I have a Q&A from Marcus about ankles. Mark says, 'I've seen your videos. We use the foot manipulation to alter ankle and hip range of motion with great interest, but I'm a strength coach, so manipulation is off the table. I have a client with limited right ankle mobility and plantar flexion. He also has limited hip external rotation on both sides, the left more than the right side, and a history of Achilles problems, but those are resolved after wearing a heel lift in his right shoe. Can you offer some strategy to help recapture this plantar flexion?' Okay, so we have a couple of things that are in play here, especially with this history of wearing the heel lift. So let's talk a little bit about how this foot behaves first and foremost, and then we'll superimpose the strategies on top of this. So I do have my foot in hand and I do have a surface to put the foot on. Okay, so the simplified version of the foot: three rockers. Heel rocker, ankle rocker, toe rocker. As I come down to the ground, the foot is in this supinated position. So I'm going to modify this just a little bit to exaggerate it. And so we're going to have tibial external rotation. We're going to have a talus that's resting over the calcaneus as we come down to the ground, which is going to help maintain this arch position now. Here's the little problem that you're running into. So they put this heel lift in your guy's shoe to try to take some tension off of the Achilles. In doing so, they kept him in this early propulsive phase of gait. And so what you didn't get is the normal tibial translation over top of the foot. So he had a heel rocker, but he didn't have all this ankle rocker. So chances are what you didn't get is this normal mid-propulsive foot. So what we should see is subtalar pronation in the closed chain version, if you will, which is going to allow that tibia to move over top of the foot. So if the arch is maintained, I won't be able to get the ankle rocker component of normal gait. And so what we're going to have to do is sort of recreate this gradually. So we've got to think about graded load over this foot to recapture this. So here's something a little counterintuitive.

What we might actually do is start in a heel elevated position because that's where he's comfortable. Then, start to translate the tibia over top of the foot so we can recapture this normal subtalar motion. We put them in a heel elevated position and then slowly bring the tibia over the foot. Think about something as simple as a heel elevated goblet squat, allowing the tibia to translate forward while keeping the posterior foot loaded and allowing the tibia to translate. We're gradually exposing the foot and ankle to this load, which will allow this subtalar motion to occur. Now, a couple of other things you mentioned probably need to occur as well. You mentioned that he's missing some hip external rotation on both sides, left more so than the right. So now what we have here is a left-sided issue that's going to influence the right-sided constraint. He has an anterior orientation of the pelvis on both sides, as indicated by your hip ER measurement. He's left-sided more than right. So you've got a left side of the body that's trying to get ahead of the right side. The left side is winning, and the right side is putting the brakes on. So now he's plantar flexing on the right side to try to slow down his gait because the left side is propelling forward. So we're probably going to have to bring that left side back first. Think about activities that create left posterior expansion to help reorient the pelvis posteriorly and create a left hip shift, recapturing the ability to delay the left propulsive strategy. Once we don't have the demands on the right side that promote this plantar flexion, we can start to drive the right side work. So again, the goblet squat comes into play. The front foot elevated split squat will also allow the tibia to translate forward with a reduced load. We don't want to drive load over the right foot because the strategy is so strong that all you'll do is drive harder into plantar flexion, not recapturing the dorsiflexion you're chasing. So I would work on the left side, create posterior expansion, left hip shift, anything that increases left hip internal rotation to delay the left side, then start to bring the right side forward gradually. You'll have to expose the ankle rocker, so to speak, gradually with load. So again, rear foot elevated activities to start, allowing the tibia to translate over the foot. Then front foot elevated where the foot is flat to start driving the knee over the foot. Finally, bring the foot down to the ground into a normal split squat orientation, allowing the knee to translate over the ankle.

You're going to have to expose them to the ankle rocker, if you will, gradually with load. So again, rear foot elevated activities to start allowing the tibia to translate over the foot, front foot elevated where the foot is flat, start to drive the knee over the foot, and then bring the foot down to the ground into what you would consider your normal split squat orientation once again allowing that knee to translate over the ankle. And I think that you're going to have a great outcome in that regard. But always remember that this is a two-sided issue that you're dealing with. Bring the left side back and then take the right side forward.

