When we're talking about reducing the compressive strategy on the sternum, we need to identify that a compressive strategy results in reduced shoulder internal rotation. This happens because compressing the sternum positions the scapula such that you get concentric orientation on the posterior side of the shoulder, leading to a loss of internal rotation. You can't reach across your body or behind your back, and you won't have normal internal rotation that people would measure in table tests. To address this, we need to bring the pump handle up. If we were to take a dent out of a car fender, we wouldn't bang on the outside trying to make it pop back out; we have to go from the inside out. Therefore, to bring the pump handle up, we need to push volume into that anterior chest wall to lift the sternum. Since we have left and right pump handles, we can play with that scenario, but for now, let's stick with the concept of pushing air forward. To push air forward, we need to create a compressive strategy on the posterior aspect that opposes the sternum. In the dorsal rostral thorax, we need to create concentric orientation. Any position where the scapula moves towards the traditional upward rotation creates that concentric orientation and pushes the volume of air forward. This puts us in a general range of a reach forward or quadruped position, which would be ideal. The primary strategy to get the pump handle up is forward reaches and positions like a bear crawl or bear position. The second place to capture this is by positioning the arm at your side, where internal rotation begins. Activities like crab walking, from good old fashioned gym class, work really well here. You can also do propulsive activities with your arm at your side, such as triceps activities. Tricep kickbacks, as mentioned in a previous video, are a really good exercise to help recapture internal rotation of the shoulder. Anything in these two ranges will be of the greatest benefit to bring the pump handle up.

Well, it just so happens that any position where the scapula is moving towards the traditional upward rotation would actually create that concentric orientation and would push the volume of air forward. So that's gonna put us somewhere in the general range of a reach forward or quadruped or something under those circumstances, which would be ideal. And so that's going to be your primary strategy to try to get this pump handle up. So forward reaches and anything that you would be in like a bear position, a bear crawl. The second place that you can capture this actually is positioning the arm at your side because that is where internal rotation again begins. And so some of your crab walking activities, so good old fashioned gym class kind of stuff works really, really well here. You can do some propulsive activities with your arm at your side, so triceps activities. If you go back to last week or week before where I was doing the tricep kickback activity for the gym, so that's actually a really good exercise to help you recapture some internal rotation of the shoulder. So anything in those two ranges are going to be of the greatest benefit to bring the pump handle up. So that's a generalized response. Now, let's talk about Andrew. So Andrew's talking about a golf swing. I'm gonna make an assumption, Andrew. You're talking about like a left arm situation for a right hand golfer where they have to take the arm across their body in the golf swing. And you're gonna see some sort of compensation for that when you do not have that cross body adduction, which requires that you internally rotate that left shoulder if we're talking about a right handed golfer. Same thing that we just talked about with Sarah. I have to get the left pump handle to come up otherwise I will not be able to reach across my body because again you're asking Andrew is it a scapular issue or is it a thorax issue and I would say that if you're looking at it from that perspective you're always going to be lost because you're only going to get pieces. So think about this for a second. So for me to get the left pump handle to come up, that also means that I need right dorsal rostral expansion at the same time. Otherwise, what you're going to see as a strategy for a right handed golfer, they take the club back into their backswing. This is where you're going to see the people that roll out to the outside edge of their right foot because what happens is is because they don't have right posterior expansion. They can't shift towards the right hip. And so then they lose the relative motion in the hip, the knee, and the ankle.

So then the whole lower extremity moves as a single unit, and that forces them to roll to the outside edge. Now they get their hands in the right place, but they're not using relative motions to get there. And so this is why we need the pump handle mechanics on the left anterior side to get the left arm across the body. So we can create expansion where we need expansion. We get the scapular position where we need it to be, and then that allows us to eccentrically orient and capture the internal rotations that we need to get the arm across the body. Then we don't need a compensatory strategy, but if I ignore the right side mechanics, if I ignore the right side capabilities, and I'm just thinking like, oh, it's just a left shoulder thing, it's just a left shoulder thing, you're still gonna hit an impasse. You might make some progress, but you're probably not gonna recapture everything that you wanna recapture. So we always have to think about how this interaction works on both sides of the body, especially with turning athletes, tennis players, golfers, baseball players, any kind of thrower that has to make a turn. They all use similar mechanics in the way that they produce the positions. And so again, I can't just look at one piece or one thing. So when you say that you have a cross-body adduction issue, I would also say that you probably have a rotational issue on the other side that you have to address, but it's gonna be right posterior where your left shoulder is gonna be left anterior. So I hope that gives you a couple of ideas. So use the same strategies that we talked about with Sarah, but I would also look at capturing the right posterior mechanics because that is going to be the externally rotated shoulder where I'm trying to internally rotate as I go across the body. And so hopefully, like I said, that gives you a little bit of a guide in regards to what we're talking about.

