Happy Sunday. I hope you get your neuro coffee because this is this week's Q&A. We have a lot of ground to cover, so this is going to be a fun one. Let's get ready. Alright, so a little neuro coffee to get started. I've had a lot of stuff going on, so I feel like I haven't done this in a long time because we had the intensive recently. I couldn't do the Q&A that weekend because, one, I didn't have time, and two, I had no energy whatsoever. So I'm still in a bit of a recovery mode, and we had a lot of stuff accumulate over the week. I have a fair amount of stuff to share with you in regards to what I posted. If we go to the YouTube, we have the IFAST Podcast 2 and 3. We talked about internships and then about hiring and firing. If that's of interest to you, and you're a business person, those are really good discussions with Mike Robertson and myself. We then transitioned into assessments, breathing, and training. That was a fun one and got a lot of good feedback and interest. In fact, we got a question in the Q&A about that, so stay tuned for that. I also posted about a better way to measure shoulder flexion. We did the hip flexion video a while back, and I thought it would be interesting to show the difference in how you need to measure shoulder flexion. That's a particular way to measure shoulder flexion for consistency purposes and to actually get an accurate measurement. Rather than thinking in straight planes, we have to start thinking in rotations because everything is all about the turning. I posted how to measure the infersternal angle. That got a lot of attention too because I think a lot of people have some difficulty with that and they weight certain things too heavily or maybe just grossly misunderstand how to utilize that measure. Rather than looking at things as absolutes, we have to look at them from an idiosyncratic standpoint. Again, there's a question in the Q&A regarding the ISA, so we'll get to talk about that as well. Last but not least, this morning I posted a video on how to mobilize an ankle to increase propulsion, which is a big deal, especially with people who have perceived ankle weakness or ankle instabilities, people that just don't have confidence, especially after an injury. This is a position that needs to be recaptured. I included some manual therapy and then a little bit of an exercise recommendation in regards to how you're going to recapture that propulsive position. Check those out. On the Instagram from the past couple of weeks, we talked about mixed-grip deadlifts and body orientation, and how that influences body orientation. We talked about synovial joints and how one would develop arthritis over time based on the behavior of how synovial joints work. We also talked about training to isolation early propulsion. Again, that was a nice little topic of interest. And of course, then you have your daily 16% videos for a little bit of personal motivation and just reminders about how to behave and how to think. So there you go. A little heads up. I talked with Drew Keele this week on the Quarterback Ducks podcast. That's going to be out. He said it probably in three or four weeks, but he did send me the video from that call. I'm going to throw up some snippets of that if I can get to it maybe today and we'll throw some of those up this week. It's sort of a little preview, but to give Drew a heads up, they're doing some really good work. So check them out. And that's about it for the review, so let's dig into the Q&A. I'm going to start with a discussion about pelvic orientations and its relationship to the ISA. This is going to be a combination of questions from Tim and Katie. Basically, what they wanted to know is what kind of a chessboard presentation we would be looking at that would result in a significant loss of hip external rotation and a significant gain in hip internal rotation. Katie wanted to bias this discussion towards the narrow ISA presentation. The narrow ISA, if you recall, is an inhaled axial skeleton with a compensatory exhalation strategy. It will present with certain orientations based on this compensatory strategy, but to get to where they want this discussion to go, we're going to have to go through a sequence of compensatory strategies that are superimposed on top of this first exhalation compensatory strategy. So let me grab my pelvis and we're going to talk through this in sequence. First and foremost, let's be clear that this is not a real pelvis. It does not move like a real pelvis. It does not bend and twist like a real pelvis because all bones bend, twist, elongate and compress. We have to have that understanding because what's going to happen to create this orientation is we're going to have shape change involved. This shape change is very, very easy to see in the thorax because the constraints in the thorax are just a little bit less, and it's a little bit easier to bend ribs and move scapulae as opposed to moving ileum and creating compression here. I just want to throw that out ahead of time so everybody has an understanding that this model is just not representative of what's really happening, but we'll talk through it.

