The question comes from Josh and Josh says, are there variations of the Camper Deadlift? I feel like I've seen where the front toes are elevated, the back heel is elevated, the hip's lateral is loaded, or the contralateral arm is loaded. Can you explain when you would use these variations? And yes, Josh, yes I can. But let's talk about why we would want to select this exercise in the first place. What we don't want to do is blindly prescribe exercises. We want to have a good reasoning behind our thought process. What we're talking about here is an asymmetrical variation of a deadlift that is somewhat similar to a single leg deadlift, but we've got a double foot contact. And what this allows us to do is it allows us to reorient the sacrum like the rudder on a boat. And if we have a situation where we're missing this middle part of middle propulsion. So we can actually divide middle propulsion into segments as well. And so if I break out the foot here, this middle range of propulsion is when the foot is gonna come down to flat, and it's where we have this tibial translation over the foot. And so we can buy, so we can say that this is the earliest phase of middle propulsion, and this is the end phase of middle propulsion. And through that phase is where we're gonna see a lot of nutation of the sacrum. We're gonna see a lot of internal rotation of the hip and some folks are missing some of that because of the inability, I should say, to orient the sacrum appropriately because of some strategies that they're using in the pelvis and then the bias of the foot. But this is going to affect everything from all of your activities where you need some form of nutation, like your deadlifts, your kettlebell swings, power lifting style squats, half kneeling, or even split stance activities. So this is kind of a big deal for a lot of people. But this is a really, really useful exercise, thanks to our good friend Mike Camperini for experimenting in the gym and working on this but so what we want to do is we want to alleviate the bias that's that's putting us at one end of this middle propulsive phase and so we can describe this with our pelvis a little bit And so essentially what we're talking about is this bias of the sacrum being biased in one direction or the other by this orientation of the pelvis. And so if somebody is biased towards the early phase of this mid propulsion, typically what you're gonna see is somebody that can probably squat to parallel, but when they do a hinging exercise, you'll see a little bit of a shift off to one side or the other. They can typically flex their head past 90 degrees, and you're typically gonna have a reasonably good straight leg raise, so it'll probably be 70 degrees or more. If we look at somebody that's biased towards this later stage of the middle propulsion, so this is right before max propulsion, these are typically going to be people that don't squat well to parallel. You're going to see hip flexion that's less than 90 degrees. You're going to see a very limited straight leg raise. In some cases, 45 degrees or less. And that's because they've got this additional compressive strategy in this lower aspect on the posterior side of the pelvis. So these people are really pushed forward in one direction. Again, because of this concentric orientation of the musculature below the trochanter there. So again, that's how we're going to divide this up. We're going to see somebody that's a little bit more compressed at the base, and then we're going to see somebody that has a lot more compressive strategy that's getting pushed way over in that in that late propulsive strategy. And so when we're talking about how we want to modify this, we have two influences. We can go from the ground up and we can go from the top down. And so when we talk about the ground up. This is where our foot bias comes in, Josh. And so we can talk about biasing the foot towards this early phase of propulsion. So if I have some of this bias way towards late, so this is the person with the limited straight leg raise hip flexion can't squat very deep. I'm going to bias that foot towards its early, early strategy. And so this is where I'm going to elevate the heel. And so what that does is it moves that tibia backwards and that puts me in this early phase early phase of this middle propulsion. So now what I want to start to think about, not just elevating the heel, but I also want to consider where I'm putting the load. So I'm going to put the load on the contralateral side.

So what we want to do is alleviate the bias that's putting us at one end of this middle propulsive phase. We can describe this with our pelvis. Essentially, we're talking about this bias of the sacrum being biased in one direction or the other by the orientation of the pelvis. If somebody is biased towards the early phase of this mid-propulsion, typically you're going to see someone who can probably squat to parallel but when they do a hinging exercise, you'll see a little bit of a shift off to one side or the other. They can typically flex their hip past 90 degrees, and you're typically going to have a reasonably good straight leg raise, so it'll probably be 70 degrees or more. If we look at somebody that's biased towards this later stage of the middle propulsion, right before max propulsion, these are typically going to be people who don't squat well to parallel. You're going to see hip flexion that's less than 90 degrees. You're going to see a very limited straight leg raise. In some cases, 45 degrees or less. And that's because they've got this additional compressive strategy in the lower aspect on the posterior side of the pelvis. These people are really pushed forward in one direction, again because of this concentric orientation of the musculature below the trochanter there. Again, that's how we're going to divide this up. We're going to see somebody that's a little bit more compressed at the base and then we're going to see somebody that has a lot more compressive strategy that's getting pushed way over in that late propulsive strategy.