They're kind of really good practical application questions and they're kind of related to some videos that I've done. And so I'll mention that as we go through this. The first one comes from Mike in regards to some elbow pain issues as he unwracks the bar with a low bar squat position. And so Mike, what we have to start to recognize is what are the advantages and disadvantages of this low bar position? The advantages of low bar position in a back squat is that you can create really, really high levels of intratheurastic and intra-abdominal pressure. The drawback is that under those circumstances, you're also gonna give up a lot of shoulder range of motion to acquire that position. So you think about bringing the scaps together posteriorly. So people will call that scapular retraction. You think about the hard arch that you're probably gonna use under those circumstances as well. So the whole backside is compressed, much like an arch in a bench press. So the arch in the bench press allows us to increase internal pressures, which allows us to lift more weight. Same thing with the back squat. We're creating this compressive strategy. Here's the dilemma that you have. So to position your arms to hold onto the bar and to place it in the low rack position, instead of using your external rotation capabilities, you're going to reorient the glenoid. So you're going to turn the socket of the scapula outward as a substitution for external rotation, which means that you're actually going to internally rotate your shoulder to get into this low bar position. Your hand is also fixed on the barbell in a pronated position. So what happens is you max out the internal rotation of your shoulder and you're pronated. So now you've got internal rotation on internal rotation. So we've lost a lot of relative motion in the elbow and now you're going to get a tremendous amount of load directly onto the elbow position. It's usually going to show up on the medial side. So on the inside of the elbows where you're typically going to feel that kind of stress. So that's why you're feeling it. Now, so what's the solution? Number one, I'm not gonna talk you out of this low bar position chances bar because it'll actually lift more weight and I know you wanna lift more weight. So what you have to do is you have to work to maintain the extra rotation capabilities by expanding the posterior aspect of your thorax. So the space between your shoulder blades and the space below your shoulder blades needs to stay expanded. So what I'm gonna do is I'm gonna post a video today on Instagram and probably up on YouTube that will give you a strategy to allow you to maintain those capabilities. And so be looking for that. So basically the answer to your solution is maintain post to your expansion between the scaps and below the level of the scapula. And then that's going to allow you an opportunity to maintain the shoulder range of motion that you're gonna give up with this low bar position over time. Okay, so hopefully that's an answer for you. Second Mike question. Different Mike. In a split stance like a lunge or a back lunge or a split squat, why do you see the knee deviating outward, especially on the back leg as you're lowering into the split squat? This is actually a pretty simple question. When you see this, what you have is somebody that's trying to move through the maximum propulsive base in this split orientation without being able to capture the max propulsive position of the hip and the pelvis. And so under those circumstances, that max propulsive position is going to be an internally rotated, exhaled position of the pelvis. And when you have somebody that's trying to do this using an externally rotated, inhaled position of the pelvis, which is early lay propulsion, they don't have enough force producing capabilities under those circumstances. And the pelvis is oriented as such that it's going to create this deviation into a more abducted or externally rotated position. So you can see this on the front knee. So you'll see the front knee deviate outward or you'll see the back knee deviate outward. A lot of these people will complain about anterior knee pain, whether it be the back leg or the front leg. So I do have a video that's up on YouTube and Instagram in regard to a split stance strategy to alleviate the pain on the backside knee. It's the same problem whether it be front knee or back knee. I just wanted to give a very specific representation because a lot of people complain about the stress on the back knee but it's an orientation problem and so what you need to do under those circumstances is learn how to recapture the propulsive position. So now I would direct you towards videos that I have posted up on YouTube that are designed to recapture hip internal rotation because if you can capture this internal rotation, you'll capture the propulsive position. One, you'll be able to maintain your position and orientation as you move through the lunge. And then secondly, you'll probably alleviate a lot of knee pain and you'll be able to increase load. So if your goal is hypertrophy, force production, strength, you'll have a much greater level of success with that. So hopefully those two answers help both of you, Mike's. If you have any other questions or problems, please let me know. Go to askbillharmonetgmail.com, send me a question.