We talked about synovial joints and how one would develop arthritis over time based on the behavior of how synovial joints work. We also talked about training to dissociate early propulsion. And so, again, that was a nice little topic of interest. And of course, then you got your daily 16% videos to go on for a little bit of personal motivation and just reminders about how to behave and how to think. So there you go. Little heads up. So I talked with Drew Keele this week on the quarterback ducks podcast. So that's gonna be out. He said it probably in three or four weeks but he did send me the video from that call. So I'm gonna throw up some snippets of that if I can get to that maybe today and we'll throw some of those up this week. It's sort of a little bit of a preview but to give Drew a heads up they're doing some really good work. So check them out. And that's about it for the review, so let's dig into the Q&A. So let's get started with this week's Q&A. I'm going to start with a discussion about some pelvic orientations and its relationship to the ISA. So this is going to be a combination of questions from Tim and Katie. Basically, what they wanted to know is what kind of a compensatory presentation we were looking at that would result in a significant loss of hip external rotation and a significant gain in hip internal rotation. And Katie wanted to bias this discussion towards the narrow ISA presentation. So the narrow ISA, if you recall, is an inhaled axial skeleton with a compensatory exhalation strategy. And so this will present with certain orientations that are based on this compensatory strategy, but to get to where they want this discussion to go, we're going to have to go through a sequence of compensatory strategies that are superimposed on top of this first exhalation compensatory strategy. So let me grab my pelvis and we're going to talk through this in sequence. So first and foremost, let's be clear that this is not a real pelvis. It does not move like a real pelvis. And it does not bend and twist like a real pelvis because all bones bend, twist, elongate and compress. And so we have to have that understanding because what's going to happen to create this orientation is we're going to have shape change that's involved. This shape change is very, very easy to see in the thorax because the constraints in the thorax are just a little bit less and it's a little bit easier to bend ribs and move scapulae as opposed to moving ileum and creating compression here. So I just want to throw that out ahead of time so everybody has an understanding that this model is just not representative of what's really happening, but we'll talk through it.

So if we think about the initial conditions we're starting with, we have an inhaled axial skeleton with an acceleration compensatory strategy on top of that. Typically, we're going to measure somebody with a restricted opening of the ISA, meaning they have a narrow ISA. Because we have a restricted excursion of breathing, we'll make the assumption that we've also got a narrow infrasternal angle. We don't measure that directly because it's a personal area, but we're making this assumption. The orientation we'll look at initially with this compensatory strategy is an externally rotated ilium and a counter-neutated sacrum. This gives us some of the narrow ISA element, representing an exhalation strategy superimposed on an inhalation bias of the axial skeleton. If that's an exhalation strategy, we need an inhalation strategy. Typically, under these circumstances, we'll get further descent of the thoracic diaphragm, leading to further descent of the pelvic diaphragm. This allows us to inhale again. Then we'll need another compensatory strategy to exhale. In narrow ISA presentations, this often results in anterior compression. In the thorax, this looks like a down pump handle, while in the pelvis, we get a compressive force against the pubis that moves it back. Our next inhalation strategy is to expand farther posteriorly because that area remains open. After that, we create a compensatory strategy posteriorly that starts to compress the posterior aspect of the pelvis, where we begin to see shape change. With compressive forces in both the front and back of the pelvis, and similar compression occurring in the thorax, we develop an anterior orientation of the pelvis associated with activity above it. The anterior hip orientation reorients the acetabulum to face downward, allowing for increased internal rotation due to reduced acetabular constraints that would block movement. However, the location of hip internal and external rotation measurements is crucial. For narrow ISA presentations, the gradient for external rotation is very steep, capturing a lot of external rotation quickly but losing it rapidly in early hip flexion. The pelvis remains forward-biased even before movement begins, so while significant external rotation can be shown at theoretical zero degrees, the actual position is already in hip flexion. As we move through hip flexion, the gradient for internal rotation is longer. If measuring at theoretical 90 degrees of hip flexion, the individual is likely biased deeper into internal rotation than realized. The orientation and compressive strategies used to achieve this pelvic position bias toward internal rotation. The internal rotation measurement probably occurs near the middle range of internal rotation, where it's greatest, resulting in a high internal rotation value and apparent loss of external rotation due to pelvic orientation that reduces it. In this position, muscles typically considered internal rotators function as such due to hip flexion, and the natural arc of pelvic diaphragm movement occurs through this middle range. This combination explains the significant internal rotation and external rotation loss.