So let's just say that if we look at video, we're going to say that the left hip is the affected hip that we're trying to influence. We're trying to move that hip towards an earlier phase of propulsion. I'm going to put the weight on the contralateral side. This is going to allow me to use the weight to create the reorientation. I'm actually turning my thorax into the left side. I'm actually turning the sacrum to the left side by putting the weight on the contralateral side. That's going to push me back towards my left back pocket. So now I have a bias from the ground up. So I bias myself into early. And I've turned myself into the left side. So now I've really reoriented that sacrum. So the couple of cues that you might wanna remember is make sure that you're inhaled before you descend and make sure you're exhaling up from the bottom. So again, we're gonna try to reinforce this nutation with the exhalation from the ground up. If I am early biased, so this is gonna be the person that has decent hip flexion, decent straight leg raise and can probably squat to parallel, I'm gonna flip flop that foot orientation. So I'm gonna put the toes up and the heel down and what that's gonna do, it's gonna move that tibia forward into that later stage of the middle propulsive phase of gait. Or wherever I may need to utilize that for my hinging activities. And so now I've got that ground up influence and again because I want to reorient that sacrum I'm going to keep the the weight on the contralateral side as you can see hopefully in this video here if I'm technically sound enough to to put the video in the right place. So now when do we switch the weight over to the to the ipsilateral side or the same side as as the affected hip if you will? Under those circumstances this will be after I've recaptured the hip range of motion deficits that I was trying to reacquire. So in this case, I'm going to see an improvement in my hip flexion, my straight leg raise, my squat, and I'm going to recapture the internal rotation through that middle, that full middle propulsive base. But if I look at the opposite hip now, so we were talking about the left hip before, we're going to talk about the right hip now. If I'm missing internal rotation in the opposite hip, in this case, the right hip, now I'm going to flip flop the way to the ipsilateral side. Reason being is I want to push with that opposite side back into the left hip to actually delay the propulsive strategies that I have just reacquired on this left side. What this is going to do is it's going to restore my right hip external rotation. If I have a deficit in external rotation on the opposite hip, that's how I know when to switch the weight over to the ipsilateral side. Now a little trick here: you got to be really careful because the weight will try to reorient you back into the old strategy, so we have to actually resist this. So as you can see in the video, I'm maintaining that left posterior expansion throughout the lift to make sure that I'm not losing the ability to delay that propulsive strategy on the left side.

What this is going to do is it's going to restore my right hip external rotation. If I have a deficit in external rotation on the opposite hip, that's how I know when to switch the weight over to the ipsilateral side. Now a little trick here: you have to be really, really careful because the weight will try to reorient you back into the old strategy. So we have to actually resist this. As you can see in the video, I'm maintaining that left posterior expansion throughout the lift to make sure that I'm not losing the ability to delay that propulsive strategy on the left side.

