When squatting, what do you believe the risk-reward is for old shoes and some sort of heel lift? I know the obvious benefits and risks, but in your opinion, which outweighs the other? Does it put that much more stress on the knees? Does it allow you to stack your pelvis better? I'm assuming he's asking me, does it acquire more hip IR? I think people are looking for some sort of black and white answer when they ask questions like this, but the reality is that nothing that we do is ever black and white. And so what we have to do is we have to consider the n equals one concept. It's like, who are we talking about? And so does a heel elevated squat alter the way that load is distributed throughout the system. Absolutely. And so if we elevate the heel, is there the chance that load is being shifted towards the knee? Absolutely. Does the compressive force on the anterior part of the knee increase as you squat deep? Absolutely. So again, we have to consider who we're talking about. Are we talking about an adaptive Olympic weightlifter? Are we talking about my 86 year old mother? Are we talking about a four year old accountant that sits behind a desk? We have to take all of these things into consideration. For instance, if I have somebody that has a tibial femoral external rotation problem at the knee, then I know that I have a situation here that could limit knee flexion. And so in that case, I may not choose this strategy unless I can recover that full knee flexion. And so again, you have to take these things into consideration. If we understand the elements of what a heel lift provides in a favorable way, and if we understand the potential detrimental effects of a heel elevated squat, then we can apply it to the individual. We always have to apply these things to the individual. So, Taylor, I'm sure this is not the answer that you wanted based on the way that you've asked it, but I hope you understand that we have to look at the multifactorial nature of all of these things. And so expanding our viewpoint, expanding our understanding of what these heel elevated squats can and cannot do and what they may do from a detrimental aspect, I think that that allows us to make an informed decision. And then again, we always provide our safe to fail experimental environment whenever we're introducing anything new. So that's how we decide whether this is a good thing or not so good thing. So thank you for that question.

We discussed thoracic shape and its influence on shoulder internal/external rotation measures. This was a significant point. The quarterback doctor podcast highlights and videos for the 16% were posted on Instagram this week. Let's address this week's questions. The first question comes from Taylor. Taylor asks: when squatting, what is the risk/reward of using old shoes and some form of heel lift? I recognize the obvious benefits and risks, but in your opinion, which outweighs the other? Does it significantly increase knee stress? Does it improve pelvic alignment? I'm assuming he's asking whether it enhances hip internal rotation. I believe people seek black-and-white answers, but reality is never that simple. We must consider the n-of-one concept—who are we discussing? Elevating the heel certainly alters load distribution throughout the system. There's a possibility load shifts toward the knees, and anterior knee compressive forces increase during deep squatting. We must evaluate the individual: Are we talking about an adaptive Olympic weightlifter, my 86-year-old mother, or a sedentary accountant? For example, with someone who has tibial-femoral external rotation limitations affecting knee flexion, I might avoid this strategy unless we first restore full knee flexion. We must understand both favorable aspects and potential detrimental effects of heel-elevated squats to apply them appropriately. These strategies must always be individualized. Taylor, I know this isn't the simple answer you wanted, but I hope you appreciate the multifactorial nature of these decisions. Expanding our understanding allows us to make informed choices while providing safe-to-fail experimental environments when introducing new variables.

And then that's how we decide whether this is a good thing or not so good thing. So thank you for that question. My next question comes from Tyler. Tyler asks, how would you approach working with a patient that was diagnosed with a condition related to central sensitization, such as fibromyalgia or complex regional pain syndrome? Are there any specific compensatory strategies you have found that drive central sensitization? So let me address the second half of that question first. And I'll just give you a big fat no. I don't think that there's necessarily any compensatory strategies that would lead to anything specific in regards to that central adaptation. But as far as any diagnosis, I think we always have to consider the fact that the entire system is always involved. And so with any diagnosis with any situation because the nervous system is involved, I think there's always going to be an element of central sensitization. The question is, is there an adaptation or is there rigidity in the system that may skew the influence in one direction or the other? So when we talk about CRPS, where we know we have most likely some form of immune system influence, we definitely have a central issue, definitely involves the brain. So we have situations under those circumstances where that might be the predominant influence. Now we have to look at a whole different set of strategies from spatial and perceptual strategies or desensitization strategies. In all cases, movement is obviously part of this, but again with something like CRPS where we have such a strong autonomic influence, those are the toughest people to work with. But let me offer you this: if you look at the delayed onset muscle soreness literature, you will see that there is a component of central sensitization under those circumstances. And so when we're working with these people, it again doesn't eliminate any particular strategy that we may use; however, we may have to emphasize different aspects of our treatment repertoire. Where again, with CRPS, maybe we're using a mirror. If we're looking at CRPS, we're looking at graded motor imagery concepts to help us establish new perceptual influences that will hopefully favorably influence those patients. So again, in every case the central nervous system is going to be involved. In every case, all of your sensory systems are going to be involved. In every case, the movement system is going to be involved. The question then becomes is how much of each is representative as the predominating factors, and that comes down to your processes to how you evaluate someone and then how you introduce each element that influences the system. So once again, I hope that this is a really, really good question, but it's a really tough situation to try to influence under certain circumstances. But understand that every system is involved at every time, and that's the important thing to understand.

