Literally have inside a knee joint. I have one area of the knee that's IRD and I have one area that's ERD. Good morning. Happy Monday. I have neuro coffee in hand and it is perfect. All right. Man, I had a stellar weekend. Got to see a lot of extended family that I have not seen in a very, very long time. A lot of people that mean a lot to me. So I appreciate you all. I'm going to hang out at Elvis's house a little bit. Yeah, it still looks like the 70s, as I recall. So that was kind of fun. But let's dig into today's Q&A. This is with Timas. And Timas had a question about a knee orientation that is actually quite common that I think gets misunderstood because of the way that it's described. So in many cases, things that get described as a varus knee. So varus knee is traditionally thought of as an imaginary frontal plane representation, which again misleads us as to what the appropriate resolution would be for situations where people might be painful in that situation. And what we have to understand is a series of turns. So it's a series of twists, some in the bone, some at the joint level. And we actually go through that description here with Timus. A lot of folks think that when they see this representation, there's really nothing they can to do, say, oh, well, we've got bony changes, et cetera. But if we do understand what we're looking at, so if we have a better modeling of this representation, we can select better interventions and actually make some changes in those needs, as you can see right here, if my technology is appropriate. There's a lot of things that we can do here if we have a better representative model. So thank you teamers for this question. If you would like to participate in a 15-minute consultation, please go to askbillhartman.gmail.com, askbillhartman.gmail.com. We will arrange that at our mutual convenience. Everyone have an outstanding Monday and I will see you tomorrow.

I have a representation that I would like to ask someone for guidance or more information about. Clinically, I often see that on the left side, there is a common representation where the femur moves toward the center while the foot collapses. These individuals typically have a loss of internal rotation at the knee. I often assess the knee's rotational range of motion and find they have an external rotation orientation. However, I've recently encountered other clients who have had similar pain for decades—further along in the process. They present a tricky knee presentation: the medial condyle of the femur protrudes, with a lateral shift of the tibia and a medial shift of the femur. These individuals have lost external rotation at the knee but retain some internal rotation ability from their resting position. The proximal tibiofibular joint has minimal movement, and at the distal end, the fibula appears to approach the calcaneus, with external rotation at the distal tibiofibular junction. There's usually high muscle tone and tightness in the anterior compartment.

Okay, so we have to look at space time.

Yeah.

Okay, all right. So if we start at the knee, distal femur turns inward. Proximal tibia turns outwards. So there's a twist right there. And we're talking about a bony change.

Yes.

Okay. Proximal tibia turns outwards. So there's a twist right there. And we're talking about a bony change.

So we're talking about the twist inside the femur as a bone. Yes.

So the condyle, so like if I hold the shaft of the femur still and I twist the condyle. Okay. All right. If I hold the shaft of the tibia and I twist the plateau. Yes. Okay. That's what you got. First, from the top down, I'm going to start twisting the femur into ER. So I take that initial representation that looked like that, and I'm going to do this. So as you move the leg, it starts to look like a bow. Okay. Where does the weight go on the tibia under that representation? What side of the tibial plateau is absorbing more weight?

I suppose lateral.

No, it's actually on the medial side. So when I bend a bow, the concavity is where the weight's going to be. So that's the compressive side. As I turn the whole leg into this bowed representation, the weight bearing is on the medial plateau, which slows that side down from the turn. That's why it looks like you have internal rotation of the tibia, but you don't. You have a bend in the tibia that's slowing it down so it doesn't turn as fast into ER. It's the weight bearing surface.

So where does this bend actually occur? Is that inside the tibia shock?

So let me see. If I put all the weight right here where my finger is, this angle will increase. I'm still moving sideways, so I get a bend in the tibia that goes like that. Okay, bending this way while the whole thing turns out this way. So I'm pushing down here. Again, it's like we have to move through time here. The pressure here is IR. Yes. The reduction in pressure here is ER. So this is slowing down relative to this. Like within the bone itself, this is moving faster in that direction. This side is slowing down. So it's going down into the ground. So the whole system is moving this way. This is slowing down the turn. So you can have this bowed representation with weight bearing on the inside, the medial aspect of the knee joint, and it will bend the tibial plateau. So the plateau is trying to stay level while the bone underneath it bends into this bowed representation, which is why you see ER at the bottom. The whole thing is turning, right? And they're trying to keep IR into the ground through the medial plateau of the tibia. So this is twist on twist on bend. So it's doing this.

I see. I see.

Okay. So when you see the foot responding, okay, where they're starting to pick up the medial border of the foot, that is way out there.

Way out there. I see, I see. And does that shift that happens between Dibir and Shimar occur because the medial side is delayed and the lateral side has more ER still, so it has to—is that the behavioral action or is that the femur action sliding in where that shift happens?

So the femur is pushing down. The femur becomes the weight bearing bone. It's like a medial heel. It's like a big toe pushing into the ground. But I don't have that representation because the ER took me so far out, away from midline. So for me to push down into the ground, I have to increase the weight bearing on that bone. And so when you ask me which one it is, it's like, well, I'm just creating a shape that slows that movement. So think about this. So is IR compression or expansion?

Compression.

OK. So ER is expansion. So if I'm looking at a knee, and it looks like that.

Yes.

You ever see an x-ray that looks like that?

Yes.

Okay. So I literally have inside a knee joint. I have one area of the knee that's IR and I have one area that's ER. So the outside edge of the knee is moving faster in this direction. This side is trying to slow down. You get it?

Yeah.

Yeah. That's why the representations are consistent. ER is expansion. It's movement towards that space. IR is compression that slows me down. So like literally within the knee, you've got that full representation.

That's really helpful.

You're going to have, they're going to get pushed forward on the left first. So this is your left limited straight leg raise. This is your inability to capture an early propulsive representation. Then you got to say, okay, they're most likely going to be forward on the left, but they go forward and then to the right as well. Good morning. Happy Tuesday. I have no coffee in hand and it is perfect. Okay. A busy Tuesday. As usual, we're going to dig right into today's Q&A. And this is with Pradesh. And Pradesh works with throwers, more specifically cricket bowlers, but this is going to apply to just about any throwing athlete. Whether we're talking about baseball pitchers, we do mention Javelin in this discussion as well because of the similarities between Javelin and cricket bowling. But essentially what Pradesh is just dealing with is his throwers are presenting in a late propulsive representation, which means that they're not truly capturing any representation of middle propulsion. Therefore, they're having to use compensatory strategies to drive force downward into the ground as a substitution for their internal rotation. One of the common findings you're going to find here is the limited straight leg raise as a KPI. That's going to be indicative of that thrower that is pushed more forward towards that late propulsive representation. The concern here is twofold. Number one, we're going to have a reduction in force application into the ground. So that's a performance related issue. But from an injury standpoint, what we're going to see is we're going to see these prolonged phases of ER. So the inability to capture the early propulsive representation where we're starting to superimpose internal rotation is either delayed or nonexistent and so we're gonna end up with prolonged ER phases and this is we're gonna see a potential medial elbow stress. And again, I think this is going to be useful for a lot of folks and we talk about some solutions as well to recapture that early propulsive representation. So I hope you find this useful. If you would like to participate in a 15-minute consultation, please go to askbillhartmanedgmail.com, askbillhartmanedgmail.com, put 15-minute consultation in the subject line, so I don't delete it. We will arrange that at our mutual convenience. Everybody have an outstanding Tuesday, and I will see you tomorrow.

Bill, this is about cricket fastball up. Okay. So can you visualize the delivery stride?

I'm sorry, say that one more time, you're a little choppy.

Can you visualize the delivery stride?