to be internal rotation, which is going to play into Tony's question here. But again, let's sort of eliminate this whole friction thing from the model because I don't think it's very useful in number one and probably doesn't even exist. So what we want to think about then is we want to start to think about how this extremity is oriented and where we're placing load or tension in excess over time, which is probably what's causing the symptoms in the first place. If we think about the description that Tony did. And this is actually a really good description, Tony. When you talk about the knee orientation, the limitation hip wire, and the foot orientation, it sounds like we're in a very late propulsive strategy on this right side. So chances are this runner is actually landing in a late propulsive strategy. So we don't have this transition through any of the middle ranges of propulsion where we would normally have relative motion. So we have a lot of things that are probably moving together. And so if we look at the orientation of the knee, we'd have to start up here at the pelvis. And so if the pelvis is getting pushed forward and to the right rather aggressively, we're going to see this kind of orientation of the pelvis where we have a pelvis that's turning in this direction and so far forward that we're in this later propulsive strategy. So what's going to happen as we would normally land and we move through relative motions at the knee where we'd have this nice little tibial relationship with the femur. We've got a tibia that's moving in into an ER position and we've got a femur that's most likely following it. That's what's giving that various appearance of the knee. But that means that we've also had to, sorry, rather ER this this this femur so we've got er we've got an er at the at the proximal tibia as well and so now we've got this big load that that's being driven a little bit more laterally and so that's probably why you're getting that lateral and a knee symptom to begin with. So from a strategy standpoint, we've got to start thinking about eliminating this left posterior compressive strategy that's pushing us into this. So anything that would start to move us backwards and expanding this left posterior is going to be useful strategy to all your hip shifting activities. Something in the gym that I love to do is a staggered stance cable chop, which promotes this great left posterior expansion. If you look at yesterday's video,

On the contralateral side where we're manipulating these phases of propulsion, definitely go there because that's going to help you get the left posterior expansion that you need. Now having done that, let's say we've eliminated this left posterior strategy, now we got to start thinking right side because we got to restore the relative motion in this right side. So one of my favorite things to do is crazy simple. I take people out of their shoes. I put their foot on the ground. I get them to feel first and fifth met heads in the center of the heel on the floor. So we get this relatively middle range, middle propulsive position of the foot. And then we start to bring the tibia over the foot in an alignment that would be in line with the middle of the foot. What we're trying to do here is we're trying to teach the runner to bring the tibia over the foot rather than landing in this later propulsive strategy. We want to teach them how to move through this by bringing the tibia forward. So this is not pushing the tibia forward. This is not trying to mobilize the ankle into dorsiflexion. What I want you to think about as a cue is pulling the tibia forward. If we had to pick out a muscle, we would say it's tibialis anterior. What the tibialis anterior is going to do is actually going to flex the knee, it's going to dorsiflex the ankle, but it's also going to internally rotate that proximal tibia, which is going to help me start to restore the relative motions. And that's going to trickle down into the foot. So I get this nice little middle range of propulsion where the relative motions occur. I get that back, which is definitely what I want to do. So once I can capture this, and it takes a little bit of practice to really drive this, and you'll get some of that nice little tibialis anterior fatigue. They'll get a little burning in the front of the shin. Now I can go out into the gym and I can start working on some things such as like half kneeling and split stance activities where I get a lot of this middle range relative motion. So I get the IR at the hip. I get the relative motion of the knee. I get tibial internal rotation and I can start to drive the ankle again through this middle range of propulsion. I'm going to start statically. We're probably going to have a resistance that's going to try to pull us to the right. So we have to create this resistance to hold ourselves through this middle range of propulsion.

And the thing I don't want to do is overdrive the hip internal rotation because then all I'm going to do is get another pelvic orientation problem that's going to be driven from the left. So I want to think about being square at the pelvis. So I'm going to level the pelvis. I'm going to try to create a bunch of right angles through the hips and across the pelvis. I think I have a video on right lateral knee pain that's already up on YouTube. So look at that as a reinforcement for what I'm talking about. We're going to start statically so we can capture these middle range positions and then maintaining that posterior expansion as we're holding these static positions. Once I do that I want to transition into dynamic activity so now I want to start to move again that tibia over the foot dynamically. I can still maintain my right resistance so I can again teach myself to guide myself through this middle range of propulsion but I would start with something like a front foot elevated split squat so I don't have the massive amount of load on that front foot but again I'm going to work on driving that tibia rather aggressively over the foot I can bring my foot down to the ground then in a regular split stance and again thinking dynamically of bringing the tibia forward and then finally elevating the rear foot so I get a little bit more forefoot or front foot load rather. So we're just talking about graded activities here while maintaining the capacity to drive ourselves through this middle range of propulsion. Now a little bit about the foot because we've been talking about feet for what, two weeks now, three weeks now? So if I'm in this late phase of propulsion, I also want to think about some ground up concepts. And so I'm landing in a position where I don't have the relative motion in the ankle. And usually when I have this late propulsive foot strategy it's because the tibia is translating too quickly over the foot so the easiest way for me to delay this is to get a shoe that has a little bit of an arch in it and what that's going to do it's going to reduce the the rate at which that tibia can translate okay because a late propulsive foot is very very useful for high speed high explosive activities because that's where I produce my highest levels of force, but if I land in that and an ER and that ER trickles up, then what I can do is I can end up with what we're talking about, which is this lateral knee pain, or I'll end up with a hip thing or a back thing. So again, we've got ground-up influences, we've got top-down influences to address here, but Tony, I think if you look at this as a two-sided problem and if you look at it as trying to recapture that middle range of propulsive strategies, it'll be much more useful.