Drew is my keen guy. He's my guy that uses the word keen, so thanks again Drew for throwing that one in there. Here is Drew's question. So for wide ISA, so wide infraternal angle individual trying to regain his or her squat pattern, what progressions do you use after say a goblet, kettlebell, zircher squat? In light of Mike Robertson's complete coaching course, I think the safety squat bar will be a good squat progression, allowing you to load the squat pattern and keep the posterior thorax open for expansion. Do you use the safety squat bar much in load progression of the squat pattern? Thanks again, Mr. Keen. Mr. Keen Drew Brooks, thank you so much for the question. First and foremost, let me just say that you should probably get out there and purchase Mike's coaching course. I will not speak for Mike in that regard, and so I would just suggest you take the course. It is stellar and top the line. But Drew, you bring up a really, really good question in regard to the progression of the squat pattern. We do use the goblet, kettlebell, and zircher squats all as an element to create the expansive strategy that is typically challenged by those with the compensatory wide infraternal angles. Because again, that's representative of an axial skeleton that is exhaled and compressed. And so they use the wide ISA as a compensatory strategy to inhale. Moving towards the safety squat bar is a very useful strategy. In fact, I use it in combination often with box squats. I'll use it with the static squats, so we'll use it for overcoming situations, we'll use it for yielding situations. And I do love that I am more skewed towards favoring the spider bar in regards to the safety squat bar because the spider bar allows us to reach forward and it keeps the upper extremity and the scapula in that inhaled representation when we talk about range of motion arcs and things like that. So I do like the use of the safety squat bar. The thing you just have to be careful with is because we're dealing with somebody that may be using a compressive strategy, you do still have to attend to scapular position. You still have to attend to addressing the breathing element to make sure that I start in that inhaled bias when we're trying to overcome the axial compressive strategies. But definitely love the progression of going from heels elevated goblets and kettlebell squats, zircher squats, and like I said, use of the safety squat bar with box squats because again, very, very useful exercises, many, many variations on a theme. So Drew, thank you for that question and I appreciate ya sticking with the keen concept.