As I anteriorly orient the hip, the acetabulum is reoriented so it's going to start to face down and that's going to allow me to pick up a lot of internal rotation because there's no longer the acetabular constraint that's going to block me from an internal rotation scenario. So I'm going to tip this up and over the femur and that frees up a lot of internal rotation. Now we have to understand though, as to where you're actually measuring your hip internal and external rotation measures. As we move through hip flexion, as I start here, especially with narrow ISAs, the gradient for external rotation is very, very steep, which means that I capture a lot of external rotation very, very quickly, but I lose it very, very quickly in the early stages of hip flexion. So as I'm here, I can show a lot of external rotation when the femur is at zero degrees, but you're not at zero degrees anymore because remember the pelvis is still forward. So I'm already biased into hip flexion before I even started. So this early phase, I can get ER here, but I'll start to lose it very, very quickly. As I move through hip flexion, the gradient for internal rotation is very, very long. So it's not as steep as it is in external rotation. But I'm already in internal rotation. And as I measure, if you're measuring it at the theoretical 90 degrees of hip flexion, you're actually probably biased deeper into internal rotation than you think. So the orientation and the compressive strategies that I used to get into this orientation of the pelvis overall is already biased towards IR. I measure through the IR arc probably close to its middle range where the internal rotation is that it's greatest, and so now you're going to pick up a lot of internal rotation and so you're going to show a lot of loss of ER, because I've got an orientation of the pelvis that's going to steal it, so I've got muscles that would typically be considered external rotators in this position because of the hip flexion, so I have a bias of glute max that becomes an IR, a piriformis becomes an IR, and the natural arc of moving through internal rotation of the pelvic diaphragm is through this middle range. So I pick up a lot of internal rotation and so I would lose external rotation as a result of this entire orientation. Now I realize that's really, really confusing. So let's go through it one more time. My ISA is narrow. That's the exhalation strategy. To breathe in, I'm going to drive the diaphragm down farther. That's actually going to hold that ISA in and not let it expand, but it's also going to descend the pelvic diaphragm even farther. That's my inhale strategy. I'm going to exhale again. I compress the front. I'm going to inhale and move it back, but I gotta exhale again. Now I start to compress the back. I'm doing the same thing above in the thorax, which is going to orient my pelvis forward. That biases me into the internal rotation element of hip flexion as I move through flexion. And so I'm already reorienting musculature into internal rotation. I measure in the internal rotation position of the hip. So as I flex the hip, it internally rotates here. And so that's how you're going to pick up a whole lot of internal rotation and lose external rotation.

I'm doing the same thing above in the thorax, which is going to orient my pelvis forward. That biases me into the internal rotation element of hip flexion as I move through flexion. And so I'm already reorienting musculature into internal rotation. I measure in the internal rotation position of the hip. So as I flex the hip, it internally rotates here. And so that's how you're going to pick up a whole lot of internal rotation and lose external rotation. So hopefully I made some sense. If I didn't, ask the question again, and we'll go through it as many times as we need to get this thing right, because I know it's confusing. But what we're looking at is layers of compensatory strategies to inhale and exhale that result in this loss of external rotation and the gain in hip internal rotation.

Coach Ledesma asks something referring to the infrasternal angle after establishing a wide versus a narrow, what will be your next step? The reason that we use the concept of wide versus narrow is because it allows us to determine what the compensatory strategy may be in a situation where somebody does not have full excursion of exhalation. That's simple and that guides our interventions and allows us to make better decisions based on probabilities. They're not absolute, which is a very great area. So always keep that in mind. And this concept is going to be idiosyncratic to that individual because their physics are going to be individualized. So that would be step one. He continues: 'What is done with individuals who do not have a wider narrow? So you could say you're 108.8. what strategies would be used there?' So the 108 thing is the vortex angle. We're using the ISA as an estimate of the vortex angle, which would be representative of the ability to move through this full excursion of compression and expansion, or inhalation and exhalation, as we would say for us humans. But what we're looking for is not some ideal measurement. We're looking for the dynamic ISA. So we want an ISA that will open into inhalation and close into exhalation sufficiently to be able to access extremity and actual skeletal range of motion so we can do all the fun things that we like to do from a sports perspective. So we're not really looking for any specific one angle. And again, people are going to be idiosyncratic because people's structures are different, and so what their optimal is going to be determined by those individual physics. So hopefully that touches on what you're looking for. But to reiterate, We're using the assay to identify the first level compensatory strategy to allow us to select the best intervention for that individual. So again if somebody's narrow we're going to make an assumption in regards to their orientations that would benefit from certain positions like quadruped for instance. Wides tend to not do as well early with quadruped activities and will tend to be more biased towards the sideline strategy in most cases for those wide. So hopefully that gives you a little bit of information as to how you want to start based on the infrastructure angle presentation.