So basically the answer to your solution is maintain posterior expansion between the scapulae and below the level of the scapula. And then that's going to allow you an opportunity to maintain the shoulder range of motion that you're gonna give up with this low bar position over time. Okay, so hopefully that's an answer for you. Second Mike question. Different Mike. In a split stance like a lunge or a back lunge or a split squat, why do you see the knee deviating outward, especially on the back leg as you're lowering into the split squat? This is actually a pretty simple question. When you see this, what you have is somebody that's trying to move through the maximum propulsive base in this split orientation without being able to capture the max propulsive position of the hip and the pelvis. And so under those circumstances, that max propulsive position is going to be an internally rotated, exhaled position of the pelvis. And when you have somebody that's trying to do this using an externally rotated, inhaled position of the pelvis, which is early lay propulsion, they don't have enough force producing capabilities under those circumstances. And the pelvis is oriented as such that it's going to create this deviation into a more abducted or externally rotated position. So you can see this on the front knee. So you'll see the front knee deviate outward or you'll see the back knee deviate outward. A lot of these people will complain about anterior knee pain, whether it be the back leg or the front leg. So I do have a video that's up on YouTube and Instagram in regard to a split stance strategy to alleviate the pain on the backside knee. It's the same problem whether it be front knee or back knee. I just wanted to give a very specific representation because a lot of people complain about the stress on the back knee but it's an orientation problem and so what you need to do under those circumstances is learn how to recapture the propulsive position. So now I would direct you towards videos that I have posted up on YouTube that are designed to recapture hip internal rotation because if you can capture this internal rotation, you'll capture the propulsive position. One, you'll be able to maintain your position and orientation as you move through the lunge. And then secondly, you'll probably alleviate a lot of knee pain and you'll be able to increase load. So if your goal is hypertrophy, force production, strength, you'll have a much greater level of success with that.

I have NeuroCoffee in hand. And it is perfect. Outstanding. Another tremendously busy day. So this is really good. The clinic is starting to pick up again, which is great. Able to help a lot of people that have been sort of sequestered as we all have been. So this is really good. I got a great question on the Q&A. It's stuff that we haven't talked about in a while. So I was kind of excited about this. And so the question came from Rick and Rick says, I'm having trouble helping my neck patients. I've used a number of techniques with good success, but not great success. I'm getting close to restoring full ranges of motion and also helping patients with pain relief. But I feel like I'm missing something. Do you have any thoughts or ideas that can help me clean up the leftovers when you know there's more change available? Quite possibly. So there's a lot of resources out there on the cervical spine and a lot of the fine mechanics and such and that can drive you relatively crazy because it does seem like this really really complex area. So let's really try to simplify this. There's a couple of things that stand out in the cervical spine, especially the lower cervical spine. So a lot of times when we're restoring neck range of motion, the upper cervical spine actually is fairly easy to restore in many cases. And so a lot of people to do manual therapy get really, really good responses. But then when it comes time and you're checking those end ranges and you still have that little bit of pressure or pain at end range and they don't quite have this full comfortable range of motion, there's a couple of things and a couple of tells that will let you know where you need to go. So let me grab my little skeleton guy here. So we're going to talk about a little bit of dorsal rostrum on lower cervical spine. So the shape of the facets in the lower cervical spine are not the same shape as they are higher up. So the facets in the lower cervical spine are kind of dome shaped, which means that you need to restore lower cervical flexion, if you will, if we're thinking old school, it'd be flexion, to create rotation to the ipsilateral side. So if we're looking at the left side of the neck, I need lower cervical flexion to recapture left rotation. Now, there's a combination of factors here to help you restore that motion. And that means I also need dorsal rostral, upper dorsal rostral to be specific, upper dorsal rostral expansion on the same side that I'm trying to turn the neck towards. So if I am restricted in the dorsal rostral area and I'm trying to get the cervical spine to capture that in range rotation, good luck with that if this doesn't expand.

