Good morning. Happy Monday. I have no coffee in hand and it is perfect. All right, coming off a stellar weekend with recovery weekend had some company, really good time, and now we're ready to dig into a Monday. So let's go right into the Q&A for today. This is with Zach. Zach had a great question. He's working with a young athlete that is presenting very specifically with some interesting findings and your orientation in the pelvis, but a response in the foot. And so this is one of those things that gets misrepresented a lot because in the literature and clinically, a foot is identified as being pronated as the arch approaches the ground, which is fine if we can understand how we get there. And the thing we want to recognize is the fact that everything is a turn. And so a pronated foot often gets misrepresented as something that is occurring in the imaginary frontal plane when it's actually a twist through the foot. And so what we'll actually see is a turn through the tibia here, and then that's going to bring the arch down. But what we have in this case that we discussed with Zack is we actually have an ERD foot that's getting pushed downward into the ground. As the center of gravity passes forward, the arch is going to get closer to the ground. And so we don't have a relative motion at the subtalar joint that's producing this pronated appearance. And so it creates some confusion. So we talk Zack through this, we give him a little bit of strategy that you're probably going to want to pay attention to in regards to how to restore normal contacts to the bottom of that foot. So this is very, very useful for a lot of people. So thank you, Zach, for bringing this question. If you'd like to participate in a 15-minute consultation, please go to askbillhartman at gmail.com, put 15-minute consultation in the subject line so I don't delete it. We'll arrange that at our mutual convenience. Don't forget, put your question in the email as well. Everybody have an outstanding Monday, and I will see you tomorrow.

So, a 14-15 year old high school girl presented to me with bilateral hip, knee, and foot pain. I have a picture where it won't show her face.

Sweet.

So she initially came to me. She's a 14-15 year old high school girl with bilateral hip, knee, and foot pain. I have a picture where it won't show her face.

Yep. Got it.

Yep.

All over. Yep.

In working with her, yes, as you mentioned the hip and foot pain once, but it's really about the knee pain. That's the only thing she ever talks about, either within PT or when she's playing soccer. Every single time, it's very clear how she describes it. So basically, take this side of her hand and draw a line through her patellar tendon. Is she indicating where the pain is?

Longitudinally or horizontally?

Horizontally.

Okay. So like top half is painful, bottom half is not kind of thing?

Yes.

Gotcha.

From what provokes her symptoms the most other than playing her sport, pretty much anytime we get into a split stance position, the back leg. From a range of motion standpoint, I can get her to a point where she's pretty much clean. But anytime, even when I get the range of motion back, whenever we go back into that position, we can do a set of a split squat, but when we go into a second or third set, the symptoms always come back. I'm trying to figure out if we'll eventually have to relearn how to put force into the ground based on the fact that she's just not tolerating it. But right now, I can't figure out how to bridge the gap from on the table to getting her to stand up and tolerate this position.

Gotcha. Okay. Perfect.

From a capturing range of motion standpoint, I can get her to a point where she's pretty much clean. But even when I get the range of motion back, anytime we go back into that position, we can do a set of a split squat, but anytime we go into a second or third set, the symptoms always come back. So I'm trying to figure out—eventually I think we're going to have to relearn how to put force into the ground based on the fact that she's just [unable to tolerate it]. But right now, I can't figure out how I'm bridging the gap from on the table to getting her to stand up and just tolerate this position.

Yep. So can you hold that picture up? Can you share that?

It's on my phone right now.

Just hold it up again. OK. Now lower it down a little bit. Just a little. Like slide your phone down. I want to see your hips. There you go. She's a little pile on it, yeah? So you have a public circumference that's a little bit bigger than the thoracic circumference, right? So velocity favors a downward representation, does it not? Okay, awesome. Now, hold the picture up again. Look at her feet. Get it closer and lift it up a little bit. Awesome. Okay. Is she pushing into the ground?

Yes.

Okay. You have a pelvic circumference that's a little bit bigger than the thoracic circumference, right? So velocity favors a downward representation, does it not? Okay. Now, hold the picture up again. Look at her feet. Get it closer and lift it up a little bit. Awesome. Is she pushing into the ground?

It appears that she is pushing into the ground. I think she's losing that as well.

Uh, you could say that.

And I think she's losing that would also be a safe statement.

Okay. All right. So, what kind of foot you got going there? You got a yard foot or an iron foot?

I was wrong. Uh, so is she ER and then just oriented?

Uh-huh.

What's your giveaway for that?

The fact that she's got an ER foot in the arch is really close to the ground.

Where are you seeing that?