Good morning. Happy Monday. I have neuro coffee in hand and it is perfect. A very busy Monday coming up. First, a housekeeping item: the dates for the Intensive 20 have changed and are now December 8th through the 11th. Please note for those still waiting to apply, applications will remain open until the end of today, then close, as we'll exceed our target number. I appreciate those who have applied; apologies for the date change, which was necessary. To those who can't attend, I apologize, and we'll make it up to you in 2023. The next instance will likely be in March. Thinking about today's Q&A with Taya, who is working with a client/friend experiencing medial knee pain. As discussed in the video, the typical presentation involves magnification of normal representation in the distal knee during so-called extension—when the femur is centrally rotated relative to the external rotation of the proximal tibia. This often causes medial knee pain. An additional factor here is that this person was training on sand, which prolongs the yielding action during ground contact, potentially magnifying forces at end range and creating a fluid shift that can worsen the situation. We must account for such factors in training. This gives you ideas of what to expect when dealing with clients who have medial knee pain. Thank you, Taya, for bringing this question to the Coffee and Coaches Conference call. Have an outstanding Monday, and I'll see you tomorrow.

All right. I just have a little follow-up on this knee discussion that we just had. And it's regarding the late representation of the knee. So when someone has pain on the medial side of the knee when they try to extend it, I'm just curious whether it's like too much of a twist in the tibia that makes the fluid shift in the anterior medial part that causes the pain.

Generally speaking, the orientation that you're going to get with medial knee pain is going to be the, it's an exaggeration of the normal representation. So typically you're going to have femoral internal rotation relative to the tibial external rotation, but if I magnify that relationship, that's where you're going to start to see the potentially you're going to see the medial knee pain. That would be the orientation that would be most common.

So I'm asking because my friend was sprinting on the beach. They were barefooted and then she started to feel the pain on the medial side of the knee while straightening it. Yeah, I'm just curious.

Yeah, so take a normal, here you go. Think about this. She didn't have knee pain before she ran on the beach?

She did not, but she had the knee ACL operated a few years back.

But point being, she didn't have the knee pain prior to running on the beach, right?

Mm-hmm.

Okay, so if she lands in what would be a normal representation, but she can't control the rotation and the rotation becomes greater, so she doesn't capture that middle representation. She's pushing through a late representation of the knee, which magnifies the tibial external rotation and femoral internal rotation. That might be why she has the knee pain. So it's the same mechanism that caused her ACL on that side. Tell her to quit running on the beach.

I did.

Okay. I mean, talk about great doctoring right there. It's like, every time I run the beach, my knee hurts. Okay. Don't run on the beach. Right. Step one. It hurts when I do this, doc. Yeah, don't do that. Problem solved.

So I'm just guessing that one of the mechanisms that would help would be to learn the transition of the tibia over the ankle to capture that medial.

Right. So you're going to try to have her hang on to some of that tibial IR that we were just talking about that she probably doesn't have or can't access it. And we've talked a little bit with Zach about ACLs and then how the active rotation of the tibia changes after the surgery. And so she may not be able to control that, which unfortunately could predispose her to a re-injury. So we have to be really, really careful with that. So yeah, I would be worried. Do you work with her or are you just friends?

She lives in Africa, so yeah. Not so much.

Not so much.

Well, not in person. So yeah.

Well, but again, there's ways to access that internal rotation. But again, some of your exercise selection is going to help with that. If you coach it all, just make sure you get the tibial IR.

I'm just guessing that because when she runs and she doesn't have that medial peer representation, I'm just guessing that she's already so late that she is not able to capture it. And I'm guessing when she steps, the medial arch doesn't go down, it just goes straight into late and on the toes.

Yeah so she'll she'll go around her middle representation.

Oh okay on the outside of the.

Yeah, because she's not capturing all the medial stuff. Now she can still push down into the ground, so this is the thing you have to be careful of. This is stuff we talk about all the time. It's like, remember, IR is going down. It's downforce. So if she can't capture a true medial representation of the extremity, she will still push into the ground. She's going to orient her pelvis forward. She's going to take an ERD foot and jam it into the ground, but the tibia is not going to follow. So she's still in this late representation of tibial ER trying to push down into the ground. That's bad news, right? She never captured the IR position. So that's what I would be working on with her. Yeah, so you capture, you get the early tibial IR first and then you teach her to hold on to her ground contacts and push up into medial so she can push down into the ground.

Okay. Would it also be helpful to first capture the good contact with just the heel elevated?

If you need to capture the early foot representation, are you talking about just the heel?

Yeah.

Okay, that's a late foot.

So I know, but I was just curious whether it would be good to teach her to capture the good context or if she already has that ER representation of the foot, it doesn't have to just get elevated.

The goal would be to try to get her into that early foot representation first. Are you in a coffee shop somewhere?

Yeah.

Are you wearing regular shoes?

Yeah.