So don't forget that. So how can I tell whether I have that upper dorsal rostral expansion? So now we have to go to your shoulder flexion measure. So near-range shoulder flexion. About the last 60 degrees or so of shoulder flexion on the ipsilateral side demands that you have this upper dorsal rostral expansion. So if I have somebody that comes in with a neck complaint and I'm not attending to this shoulder flexion measure, I might be missing something. So put them on the table. If you don't have near-range shoulder flexion, then chances are you don't have near-range lower cervical rotation to the ipsilateral side. Let's just say that it looks like you do have shoulder flexion when they still can't turn their head to end range rotation to that side and you've checked out upper cervical. Upper cervical looks great. You take lower cervical out of the equation, you check it, you say, well, I've got 45 degrees of upper cervical rotation. And it looks like I've got full shoulder flexion. Go to the ipsilateral hip. Check the ipsilateral hip because the mechanics in the sacrum and the lumbar spine interact exactly the same way as the dorsal rostral and the cervical spine do. And so under almost every case, you will have sort of this mirror relationship between the pelvis and the thorax that will help you identify whether you do have this dorsal rostral limitation, even if it appears that you have shoulder flexion for whatever reason, because there might be a table orientation of the thorax that makes it look like you have full shoulder flexion. But I would go down and I would check the ipsilateral hip's conformity. So here you go. So for the cervical spine, you've got a shoulder conformity and you've got a hip conformity that will help guide you as to whether you're recapturing this full rotational capabilities of the lower cervical spine. So Rick, I hope that helps you. It guides you a little and helps you clean up the rest of this stuff.

And it might feel good for a little while. You might gain motion for a little while, but it never stays because the tissues will always go back. It's like a stretcher arm strong, you know what I'm talking about? So stretcher arm strong is viscoelastic. So I pull on him and his arms get really, really long and I sit him down and he goes like that. They teach levers in school. That's how we move because people see on a cadaver, they see pulleys and ropes and levers. Dead guys do have levers. Live humans don't, right? So if we use that model as a representation of how we move and then that's how you're trying to apply it, you'll be successful on some level because you're moving in the right directions under some circumstances, but then the model will top out when you start to recognize like, oh, this isn't the lever.

Day three. It's coming back for Halloween now. Oh, yeah? I'm going full dodgeball. Just in terms of from a conceptual standpoint, in terms of building out my model as a coach, something that I struggle to do. In application, it's fine. Once I've got the context of an individual, it becomes so much easier to kind of explain and conceptualize and talk about my model when I've got an individual with whom to apply it to. What I really struggle to do is to do that when I don't have the context of an individual with which to apply it to. And I'm also finding that when I run up against something that I haven't come across before, obviously my model, I'm reaching the boundaries of my model and the limitations of it. What have you found most useful in terms of, because I'm super visual, so I really like graphical representations of things. I'd just be interested to know what your experience have been in terms of developing those models and if you've found anything useful in terms of graphical representations of them.

Day three? Day three. Because you know he's back to work. You know how you can tell, right? The staff is going on. Yeah. It's coming back for Halloween now. Oh, yeah? I'm going full dodgeball. Just in terms of from a conceptual standpoint, in terms of building out my model as a coach, something that I struggle to do. In application, it's fine. Once I've got the context of an individual, it becomes so much easier to kind of explain and conceptualize and talk about my model when I've got an individual with whom to apply it to. What I really struggle to do is to do that when I don't have the context of an individual with which to apply it to. And I'm also finding that when I run up against something that I haven't come across before, obviously my model, I'm reaching the boundaries of my model and the limitations of it. What have you found most useful in terms of, because I'm super visual, so I really like graphical representations of things. I'd just be interested to know what your experience have been in terms of developing those models and if you've found anything useful in terms of graphical representations of them. Yeah. Have you ever drawn it out? Have you ever drawn out your model? Yeah.

It's coming back for Halloween now. Oh, yeah? I'm going full dodgeball. Just in terms of from a conceptual standpoint, in terms of building out my model as a coach, something that I struggle to do. In application, it's fine. Once I've got the context of an individual, it becomes so much easier to kind of explain and conceptualize and talk about my model when I've got an individual with whom to apply it to. What I really struggle to do is to do that when I don't have the context of an individual with which to apply it to. And I'm also finding that when I run up against something that I haven't come across before, obviously my model, I'm reaching the boundaries of my model and the limitations of it. What have you found most useful in terms of, because I'm super visual, so I really like graphical representations of things. I'd just be interested to know what your experience have been in terms of developing those models and if you've found anything useful in terms of graphical representations of them.