Then I love your lateral orientation comment because that's what I think is going on. If we look at the pelvis here and if I shift him straight over to the right, what's going to happen is I'm going to pick up some concentric orientation of the upper portion of the right adductor magnus. So the right adductor magnus, especially in this upper area, has a very strong external rotation element to it. So if I lateralize myself this way, so if I shift straight over to the right, I'm going to pick up concentric orientation there. So it helps me maintain my external rotation because it doesn't limit external rotation, but it's going to limit internal rotation. And because the adductor magnus has a component of what we would consider traditional hip extension, it's also going to limit the hip flexion on that side. So I think that while you're trying to get hip flexion into orientation, you're going to get that compressive strategy on the front. And therefore, that's going to be your client's groin issue, if you will. So we want to think about taking somebody from this sort of right shifted over strategy to a left shifted over strategy. So the reason that this occurs in the first place is you probably got somebody that is in a left late propulsive strategy. And so we want to try to flip flop that, Carmine. So here's what you're going to do. You're probably going to have to put them in a sideline position, especially left sideline and drive right propulsive strategies if you're in a rehab mode. Once you get past that, you start to see the recapturing of normal hip ranges of motion, normal pelvic orientations and full excursion of your breathing strategies, then what I would probably do is take him into the gym and I would start with a shallow parallel stance cable chop to the left. So we're actually going to try to recreate or we're going to try to delay that propulsive strategy on the left and improve the propulsive strategy from the right. There's a couple videos on Instagram that actually utilize that stance probably within the last few weeks. So look back on those and start to apply those. Sled drags to the left, definitely going to create the delay on the left and increase the right propulsive strategy. Staggered stance, high to low cable pressing then comes into play. We're actually going to be pushing backwards on the left, pushing back and to the left with the right side. Half kneeling cable chop, left knee down, going high, right to low left, will also be on the table there. So those are your early gym strategies. Later on, now we can start to impose some more dynamics. So this is where we're going to actually start to increase the load and increase the ability to manage this left propulsive strategy under load so we don't reinforce it so we can overcome it by maintaining the right propulsive strategy.

To overcome this left propulsive strategy under load, we don't reinforce it so we can overcome it by maintaining the right propulsive strategy. The dumbbell loaded left side and split squat comes into play at that point. Split stance one arm kettlebell swings allowing you to shift back and shift out. So you're going to be learning to shift into this position out of this position without it becoming the dominant strategy. Left cross body medicine ball throw so again dynamics turning into that left side using the right propulsive strategy to push me into the left side. Cross connect step ups become very very powerful in this situation because of the the way that you're going to elevate the pelvis on the on the cross connect we're going to also reinforce this right propulsive strategy with the delay on the left Then you're going to move into some more progressive type things. So like A marches, A skips, lateral cutting drills. So whether this is an athlete or not, I would try to work those strategies into this because ultimately you want somebody to be able to control this dynamically. And so we all behave at different loads and speeds. And so you always want to make sure that we're progressing these people to where they can manage these strategies in the higher dynamic type of activities.

So Sandy says, I'm stuck trying to understand how a regular squat, inhale down to yield and exhale up to overcome converts to a competition squat. So she's talking about power lifting, where you set the pelvic position for both yielding and overcoming at the top and hold until the lift is complete. When inhaling at the start to get counter-nutated sacrum, which isn't ideal for overcoming at the bottom, how would you coach that at the pelvis? And she wants me to use the pelvis to demonstrate, so that's going to be kind of easy. But the thing that we need to understand here is that, so Sandy, your interpretation is actually not correct, so you don't have a clear understanding of what we're talking about with the yielding and overcoming because you're looking at yielding as this overarching kind of position thing where you're including the counter-nutation and the ilium public floor and guts etc in this. So what I want you to understand about yielding and overcoming is the yielding and overcoming actions are the distribution of the forces through the connective tissues. We don't want to include the contractile element the musculature in that because that's what's actually going to alter the rate at which the connective tissues are loaded which determines whether we have a yielding or an overcoming strategy. So when I load connective tissues very, very quickly they become very, very stiff and overcoming. When I load them very, very slowly they actually yield and that's where we start to see the expansive capabilities even with situations of concentric orientation of musculature. So a concentric yielding strategy is a constant orientation, so a muscle that is moving into a shorter position, but the connective tissues are allowing the expansion to occur at the same time. And that's how we distribute some of these forces.

