Regarding a heel raising strategy during squatting, in this case not using a heel lift, but seeing someone's heels lift when they descend into a squat or a jump. I've seen this commonly in children and adolescents and more recently in some adults. Is this an example of individuals who cannot delay the max propulsive moment and need to better control the early to mid stance phase? Alex, you are on point on this one. Yes, every time we see these heels elevate, like when you're watching a squat or even when you're watching someone walk, you'll see the early heel lift. What you have is somebody that cannot create this yielding strategy posteriorly that is the requirement of lowering the center of gravity or delaying the propulsive phase so we can get the tibia over the foot as we're walking. Now, here's what I would also offer you, Alex, is that under most circumstances, squatting requires a much more significant yielding strategy than gait does. So they are probably achieving some form of max propulsion during gait, but they're going to acquire it somewhere else. It's not going to be in the foot, as you have so well identified. Chances are they're going to do it somewhere else. When we talk about max propulsion, we need relative motions to capture the position for max propulsion. So some people are going to try to do that in different places if they can't move through their typical external rotation to internal rotation to external rotation strategies. And so some people will try to do it through their big toe and so we call that a hallux valgus. Some people will try to do it through their knee and so we call that a knee valgus. Some people will try to reorient the pelvis. So when I see somebody with an anterior orientation of the pelvis, what that is is the pelvis moving up over the femur. I want the acetabulum such that it's a substitution for the lack of internal rotation that I need to achieve this max-propulsive strategy. So like I said, so they are achieving it somewhere. Now, let's suppose I do have these compressive strategies posteriorly, where they're going to shove my center of gravity forward.

So in many cases, I'm going to need a strategy in the ankle and the foot that keeps me from tipping over forward. And so this is where you're going to see some concentric overcoming activity in the musculature, especially down in the foot and the ankle that are going to prevent me from coming forward. So a lot of times this is what you're also going to see. So this is why the heels come up when they walk. This is why the heels come up when they squat. But this is also one of the reasons why the heels elevated stuff in the gym kind of works. So if I give you a representation of the foot, so if we have an early foot, we're going to have a tibia that's going to be in relative external rotation. I'm going to have an arch that's up rather high and I'm going to have a toe on the ground. So I get this really, really high arch. Well, if that arch stays up, because this is a center of gravity issue, I can't translate the tibia over the foot because to do that the arch has to go down. And so I have this arch that comes up. So my alternative strategy then is if I just elevate if I elevate the heel, so this would be where the foot would rest, if I drop the toes down and keep the heel elevated, I've essentially dropped the arch out of the way. And so now I can actually translate my tibia forward. So now I can capture the yielding strategy at the beginning of the movement. So if I was doing the heels elevated squat or some form of split squat with heels elevated, what I've done is I've allowed myself to reduce the overcoming element of this concentric strategy posteriorly. I've created a yielding strategy, which is the expansion, which is the delay that I needed to acquire to allow this tibia to translate over. And so again, that's why we start with heels elevated under these circumstances. So the people are telling you exactly what they need. I don't need to throw people on the table and measure. I just need to understand the representation that I'm seeing. So from here, once I have this yielding strategy captured, whether I have to adapt it with the heels elevated, then I got to start thinking training strategies. So again, I have to promote the reduction of the anterior orientations that are thrown the center of gravity forward. I have to overcome the compressive strategies that are limiting my anterior posterior expansion because if I don't have posterior expansion, I don't have a yielding strategy to help me delay this max propulsion like I need to. So again, you go from heels elevated to a front foot elevated and then teach them to translate the tibia over the foot with a reduced load.

So now I can start to capture these relative motions from the ground up. And then I eventually progress to increasing the load over the front foot if you will. to allow them to learn how to maintain their ability to capture these relative motions under heavier loads, higher forces, etc.

So we have the medial epicondyle along with the rest of the elbow structure making this nice squared off cubital tunnel that allows the ulnar nerve to move through its normal groove. But if we have something that would change the shape of that tunnel, and I think that we do, then we're going to have the ability of this ulnar nerve to move a little bit differently. So rather than having this nice squared off shape, what we end up having is it becomes more of like a half moon kind of a shape or a little bit more curve, which allows the ulnar nerve to slide up and out of the cubital tunnel as we flex the elbow. So these symptoms typically show up around 90 degrees of elbow flexion, which is where we put a lot of tension on the ulnar nerve. So the ulnar nerve has to bend around the elbow at this 90 degree point. And if it doesn't have this squared off rigid tunnel to hold it in place, it's just going to slide up and out. And that's basically what happens.

Distal to proximal because I have to pronate my hand in many cases, such as when keyboarding. A lot of times we relate this to baseball, which is a really good representation because when I throw and release the ball, I actually have to pronate my hand and distal forearm. So I get a lot of pronation coming from distal to proximal. Approximately, I'm trying to externally rotate and supinate distally, but I'm trying to pronate. So I get this perfect storm of twist, which keeps tension on that pronator teres, which pulls the medial epicondyle. Again, we get that shape change at the medial elbow. What this ends up looking like is that people will get accused of having an increased valgus elbow. It's not a valgus; it's a twist. Go back to the valgus elbow video from a while back and you'll get that explanation. They'll get accused of having hyperextension of the elbow. It's not hyperextension; again, it's the twist at the elbow that's associated with the concentric orientation in that posterior-lateral aspect. So now we actually have a representation of what we're looking at.