We've got ground-up influences, we've got top-down influences to address here, but Tony, I think if you look at this as a two-sided problem and if you look at it as trying to recapture that middle range of propulsive strategies, it'll be much more useful. Have a great day, I will see you guys later.

Yes, it was a new patient and she hasn't really had a lot of conditioning over the last few years. So she just doesn't have a lot of movement skills. So we're going through some interventions and she's just not picking up on it. I'm trying to give her a cue after a cue and everything is just crashing and burning. And you enjoyed every second.

I did. I did enjoy every second. But every student, you don't qualify as a student, but every student that comes through here experiences that. Because I let it happen because it has to happen. And you just have to recognize it for what it is. So that it is just part of a process. But it also gives you information as to how many options you have in mind, right? And so you sort of like, you use up all of your strategies and then it's like, then where do you go? And I think that one of the things that people need to recognize in these circumstances is that it doesn't make you a bad therapist and it doesn't make them a bad person because I think that people get frustrated with patients a lot because you think you're giving your best cues. You think you know what you're doing. And then they just, it's not that they're not receptive to it. It's just that they don't have, they don't have the background to even understand what you may want them to do. And I think she is one of those people where you could give her the best possible information and you gave her good cues and you gave her like from a strategy standpoint, I think you were on point. But again, it just didn't come out the way you wanted it to at all. And I think that ultimately we were successful before she walked out the door. That's another thing to recognize. It's like, okay, we just gave her everything that she could execute effectively. And I think that's the difference. We always have to remember that it's not about us, it's about the patient and it's about how successful they are. So we put her in the only position that she was successful in and then allowed her to execute. And so like I said, ultimately you can look at this in any perspective that you want. As I always say, I go home with a big red mark on my forehead quite a bit where I bang my head on my steering wheel all the way home thinking like, I could have done this, I could have done this. But the thing that I want you to see is that yeah you failed and you failed and you failed and you kind of failed your way to success till you finally got to the point where you you recognize the fact that this is the best that she's going to do today based on her experiences based on her capabilities and then she will move forward and she will progress you know it's like not everybody feels like hitting a home run And yesterday was like the big K, if you will. But you gotta go through that. You gotta feel that.

And so all the people that have been through the purple room experience right now that are actually watching this will probably throw you a comment that goes, ah yeah, I had to do that too. It's just part of the process, but it never goes away. It's like, I experience this every day too. It's just that from a perspective and having 30 years of experience you just go okay. This is just the next step and it's like okay what I just told you didn't make sense. You don't understand what I'm trying to say and then you just got to figure out the way that they understand you and then like I said you find the position where they are most successful right rather than you know, kicking yourself or being an idiot, when you're not, you're just again, this is one of the hardest things is this interaction between people. People can come onto the internet, social media, and they can talk about how great things are, but people also need to recognize that these failures are as important as the days where you really do feel like a God and you helped everybody and everything went exactly as planned. This was an important experience for you. You've been practicing, this is what people don't really, you've been practicing for a long time, but you're trying to evolve something different and that's why that presents an even bigger challenge. And so I tip my hat for you for not, you know, going off the deep end. You handled it really really well and but again I thought it went great then at the end. It's just I had to let that happen sure, you know, so you do understand this and then this is the lesson that you teach the next guy that you're gonna help cool. Yes, awesome. See you guys later. Happy Thursday. I have neuro coffee in hand and it is perfect. Good morning, welcome to the call.