Ryan starts out with, how do you determine if a proxy measure of the extremity is pathological? And so he's referring to ligamentous laxity or capsular instability. On the opposite end, how would you determine a true tissue extensibility limitation assuming you've maximized axial position and respiratory variability? How would you treat these two presentations differently? So let's attack this from the beginning. So how do you determine proxy measures in the extremity pathological? Well, first and foremost, the history is going to give you a lot of information in that regard. So if somebody has a dislocation episode of some sort, then chances are you're going to be dealing with some form of tissue adaptation or a traumatic instability. And so again, when you have a history like that, we're going to make an assumption that we do have a pathology. I think a lot of people, and I think this is where your question is going, is that when we get a measure that seems to be abnormal in regard to a larger excursion than expected, a lot of people will jump on the bandwagon that, oh, we have ligamentous laxity. The thing that you have to consider under those situations is if we have an orientation of the thorax or an orientation of the pelvis, we can get a magnification of what we perceive as to be the normal excursion range of motion. So let me give you for instance. So if I can anteriorly orient a pelvis enough that the acetabulum is facing more downward, I can get an excessive amount of total excursion of hip range of motion. So under normal circumstances, we might say that extra rotation is 60 degrees from the imaginary zero point and 40 degrees of internal rotation from the imaginary zero point, so that's 100 degrees of excursion. But if I can actually orient that pelvis enough to get the anteverted acetabular position that allows it, I might even capture 120 to 130 degrees of total hip excursion, but that's just an orientation problem. That is not indicative of the fact that somebody has developed some imaginary capsular laxity, so don't immediately rush to judgment under those circumstances. Secondarily, I don't know how much that changes things a whole lot anyway. The goal is to acquire dynamic control of orientation of the axial skeleton and dynamic control of the excursion of the peripheral joints, and that's a muscular control issue rather than just looking at the laxity issues. Granted, we might have some proprioceptive deficits that are associated with a true laxity or some form of traumatic laxity that occurs, but under most circumstances, I think that's going to be determined through process. So when I have somebody that can't consistently recapture a position or can't hold on to their changes, now you may have a situation where we have a structural adaptation that is influencing the outcome and that might be when we have to make the consult with the orthopedic surgeon under those circumstances. But that's how you're going to determine this, Ryan. It's going to be part of the process. It's not about making an immediate leap because people overcome things all the time. People walk in with rotator cuff tears that they will overcome; those people come in with these perceived laxities and they're able to overcome those. So again, I always default to you make the attempts first; you run yourself through the process and you see what they can reacquire; you see what they get they can learn to control. And if that doesn't work, that's when you start to make the assumption that, okay, maybe I do have a situation where structure has changed to such a degree and that I need to bring in another element of service or integration. So hopefully that answers that first part. When we talk about a tissue, would you call it a tissue extensibility limitation? So the thing that pops into my head under those circumstances or situations where maybe we have a person that comes in that has been diagnosed with a frozen shoulder. And so under those circumstances, what would happen as you run through the process as you attempt your global or more systemic influences in treatment? You'll see that you don't get the local changes that you expect. In that circumstance, now you need to think about what you have in your toolbox that will address those local issues. Maybe you do have a tissue adaptation that can occur under those circumstances. And so again, that's going to be just a longer process, and so your strategies will be a little bit different because if you're truly looking at a tissue adaptation, it's rare; I think those situations actually occur. I think there's a lot of other influences that are going on in regard to the way that the nervous system is behaving and based on the way that those changes take place because some of those adaptations, if they were true, I don't think all of those would be recapturable, especially with some of the capsular adaptations and then the aggression with which you would have to apply forces to make those changes. Having worked with a fair amount of people that have been diagnosed with frozen shoulders and seeing what is truly able to be recaptured, I don't think that we're looking at those adaptations necessarily. I think we're looking at a lot of influences of the nervous system which can occur locally. We do have local environmental changes in regard to the shape change of the proteins themselves. So we talk about the contractual elements changing. And so those environments can change with different forms of manual therapy, different influences of medication, etc. So again, I don't think they occur as much as many people blame them on. I think that we just need to look at expanding our perspective in our toolbox. But under those circumstances, if you do have a true tissue limitation, then maybe you're looking at a very, very long-term strategy in regards to trying to add length to tissues. And that would be using some of your dinosaur plant strategies, perhaps, a lot of time and effort you applied by the client to restore that range of motion through repetition and avoiding situations where you're creating a negative influence associated with pain and discomfort and in ranges and just reacquiring some of that range of motion through the desensitization strategies. So I think there's many ways to go about this, but again, I caution you to make against making that leap that you're making an assumption that you do have a tissue change. They do most likely occur; I just don't think they occur as often as we think. The second half of Ryan's question piggybacks off of a question from last week where you ask what tests or measures do you apply to determine whether the elbows are oriented towards ER pronation or IR supination. Ryan, this is actually pretty straightforward because assuming we're doing table tests and such, we would have our axial representation. We would have extremity measures that we would have taken that would tell us whether we have a humeral position in external rotation or internal rotation, again, based on those table tests. And then it's just a matter of looking at the pronation and supination available at the elbow. And so if we have identified a shoulder that is in humeral external rotation, we would stabilize the epicondyle at the elbow, we would check our pronation supination and come up with a determination what we're looking at in the forearm. However, I would offer you this that you probably need to look at the wrist for confirmation of that forearm position because in some cases you may have eccentric orientation at the elbow or concentric orientation at the elbow that will skew your perspective. So if we add the wrist measures into this, so we've got a shoulder, we've got an elbow, and then we've got the wrist measures, if you have a deficit in ulna deviation and extension, you most likely have a pronated forearm. And if you have a deviation inflection radial deviation, then you probably have a supinated form. And that's just the orientation of the distal radial ulnar position. When the form is pronated, there is this perceived retraction of the radius that would position it more towards radial deviation and the ulna would appear long under those circumstances, so we would lose that ulna deviation. So that's what occurs in pronation as the radius crosses over the ulna. So just being aware of that, now you have your shoulder elbow and wrist providing you that information to give you the determination of what position and orientation you're looking at at the elbow and then it's just a matter of, do I need a retraction strategy? Do I need an inhalation strategy? And then what orientation do I need to put the forearm and humerus into to restore the ability to capture that full excursion at the elbow? So Ryan has a third part to his question. It goes as such: from a practical standpoint, what do we do with a narrow Campari angle versus a wide Campari angle? I understand that is a representation of the superficial helical angle that compresses the underlying axial helices. But how does it actually change our approach to gaining more variability or more performance? So the Campari angle is the angle formed by the clavicle and the scapula with its apex at the midpoint of the acromion. And so what this actually does measure is how much of a compressive strategy that we have with the superficial musculature. So it's not representative of the superficial helical angle as much as it is representative of how much of a compression strategy we have. So if we have superficial musculature that is compressing the axial skeleton, what happens is the scapula will begin to elevate, and so we get this compression between the anterior and posterior aspect of clavicle scapula and so it compresses that angle and it rides up on the thorax. And so that's why we get this narrowing of the angle. So a normal angle is about 60 degrees give or take. And so if we see that we have a compressed angle there, then we know we have a much more superficial compressive strategy. So from an approach standpoint, there are any number of ways that we can actually reduce that compressive strategy. So under many circumstances, we may just be able to reorient the movement system such that we reduce the compressive strategy and we would see an expansion of that Campari angle. There's a video on YouTube that I talked about earlier that shows a manual technique to actually reduce that compressive strategy. In the gym, we may use something like a suitcase carry that actually reduces that strategy. And so again, there's any number of ways, but as far as using that measurement, it is a useful measurement; it's not an absolute by any stretch of the imagination. Obviously because we named it after one of the padawans, I'm just giving them a hard time. But again, what I don't want you to do is think that it changes a lot in regard to what strategy you may be using.