Yeah. Have you ever drawn it out? Have you ever drawn out your model?

Yeah. Have you ever drawn it out? Have you ever drawn out your model?

Okay, so that's huge, first and foremost, because rather than having something that ruminates and spins around in your head all day long, getting it down on paper is gigantic step one. Then it becomes real, and you start to see your piece of paper grow, realizing you have all this stuff to account for. There's nothing wrong with that. Step two is: you say you do it fine when you have a person in context. Why does it have to be a real person? You've had enough experience with people that you could come up with eight to ten examples and run them through your visual model. That helps you fill the gaps. You'll think: 'This person represented this. Under these circumstances, here's my expectation. Here's what I know from an intervention standpoint, what happened.' Then you start to see the probabilities. The why question is always the most important one, because it leads you toward more information and more questions. The why question is what gets started. People ask me how to learn to question this, and the answer is: ask why, then don't be satisfied with the current answer. Questions are infinitely more valuable than answers. Answers are true.

I like that Feynman quote of, I'd rather have questions that can't be answered than answers that can't be questioned.

Isn't he awesome?

Yeah.

Yeah. We really missed out. We didn't take advantage of him while he was around, I think. So think about this for just a second. It's like, what question do you not get answered when you type it into Google? I mean, it's that simple. But you have to ask a really good question to get really good answers back. So it's the quality of the questions. It's the intention of the questions that matters now. It's not about information. And Steve Bond, we always talk about education when you're on for some reason, because I think you're my connection to that. It's like, it's the questions that matter. Answers are easy. Kids, if a kid's got one of them, he's the smartest kid in the room, when it comes to an answer, but if he's not asking good questions, he's lost, right? Yes, sir. Yeah, it always comes down to the questions. That's where people are lacking now, right? The quantity of information is not a problem at all, at all. People should not be buying information. It's free. Okay, you ever get a pump? Like the yoke pump, Yeah, like, I'm not talking about the pomp. He's the happiest guy in the world, right? Remember that one? Sorry, Washington. If you don't know what I'm talking about, if you don't know about that movie scene from Pumping Iron, you really shouldn't be on this call. Good morning. Happy Friday. I have neuro coffee in hand and It is perfect. Wow, Dr. Mike, well done. Wow, great fight. It's been a great week. The clinic was busy this week, so a lot of fun there. And then got a lot done, talked to a lot of good people. So I'm having a blast. I'm taking this opportunity with the weird schedules and stuff to actually stay in touch with a lot of good people, a lot of smart people too. So I'm having fun. Today's Q&A's a little bit different. So I'm gonna start here, we're gonna do a little intro thingy that I'm doing right now. And I need a better representative model so I gotta run over to the purple room and shoot the rest of this. The thing that we're gonna talk about today is respecting the initial conditions of how someone presents in regards to table tests because I had a bunch of questions that came through in regards to interpretation of table tests. We had a thing that happened in the intensive group That was a question came up where we had a symmetrical measure that was not symmetrical. And so we're going to talk about that today, which is actually kind of a cool thing to understand because I think a lot of people misinterpret some tests. When they see equivalent measures on both sides of the body, they're making an assumption that the same thing is happening and it's not. So with that in mind, I'm gonna cut away.