I have a young patient currently a senior in high school. He's a lefty and he's got probably the largest cue angle I've ever seen. And he is sent to me status post UCL repair. And he's a narrow and I already know, even though he's still in a brace, I know that he's going to be pronation biased. So I wanted to ask Bill the mechanisms that create the UCL with a presentation like that.

The mechanism that probably created the injury tends to actually be the ER and then the prolonged supination during the throw.

Yes.

And what you'll notice is like even though he's oriented into pronation at rest, he probably shows a limitation in pronation. And what you want to do is actually take a look at how much pronation he's got approximately relative to the wrist. So when you grab his wrist and you turn him over into pronation, you go, oh, he's limited. It's like, get a little bit more proximal and see how far you can bring the radius over into pronation and then compare it to the other side. Because chances are he's got a radius that's bent.

Yes.

And what you want to do is actually take a look at how much pronation he's got approximately relative to the wrist. So when you grab his wrist and you turn him over into pronation, you go, oh, he's limited. It's like, get a little bit more proximal and see how far you can bring the radius over into pronation and then compare it to the other side. Because chances are he's got a radius that's bent. And then if you look, was it the picture that you sent me?

Yeah, that's his carry angle.

Okay, because if you look at his hand, he's going to fail the Apple test because he's definitely got a hand that's also in relative pronation to the distal radius. So he's really cranking over into pronation rather aggressively because he can't access the position without a compensatory strategy.

Wondering about taping somebody like this like you're twisted femur tibia.

Yeah. Why not? Why not? Absolutely. Absolutely. Just to kind of teach him to feel the orientation a little bit differently. He's not walking on his hands or anything like that. But like I said, to teach him some of that, to reorient the elbow, changing it

Yo, yeah, we're doing real well with that. He's had a schedule.

Okay. But you can start to retrain the distal stuff right now.

I started with your NRRCI mode.

Yeah. So you start there. Um, and then, you know, there's a lot of stuff that you can be doing. It's like UDR. Yeah. When they're in the protective phase, it's like people don't recognize all this other stuff that you could be doing that is supportive. Like, you know, people coming off a rotary cup repair or something like that. When they're in the protective phase, people think that, oh, you just do like this little bit of passive range of motion or whatever, whatever. And then that's all you can do. It's like, hey, you got like three other limbs there that are going to be influencing the capacity of the body to be moving around volumes and pressures and changing shapes and stuff. And all that was an influence that probably perpetuated the need for the repair in the first place. So again, you always evaluate the person, not the diagnosis. So my concern here, and again, you look at it as radius. And if you measure the pronation just from the rest, and that's your representation of pronation, I don't know that's going to be terribly accurate because it's going to be limited, but I think it's limited by the fact that you've got to twist in the radius itself. But again, it's like, every time you see an adaptation that you perceive as favorable, recognize the fact that something else had to change for that to occur too. And so if I direct resources towards an adaptation, that means that something else is sacrificed. And it might not be impactful at all. But then again, maybe it is. And so this is why, but again, this is why we always evaluate the human and not a body part or not a single representation or adaptation. We have to look at them as a whole all the time.

Sure, I see it now.

But again, it's like, every time you see an adaptation that you perceive as favorable, recognize the fact that something else had to change for that to occur too. And so if I direct resources towards an adaptation, that means that something else is sacrificed. And it might not be impactful at all. But then again, maybe it is. And so this is why, but again, this is why we always evaluate the human and not a body part or not a single representation or adaptation. We have to look at them as a whole all the time.

Bill, I was kind of thinking about this yesterday. I'm going to go back to basics. So you get counter-nutation of the sacrum and you get a retroversion of the acetabulum. If the femur stays fixed, when you get a concentric orientation of musculature on the front of the trochanter and an eccentric orientation of musculature behind it, then wouldn't that set up a better environment for internal rotation as opposed to external rotation?

So you're weight-bearing through the extremity?

So let me just standing, take a breath, counter-nutation, and then you get an ER of the ilium. Wouldn't that create a concentric orientation on the front and then eccentric orientation on the back? Fluid shift would be able to go backwards.