Now you may have a situation where we have a structural adaptation that is influencing the outcome and that might be when we have to make the consult with the orthopedic surgeon under those circumstances. But that's how you're going to determine this, Ryan. It's going to be part of the process. It's not about making an immediate leap because people overcome things all the time. People walk in with rotator cuff tears that they will overcome those people come in with these perceived laxities and they're able to overcome those so again I always default to you make the attempts first you run yourself through the process and You see what they can reacquire you see what they get they can learn to control and if that doesn't work That's when you start to make the assumption that okay, maybe I do have a situation where structure has changed to such a degree and that I need to bring in another element of service or integration. So hopefully that answers that first part. When we talk about a tissue, would you call it a tissue extensibility limitation? So the thing that pops into my head under those circumstances or situations where maybe we have a person that comes in that has been diagnosed with a frozen shoulder and so under those circumstances what would happen as you run through the process as you attempt your global or more systemic influences In treatment, you'll see that you don't get the local changes that you expect. In that circumstance, now you need to think about what you have in your toolbox that will address those local issues. Maybe you do have a tissue adaptation that can occur under those circumstances. And so again that's going to be just a longer process and so your strategies will be a little different because if you're truly looking at a tissue adaptation it's rare, it's rare I think that those situations actually occur. I think there's a lot of other influences that are going on in regard to the way that the nervous system is behaving. and based on the way that those changes take place because some of those adaptations, if they were true, I don't think all of those would be recapturable, especially with some of the capsular adaptations and then the aggression with which you would have to apply forces to make those changes. Having worked with a fair amount of people that have been diagnosed with frozen shoulders and seeing what is truly able to be recaptured, I don't think we're looking at those adaptations necessarily. I think we're looking at a lot of influences of the nervous system which can occur locally We do have local environmental changes in regard to the shape change of the proteins themselves. So we talk about the contractual elements changing. And so those environments can change with different forms of manual therapy, different influences of medication, etc.

I don't think that they occur as much as many people blame them on. I think that we just need to look at expanding our perspective and toolbox. But under those circumstances, if you do have a true tissue limitation, then maybe you're looking at a very, very long-term strategy in regards to trying to add length to tissues. And that would be using some of your dinosaur plant strategies, perhaps a lot of time and effort applied by the client to restore that range of motion through repetition and avoiding situations where you're creating a negative influence associated with pain and discomfort in ranges, and just reacquiring some of that range of motion through desensitization strategies. So I think there's many ways to go about this, but again I caution you to make against making that leap that you're making an assumption that you do have a tissue change. They do most likely occur, I just don't think they occur as often as we think. The second half of Ryan's question piggybacks off a question from last week, where you asked what tests or measures do you apply to determine whether the elbows are oriented towards external rotation pronation or internal rotation supination. Ryan, this is actually pretty straightforward because, assuming we're doing table tests and such, we would have our axial representation. We would have extremity measures that we would have taken that would tell us whether we have a humeral position in external rotation or internal rotation, again based on those table tests. And then it's just a matter of looking at the pronation and supination available at the elbow. And so if we have identified a shoulder that is in humeral external rotation, we would stabilize the epicondyle at the elbow, we would check our pronation supination, and come up with a determination of what we're looking at in the forearm. However, I would offer you that you probably need to look at the wrist for confirmation of that forearm position because in some cases you may have eccentric orientation at the elbow or concentric orientation at the elbow that will skew your perspective. So if we add the wrist measures into this, so we've got a shoulder, we've got an elbow, and then we've got the wrist measures, if you have a deficit in ulnar deviation and extension, you most likely have a pronated forearm. And if you have a deviation into flexion and radial deviation, then you probably have a supinated forearm. And that's just the orientation of the distal radio-ulnar position. When the forearm is pronated, there is this perceived retraction of the radius that would position it more towards radial deviation and the ulna would appear long under those circumstances, so we would lose that ulnar deviation. So that's what occurs in pronation as the radius crosses over the ulna.