And so, again, we can't say that one is optimal or not. We can talk about ranges of like 120 to 60 through this full excursion. We can also mention, as we talked in the earlier question about the 108.8 concept, which is, again, an angle that we need to pass through to optimize the expansion and compression strategies that are associated with inhalation and exhalation. So, but again, this is going to be one of those things that we have to individualize. So we're in a very, very great area as to what optimal is. And so you have to look at this in combination. What I would offer you is that if you have an ISA that does not open and close sufficiently, you will see extremity ranges of motion that are most likely limited. Whether this is good or not depends on what the goal and intent is. Are we trying to raise performance? And so we might have a restriction intentionally. Are we trying to optimize health where we're going to try to expand the adaptability of the system? So again, you have to make these decisions based on the individual, but you're on the right track as far as this thing needs to open and close as a representation of our movement capabilities. So I think you're right on track, Michael.

Turning is a big deal in regards to most sports and from a health standpoint. I like to do a lot of cross connect variations. This might be a cross connect in a side split squat or it might be a cross connect in an anterior or posterior orientation with a split squat or we might use a series of lunges with cross connects or backward lunges with cross connects. Then that moves into what looks like an A march with a cross connect, and then that becomes more and more dynamic so then this becomes an A skip and so on and so forth. Then we can look at some sort of isolated activities that we might need. Depending on the individual, let's just say I get a big strong muscular individual, what they might have to do is doing some loaded eccentric orientation in certain areas in an isolated manner. So old school dumbbell flies done not to enhance muscle strength or hypertrophy, but just to achieve an eccentric orientation. People that are very concentrically oriented need help achieving some of these eccentric positions to allow them to recapture this full excursion of inhalation and exhalation. So that might be included as well. There's any number of activities that you can throw into your warm-ups rather than just blindly creating a sequence, but keep in mind that all of these exercise strategies can be used as training and as your assessment because if you understand how this shape change occurs, one you get to select those activities whatever they may be. So maybe we're doing old school gym class exercises like bear crawls and crab walks to restore movement capabilities, but again we can also keep our eyes on people and use them as our ongoing assessment. So if you look at your key performance indicators in regards to whatever you're trying to recover, achieve, or promote, we can use these activities in that manner. So in a nutshell, what does my warm-up consist of? Whatever it needs to consist of, because we have to understand that what shape change are we trying to influence and what capabilities are we trying to enhance.

In a nutshell, what he's asking is about whether fascial planes influence how we drive internal fluid pressures, and if individual limbs move only in spiral trajectories or if there are straight-line and diagonal influences as well, suggested by collagen lay-down patterns. How do internal fluid pressures influence this? Would it be correct to consider a concept of spiral muscular-fascial loops that work like compression and tension type fluid-filled springs? I think you're actually on track with this last element of your question. I would offer that there aren't any straight lines at all. What appears to be straight lines is because the helical angles are very, very steep. And you have to look at every element of the system; you can't just look at fascia, muscle, or bone in isolation. You have to look at how everything is organized because it's all made of the same stuff. Everything you are is water and collagen. So you have to look at the entire orientation. But like I said, I think you're absolutely on track with the fact that we're looking at diagonal and rotational relationships, and what we want to see are reciprocal rotations through each segment. It's when the system tries to move simultaneously in the same direction that we run into problems. That's how you blow an ACL or the UCL ligament of the elbow. That's when you get compressive strategies and joints like hip and shoulder impingement. We lose the ability to create this reciprocal rotation between segments, whether it's side-to-side or through an extremity. So I think you're absolutely right. This is exactly what we're doing—moving these fluid pressures to demonstrate our capabilities of movement. So I think what you're studying now is on track, but respect that it is all rotational, spiral elements that we're actually looking at.

At the back end, at the latest element of the propulsive phase where my foot is still on the ground, because I am grounded, I have to have an orientation of the pelvis that's moving on the femur, but I'm moving towards that same position of external rotation, supination, and inhalation. So that would be the difference is that as I'm positioning myself early, it's going to be more femur moving on the pelvis, and then as I am late, it's going to be the pelvis that's going to be orienting relative to the femur. So that would be the biggest difference in the two. So I hope that answers your question.

For instance, with the toe touch, typically what you would need for a toe touch is the ability to inhale posteriorly where you can get a counter-irritation to the sacrum to allow you to touch your toes. However, there are many people that have compensatory strategies that allow them to touch their toes without counter-rotation. The same thing applies to the squat. There are many variations of a squat that you may actually be able to squat below parallel but you don't have full counter-rotation. So I prefer asymmetrical tests as representation with the two simplest being the back-to-wall flexion and the single knee-to-chest, because as I inhale on one side I have to exhale on the other. Therefore, you could use those strategies as your self-test to determine what your movement capabilities need to be.