If we don't have that expansion downward, you're never going to get into that deep squat. Now let's take this over to powerlifting. Under most circumstances, there are exceptions to the rule, but under most circumstances when we're talking about a powerlifting style squat, we don't want as much eccentric orientation. In fact, we hardly want any at all. We want just enough to get competition depth and then get back up. So the power of the squat is all about staying as close to this maximum concentric orientation as possible. We're going to use a compensatory breathing strategy throughout the entire lift. Because if you think about where you're going to position the bar in a back squat, you're going to try to retract the scapula to a degree. That's going to create upper back compression. So dorsal rostrum is going to be compressed. Upper dorsal rostrum is going to be compressed. You're going to engage the lower posterior rib cage musculatures like lats and things like that. So we're going to try to compress that. You're going to compress everything that you can across the backside of the pelvis to make a very, very stable structure. You're going to use your final compensatory strategy in the lower part of the pelvis where you're going to drive the extra rotation moment. You're going to try to compress this apex of the sacrum. So we want the minimum amount of eccentric orientation to allow us to get into that position, because the minute that you release the concentric orientation to any significant degree, you are going to accelerate towards the ground under maximum loads, which is really not effective, especially in competition, because you tend to not get your white lights under those circumstances. So again, so we're going to actually limit this. So you don't want to go past this, this concept of orientation. So you're set up that you're talking about at the very beginning of the squat. Yes, you're going to charge your thorax with air and then you're going to squeeze the bejesus out of it, cut it off at the throat with a vasalva, right? Because we don't want to, we want to create this incompressible body that we can stack a bunch of weight on top of. And I cannot release that at any significant degree during the lift otherwise I am going to lose my position rather readily and again I'm going to miss my lift. So the breathing that you're talking about in the competition squat is a compensatory strategy all day every day. It's concentric on concentric. And so we're not going to follow the normal mechanics that we would under a normal circumstance when we're talking about a regular, if you will, or a body weight squat, where we have this transition from expansion to compression to expansion. Again, the power lifting squat is compression on compression on compression with the most minimum of eccentric orientation.

That's why the box squat is so popular with power lifters is because it does allow them to capture eccentric orientation at a depth but it's the minimum allowed, and then they learn how to yield throughout the entire system. So all of their connective tissues are providing the yielding strategy to even get into position, which is why we tend to see connective tissue issues with a lot of power lifters. We see a lot of bony changes with a lot of power lifters over time because of the dramatic, compressive strategies that they're utilizing. That affects blood flow to the joints, affects blood flow to the connective tissues. We've got a whole world of hurt in our futures if we don't take care of ourselves. So I hope that clarifies a little bit of the yielding and overcoming strategy. If we're looking at the power lifting style squat at the bottom, you're going to be as nutated as you can, but also compressed underneath. I can't even create the position with my pelvis model because you're going to probably bend the sacrum underneath you to a significant degree. So from a health standpoint, from a power living standpoint, it would behoove you to work on both styles of squat—one squat, obviously for your maximum effort for competition purposes, and the other one to help you maintain some health and mobility. So again, I hope that helps you, Sandy.

Yeah.

Yeah. So I used to watch more. That's how old I am. But, point being is like, literally it's like they may not. They might not like your hairstyle. They may not like your shirt. They, again, it could be anything and they don't even recognize it themselves. But for some reason today, Nikki's not their favorite person. I don't know how that would be possible, but it is probably possible. Okay. But that's not under your control ever. So don't worry about it.

Well, speaking of belief systems, I know we've talked about this before for sure. And we don't really control someone else's belief system, but we certainly do have the potential to influence it to a degree. I mean, what would be some of the ways that we would be able to more usefully influence that to where, you know, we can create some progress or what we would perceive as progress for them.

So everybody's story is based on their perceptions, right? Nobody sees reality; they just see whatever their perceptions provide. So you need to establish rapport to find out what their story is. We do that through subjective questioning and so on to understand their thought process. Then you start there and work toward where you want to take them. They're at point A, you're at point B, and you've got to close the gap. The best way to do that is to move from their story to your story. People walk in with structural reductionist thought processes because that seems reasonable to most. We have a broader perspective influenced by other factors. You have to take them from their current mindset to your broader perspective. The best way to do that is to demonstrate change. People ask, how do you succeed with clients? Find a limitation you can influence. If there is one, influence it favorably and get them to recognize it. For instance, I had a CrossFit competitor in yesterday—top three in her age group, really good. But she couldn't turn to save her life. I had her do rotation interventions she could feel, then we retested. Right away, she smiled and said, 'Now I get it.' While doing the interventions, she was questioning it because she'd rather be lifting heavy or running with a weight vest. She's not used to gentle interventions. We shifted everything in one direction, making her loosey-goosey for the first time in a long time. She felt the difference. Now she's my friend and wants to know what else she can do.