The Camperini angle is the angle formed by the clavicle and the scapula with its apex at the midpoint of the acromion. This measures how much of a compressive strategy we have with the superficial musculature. It represents a compressive strategy rather than the superficial helical angle. If we have superficial musculature compressing the axial skeleton, the scapula will begin to elevate, creating compression between the anterior and posterior aspects of the clavicle and scapula, causing it to ride up on the thorax. This results in a narrowing of the angle. A normal angle is about 60 degrees give or take. If we see a compressed angle, we know we have a more superficial compressive strategy. From an approach standpoint, there are many ways to reduce that compressive strategy. Under many circumstances, we can reorient the movement system to reduce the compressive strategy, resulting in an expansion of the Camperini angle. There are various methods to achieve this, such as manual techniques or using gym exercises like a suitcase carry to reduce that strategy. The Camperini angle is a useful measurement, but it's not absolute. What we don't want to do is think it changes significantly regarding the strategy we may be using.

It's just a matter of reducing that upper thorax compressive strategy that tends to accompany the sequence of exhalation-based strategies for those people that are restricted in their breathing excursion. So hopefully that gives you a little bit of strategy and a little bit of understanding of the Camperini angle. So our next question comes from Brian and Brian asks, why might we use rolling activities for a wide infrastructural angle and quadruped activities for a narrow infrastructural angle? So first, if we understand what the wide ISA represents, so that is a compensatory inhalation strategy against an exhaled axial skeleton. And so what we have to do to restore full breathing excursion is we have to reduce the compensatory inhalation strategy and restore that dynamic. So what we can do with rolling activities, so if we're doing forward shoulder rolls because of the diagonal nature of that we can actually teach someone to exhale more effectively in a forward shoulder roll and that may actually help us reduce that compensatory inhalation strategy because to effectively roll forward I have to be able to exhale under those circumstances and so then the rolling becomes useful. Another strategy that we use is actually a log rolling technique so that is rolling along the long axis of the body and because of the wide infrastructural angle actually represents a widening of the thorax and the pelvis so it's a reduction of the anterior posterior diameter and expansion of the medial lateral aspect of that and so by going through the log rolling activity we actually compress the thorax again helping us to reduce the compressive strategy into your posterior and allowing that expansion to occur. So those are two ways that we can use rolling activities for the wide ISA. When we talk about quadruped activities for the narrow ISAs what the narrow ISA represents is actually a straightening of the ribs. And so if I was to represent the infrastructure with my fingertips here so the thumbs represent the spine and I've got a relatively round thorax and let's just say I have some sort of normal dynamic ISA but if I have a straightening of the rib cage you can see that the infrastructural angle would become more narrow and so what we need to do under those circumstances is we need to be able to bend the ribs. One of the easiest ways to do that is to put people in quadruped. Now if we look at compensatory strategies for the narrow infrastructural angle as the infrastructural angle narrows they create a posterior compressive strategy below T8. And so under those circumstances for me to bend the ribs I need to create expansion posteriorly from T8 inferiorly.

And so one of the great things about quadruped is if I put you such that your hands are below the shoulders in quadruped that puts the shoulder about 90 degrees of shoulder flexion which is mid-range through where the scapula would be upwardly rotating which creates a posterior compression in the posterior upper thorax and the dorsal rostral thorax is compressed and then that provides us a way to expand below the level of the scapula as we inhale. And so again, quadruped becomes this great strategy for people with narrow infrastructural angles, assuming that they're strong enough to support themselves through the upper extremity. Because we're bending the ribs, we're widening the ISA, and we're expanding the posterior rib cage below the level of the scapula, so from about T8 on down. And so that's why we would use this quadruped strategy for narrow ISAs.

So what we have to do with going into and out of the cut is make sure that we know what direction those internal forces are going, and then we have to be able to redirect them. And so that's the big challenge of getting into and out of the cut. And so the internal and external rotation representations are the same going into and out of. So one is not external rotation, one is not internal rotation.