We're going to the purple room. Have a great Friday. I will see you guys later. There will be some stuff coming up. The podcast will be up this weekend. Things like that. Instagram will be busy as usual. And then please send questions to askbillhartman at gmail.com. Or post them up on Instagram. I will see you guys at the purple room in just a sec. So I got a question from Jennifer, and then we had a situation that came up in the Intensive Facebook group that I thought would be a really good Q&A to answer here in the purple room. And I'm going to use Alfred here as our model, which he is. He is a representative model of a skeleton. And one of the assumptions I think that confounds people, especially when they're doing table tests and we have the constraint of the table, is not getting an idea of what this initial representation is. Some people, and I think this is one of those situations where when you first come out of physical therapy school or however you've been educated, is that we're taught this dead guy anatomical position in the assumption is that when you lay in the table, that's the position I'm actually starting in. And it's not even close to that representation. I'm going to use Alfred sort of to demonstrate this. And so one of the things that I want you to recognize is that, yes, the table provides this constraint to measure against. But as someone is laying on the table, we cannot make the assumption that they're in some magical position where everything is even. And we have this equal starting point. So I can do something as simple as turning Alfred's head, and if you look down at his feet or at his legs, I'm actually changing his leg length just by turning his head. And obviously you can see that I move the thorax and the shoulders a whole lot more because they're a little bit closer to the head, but I'm even manipulating his leg length and foot position just by changing the orientation of his head. So right away, just consider the fact that if I have a patient or a client laying on the table and I'm making the assumption that this is somehow even, if they have their head turned slightly, just to one side, I've immediately changed the starting conditions for all of my tests. This is why getting a full chest board, a full measurement of orientations and positions helps you determine what the next intervention should be. So now let's talk about a specific test like the straight leg raise and how this situation of the initial conditions can influence your interpretation of the test. So if I measure a straight leg raise test, and let's just say that Alfred has about 70 to 80 degrees here, and I raise this leg, and I get 70 to 80 degrees here, if my assumption is that he's somehow magically laying on the table in this perfectly even dead guy anatomical position, I would have to say that well both hips are showing me the exact same measure. So my assumption is that orientation positions, muscle activity is equal on both sides. However, I can't make that assumption because I can't rely on that one singular test. One is a representation of position. So all I would have to do is tilt his pelvis on an oblique axis, and I've changed the initial conditions. So I've reoriented both of the acetabulum, both of the hip sockets have changed position. Now when I raise up this leg to 70 degrees, I have a totally different orientation of the hip than I have on this side to get the 70 to 80 degrees. So if this hip is already beginning in a more flexed position because the orientation of the pelvis started in hip flexion, if they end in the same place, I actually have more hip flexion on this side than I had on this side. So to make the assumption that both sides are equal, my intervention may fail simply because my interpretation was wrong to begin with. So I have to take into consider these initial conditions. How do you do this? Well, that's why we measure all the other movements and then we create a three-dimensional or four-dimensional picture in our head as to what the orientation of the body is in space. Then we can be a little bit more secure in our decision-making in regard to the interventions that we'll choose because we've narrowed the probabilities of what's actually going on. We can't have a faulty assumption that everybody's starting from this ideal position like we learned in school because that really doesn't exist. And so again, take into consideration initial starting conditions and then the representation of the end conditions and that's going to allow you to determine where things are in space, narrow down your probabilities and your interventions will be much more successful.

So if I measure a straight leg raise test, and let's just say that Alfred has about 70 to 80 degrees here, and I raise this leg, and I get 70 to 80 degrees here. If my assumption is that he's somehow magically laying on the table in this perfectly even dead guy anatomical position, I would have to say that, well, both hips are showing me the exact same measure. So my assumption is that orientation positions and muscle activity are equal on both sides. However, I can't make that assumption because I can't rely on that one singular test. One is a representation of position. So all I would have to do is tilt his pelvis on an oblique axis, and I've changed the initial conditions. I've reoriented both of the acetabulum; both of the hip sockets have changed position. Now when I raise up this leg to 70 degrees, I have a totally different orientation of the hip than I have on this side to get the 70 to 80 degrees. So if this hip is already beginning in a more flexed position because the orientation of the pelvis started in hip flexion, and they end in the same place, I actually have more hip flexion on this side than I had on this side. So to make the assumption that both sides are equal, my intervention may fail simply because my interpretation was wrong to begin with. So I have to take into consideration these initial conditions. How do you do this? Well, that's why we measure all the other movements and then we create a three-dimensional or four-dimensional picture in our head as to what the orientation of the body is in space. Then we can be a little bit more secure in our decision-making in regard to the interventions that we'll choose, because we've narrowed the probabilities of what's actually going on. We can't have a faulty assumption that everybody's starting from this ideal position like we learned in school, because that really doesn't exist. And again, take into consideration the initial starting conditions and the representation of the end conditions, and that's going to allow you to determine where things are in space, narrow down your probabilities, and your interventions will be much more successful.