This is a condition that basically it's genetic that reduces the size and total numbers of hemoglobins in the blood that will cause anemia. So she's constantly very vigilant and well, this can be good or bad depending on circumstances. So we try to get it into a more rested state. So her resting heart rate is now around 75 to 85 in the morning. So I figure if we can lower her resting heart rate, that would be a good indication of improving her recovery. So we've been doing some low intensity aerobic protocols but didn't see very much improvement in the resting heart rate. So my question is if it is even possible to lower her resting heart rate or if the condition is a physiological constraint that is very difficult to overcome.

Well, I think that this is a little bit beyond my scope. I'm not a hematologist or anything like that. Is that hematology? Yes. Not really my forte, but I do understand the concept of constraints. And so if we have a limiting factor, a physiological limiting factor, if she doesn't have a normal level of hemoglobin, then the amount of oxygen carrying capacity will be reduced, right? So it stands to reason, it stands to reason that the way that she produces energy is going to be biased towards a shorter-term energy system, which, as you already know, it already ramps up her behavior, one second, very important. So everything's gonna follow suit, right? So, and again, it's like, I don't think you're doing the wrong thing by seeking out those type of strategies, but I think we have to understand what the limitation may be here. Right. But I would also argue that maybe your intensity is not even low enough. So how low an intensity are you, are you training?

It's basically 30 minutes on the bike or very, very low intensity. Are you monitoring nasal breathing?

Are you monitoring?

During not really.

Okay. So here's what I would do. This is just to see; I have no idea what the outcome is going to be. Don't change a thing. Monitor her heart rate and see what she's performing at to understand where she is starting. Then I would start to manipulate that. I would also consider the duration. I don't know if 30 minutes is long enough to even create an adaptation. If it was me, I would probably be trying to follow the same suit that you are in regards to what you're chasing, but I think I would get a heart rate monitor because if you follow some of the standard recommendations, like in Beeru's book on training, where they established the cardiac output development level at 120 to 150 beats per minute, that might even be too hot, especially from an intensity standpoint that she would be able to maintain at whatever level of oxygenation that she has available to her. Again, my question is to find out where she is and then start to manipulate that and see if you can change it. I would also start extending the durations as much as you can because to make some of the changes that are promoted, I think you would need to do that. I don't think 30 minutes is going to cut it. It doesn't matter so much what activity you're using, but involve as much muscle mass as you can. The bike might not be enough muscle mass. Are you doing anything else to promote the reduction in her vigilance, like meditation and things like that?

Yeah, I actually suggested meditation to her, but she didn't do it very consistently.

So are you forcing her to do something she doesn't want to do?

No, no. She wants to change it as well. So I gave her some suggestions, but she is like, she has I don't know, she's not really doing the meditation very consistently.

Okay.

So I gave her some suggestions, but she is not really doing the meditation very consistently.

Well, so that could be part of an issue. Some of the movement-based practices that are kinder and gentler and calmer, you know, that skew towards like some of the simpler yoga stuff or Feldenkrais activities or might be useful rather. So I think there's a lot of approaches that you can add here, but again, I think you're up against the constraint. And so you might have to use multiple avenues to try to address this, but a big one is self-regulation.

I was reading a few days ago where mitochondria is extremely important for helping to regulate shape change at the local level. That was eye-opening to me, just trying to further include aerobic-based work and activities for some people who are now coming off of rehab and trying to generate some gym stuff and even some of the recommendations I might make. This is speculation, but say they have compression in their posterior thorax and those muscles might now potentially have a decrease in mitochondria. If I want to increase mitochondrial density in those areas to help improve that shape change, it's almost like a double-edged sword where now if I'm doing more rowing or pulling-based activities that might close off that area, but it might help facilitate further peripheral adaptation. I'm just thinking how I might mitigate one consequence for the sake of another adaptation.

