forward into that space but can't, so he has to put internal rotation into the ground. His measures may say he doesn't have internal rotation, but he does when he goes way out. You can then put his feet down on the ground. So the little trick is to have him stand up and try to get the medial foot contacts without compensation. What you'll find is you have to keep turning the hip outward and moving the foot away from midline to eventually capture the medial foot contacts. That's where his internal rotation is—that's where he can apply internal rotation to the ground.

Like this has got point tenderness to the medial patella.

Oh, okay. So it's more like a retinaculum kind of a feel to it.

Just on the medial border of the patella, if I press there, it hurts. And it keeps that hanging right in that 60 degrees of hip flexion.

The medial patella ligament and all that kind of stuff stabilizes the patella there. It's going to be hot because everything's turning outward. Consider the orientation of the femur. Take the normal femoral representation and squish it down. Squishing the full length of the femur creates more of a bend, which turns it out into external rotation (ER). This takes vastus lateralis and moves its posterior attachment further posterior-medially, causing the VL to pull up and outward into ER. When he pushes into the ground, he doesn't get the normal internal rotation (IR) pushed down into the ground. Instead, the VL grabs the patella and pulls it superior laterally, pulling everything on the medial aspect of the knee with it. The retinaculum and all connected tissues on the medial knee get pulled into a lengthened position all the time.

Okay.

So the solution sounds really simple. You got to get some IR into the ground. But the first thing you got to do is you got to expand his ER space because his ER space is like way out here. So you got to get him some of the AP dimension back so he can apply force into the ground a little bit closer to his midline. Okay. Wide ISAs under this circumstance, you'll tend to put them on their side a little bit, like getting them roll around on the ground to create some of that AP expansion.

Okay.

Okay. And then you got to put the kibosh on some of his lifting activities.

Yeah.

Deadlifts, back squats, chin ups, bench press, overhead press, all off the table temporarily. Because it's just going to flatten them out even more.

Sure.

Does that make sense?

Yeah.

You see where you are as far as his strategy is concerned.

I believe so. Yeah.

Okay. So we're on a sideline for a while rolling, trying to get more AP expansion. Once we've got that, when I get him back on his feet, can you give me an exercise or something? What does that look like as far as trying to?

So we're on the sideline for a while rolling and trying to get more anterior pelvic tilt expansion, right? Once we've got that when I get him back on his feet, can you give me an exercise or something? What would that look like as far as trying to achieve that?

So you can use his squat as a tell. Let's just say he was doing a box squat. Where do you think he would start with his foot position?

Yeah, like superfoam.

Yes. And so, what you would want to see is the ability to move the feet closer and closer to midline. He's never going to be this guy. He's never going to be like the length and parallel kind of a squat guy, most likely based on your description. But the idea is that you got to bring him closer and closer to midline. So he's applying force into the ground. Like I said, you got to get the IR closer to where his center of gravity would be. Right now, his IR is being applied way too far away. In fact, he doesn't have enough in there to turn the hip inward.

So would this be a case where you could do like that bowler's lunge that you demoed on Instagram or some of that crossover step up action to get medial foot contacts on the right or left side? Potentially.

It's just going to depend on how much IR that he does have. Because the concern that you have when somebody is so far away from midline when you try to capture that, there's no way that they'll be able to hang on to those contacts. So you probably want to work in, again, if you think about like, here's the wide stance, you're going to work sort of like in staggers along that type of an orientation first to make sure that you're starting to increase the amount of IR that you can actually apply to the ground. And as the feet come in, so he's bringing his feet in on his squat, then you could probably start to use that kind of a strategy. But again, that's the question mark. It's like, how close can I get you to do those activities. Because there's nothing magical about those mobilizations other than the fact that there's just differences in like the impulse, some of the positional stuff, you're still mobilizing the foot by the capability of bringing the squat from the wider stance to the more narrow stance, or when you're using a stagger, like say you're doing like, it's like your chops and your lifts and staggered stance, you're still mobilizing the foot into the ground. You're just doing it in a much more ER representation because you just don't have the space to work in yet.

So, like his step up would probably be more like a lateral step up to a box or something.

There you go. Exactly right. Exactly right. That's if you're doing explosive work, he's doing like, like he wouldn't do step up straight up. He would go up to the side. You see it? Like he's not cross over yet. He can't cross over yet. Right. So he would be doing like step two sled drags, not crossover sled drags, things like that. You see the difference?

So like that lateral wedding march kind of sled drag.

There you go.

Yes.