It's going to come back to intensity of effort. One of the simplest ways to potentially measure how much effort you're using is whether you can breathe through the activity. So if I'm pulling and there's a pause where I'm using an exhalation-based strategy to pull, that's something people do all the time but don't think about. As they're pulling, they hold their breath and breathe hard in between during the recovery element. Again, intensity is going to matter under those circumstances where you're trying to potentially reduce the concentric orientation. This is also another one of those circumstances where it may be a unilateral type of activity versus bilateral. So when we're talking about thoracic shape change versus cellular adaptation, I can create compression on one side and get expansion on the other. Exercise selection might matter, intensity might matter, breathing strategy will matter. But I think that you hit on a really good point that we always need to consider. When you start reading about mitochondria, you realize mitochondria is really kind of good for everything—from brain health to cellular regeneration to shape change at all levels, from cellular to macro. If you're not aerobically fit, you're going to use more concentric orientation, which means you're going to use more short-term energy systems. If you use more short-term energy systems, you're more concentric oriented and you can't move well.

And so if you're a structural reductionist person and you believe in the imaginary planes, then you're going to look at this as a sagittal plane problem that is absolutely wrong. So what we need to recognize is that this is an internal rotation problem. So what hip extension really is, is the ability to internally rotate the hip as you pass your center of mass over the leg during gait or sprinting or during any other form of activity. Your inability to capture this internal rotation then results in a limitation of that joint excursion and then you have all sorts of compensatory strategies that get layered on top of that. And so that step one is to recognize that this is an internal rotation problem. Okay, how do you test it? You can test it in any number of ways. One, you can just look at your hip motion because the hip motion is going to tell you right away. So if I have a loss of total hip excursion, so the hip internal rotation combined is about 100 degrees. So if I have less than 100 degrees of hip ER and IR combined, you're probably going to have an internal rotation deficit, which means you're not going to have what would be termed hip extension. But you can test it in non-weight-bearing situations, like in sidelying. You can do a standing load propulsion test, which is what I teach at the Intensive, which is very, very useful. You can look at things in half kneeling and just kind of eyeball it. You can look at split stance and eyeball it. You can watch sprinting in slow-mo and you'll see the inability to extend the hips. So there's any number of ways that you can identify this. I think you do what you're most comfortable with. The thing that I kind of talk people out of or I try to is the Thomas test. I don't think it's a very good test. I think it's very difficult to control. I don't think it provides a lot of information unless you've got somebody with a ton of anterior orientation where they have like maybe like a minus 30 of what would be traditional hip extension deficit. Because then you can kind of identify those things because it doesn't really matter whether you control the test very well or not. You're going to see this massive deficit. But anytime that there's something that's close or you get somebody that's biased towards an inhalation bias, it's very difficult. It's a very difficult test to take any useful information away. So I talk to people out of that as much as I can. However, I would offer this that if you are questioning whether you have hip extension or not, you reach behind the back test.

The old Apli scratch test will work in this situation because if you can't do that with the upper extremity chance, you're not going to be able to capture the internal rotation position that we're talking about in the lower extremity either. So now we've identified what it actually is. Now how do you train to recapture the quote unquote hip extension? And so what I would say is, the first thing you got to understand is what position actually allows it to occur. And if you can understand that, then the rest is going to be kind of easy. So if we take our pelvis, and so we're talking about motion in this direction. So what we're actually doing is we're going to be inchly rotating to allow the center of mass to pass over the leg. So that's the motion that's going to be occurring. So that's internal rotation. So under those circumstances, what I need to be able to do is I need to be able to eye our the Ilium and create an antiverted position of the acetabulum, which means I need to be able to mutate the sacrum. So those are the conditions that allowed this to occur. And so all we have to do now is be able to identify what our starting conditions are. And then we move you towards that internally rotated Ilium, mutated position of the sacrum concentric pelvic diaphragm, if you will. And that's going to allow us to recapture this internal rotation in the position as we pass the body over the limb.

So if you understand your starting conditions, then it's just a matter of moving you progressively towards that position where you have an internally rotated ilium, an antiverted acetabulum, a nutated sacrum without compensatory strategies, and there you have your hip extension. So rather than trying to force things, rather than trying to blame weakness of a muscle, which is ridiculous because those are positional problems that result in a lack of force production, it's not a weakness of a muscle. Let's stop blaming muscles, let's stop blaming length, and let's start looking at orientation, and then the relative positions that we need to capture that internal rotation so we can step cleanly over that limb or we can sprint with full capability with this full excursion of the pelvis and full excursion of the hip joint. So Brian, again, apologies for not seeing this sooner. I hope this works for you. It at least gets you started. If it doesn't, ask more questions. I appreciate you. Everybody, have a terrific weekend. Have a great Friday and I'll see you next time.