We can move to oblique sit variations with elbow extended and start to work on some of this internal rotation, recapturing normal pronation of the forearm to reduce the proximal supination element. We can start to do that. We're going to move down to side plank variations. I'm starting first elbow extended and then again going down to elbow flexed with normal pronation. What I may also have to do is I may have to reduce the pronation influence that's coming distal to proximal. So I'm going to pad up my hand if I'm doing this in elbow flexion. So I got a shoulder and internal rotation. I've got normal pronation in the forearm but I'm going to block the hand so I don't get that distal to proximal influence. From there, we can move on to more dynamic activities, but we always have to respect the orientation of the shoulder, the position of the elbow, and then what the hand is driving from distal to proximal. So if we're going to do any form of elbow extension activities, we'll do an internal rotation, pronation with a limited amount of wrist deviation. So we want to keep this orientation of the hand to the wrist relatively fixed, so we're not driving, again, the distal to proximal element of pronation. Steve, and I hope that gives you at least a place to start, a little bit more understanding of what I think is going on with this situation. Again, let's not blame the owner for this. Let's look at the orientations, look at the shape change, because the owner is just following along where everybody's given it a new path.

It's the only ones we got. Let's leave the other stuff out of it. It's just confusing at this point. And so as we move through our space on Earth here and we're dealing with the load of gravity, there are forces that we have to apply upward against gravity to hold our positions to move heavy things and such. And so under those circumstances, what we have to do is we have to capture the propulsive strategy. And at some point in time, the forces ramp up. So we would call that max propulsion under certain circumstances. And the forces are variable depending on what we're doing. If we're just walking, the max propulsion is going to be a certain level of force. If we're running, it's a little bit different. If we're lifting heavy things, it's going to be a little different. But the point being is that we have to be able to capture a position that allows us to apply this upward force. That's going to be done with sufficient relative internal rotation and exhalation strategy and compression. And so that always goes along with that upward force. So when we're dealing with impingement issues, what we have done is we've created a resultant that does not allow us to distribute this force sufficiently throughout our entire system and so now we're going to use a focal strategy, a focal compressive strategy to apply this maximum propulsion depending on what activity that we're going to do. And so it's a quest, if you will, to sort of acquire sufficient internal rotation and compression to maintain our position or do whatever activity that we're doing.

I might be orienting my pelvis to such a degree that now I get focal load in the facet joints of the lumbar spine. So once again, all we're trying to do is acquire a position that allows us to apply sufficient force to hold our positions and allow us to move through space. So if we understand that this is the issue, then what is the solution? So this is why we talk about the importance of normalizing breathing, because what normalizing breathing represents is our ability to move through full excursions of internal and external rotation, which is representative of the relative motions of every segment of our body. And if we have that relative motion available to us, or we have sufficient adaptability available to us then we distribute the forces rather than creating these focal loads of impingement. So it'd be really nice if we had like this hip impingement cookbook or we had a low back impingement cookbook or we had a sub-occipital impingement cookbook But really it just goes back to understanding what these representations are. So this is why we're looking to measure internal and external rotations. This is why we're looking to identify where the compressive strategies are. They're always exhalation strategies. We identify where these compression strategies are that are limiting our ability to recapture the relative motion. So the solution at the bottom line is we have to normalize breathing to whatever degree that we need to to acquire sufficient adaptability in the system to distribute forces rather than creating these focal loads. So once again, this is going to be an n equals one situation. And in many cases, there are similarities certainly between my wide and my narrow archetypes. But in general, the rules are the same. We're trying to acquire a substitution for the lack of relative motion, typically trying to utilize an internal rotation strategy, exhalation based strategy and compressive based strategy that is creating the focal load.

I had a friend text me just the other day, kind of asking a question about something she's seen with one of her clients. And I was kind of intrigued by it as well. She's talking about an individual that she has that is extremely wide ISA and appears to be stuck in posterior tilt. It's like this is her, this is her. What she's seeing so far. She's unsure if she's actually seeing posterior tilt or just so compressed on the backside that the hips are being pushed forward and still stuck in neutral or even anterior tilt, but getting motion other places. So she's trying to figure out how to assess to get back to figure out where he really is, I guess.

Well, step one is kind of figure out where you are, right? So in most cases, it'll be very difficult for somebody who is legitimately a wide interpersonal angle, so that very horizontal helical angles. It's very difficult to create what you would consider any kind of posterior orientation of the pelvis. The amount of bending that would be required would be very, very difficult. But a lot of times you'll see these wide people and they will just be flat as a pancake across the backside, especially in the pelvis. And so it's not the sway that you would typically see with the pelvis with the narrows because the orientation of the sacrum doesn't allow it. So I would have a nutated sacrum. And so to have what would look like the traditional sway back where you have the pelvis is swayed underneath and they're almost standing in hip extension, you'd have to have a counter-nutrient sacrum to acquire that kind of appearance. And so in most cases, they're pushed, like what I describe it as they're just pushed straight through between the two femurs. And so it becomes this really aggressive kind of an external rotation. So, if I'm starting wide like that, and then I compress that. And this is, you see how the sacrum moves as a unit here, Matt? Under these hard compressive circumstances with the Y, it does not orient as such. It literally just bends. So from here down, the sacrum bends underneath. And I have MRIs and functional MRIs that actually show this. Um, and it's pretty hardcore. Like you get like a 90 degree angle, you know bent through the sacrum. Um, so again, there's a lot of compression here. And so where, where we'd have a narrow, there would be counter-neutrated and they look like they kind of just sway under like, so these wide people kind of push straight through like that. Right. Okay. And so, um, they it's like how does a wide person get so externally rotated and this is how they just get so compressed posteriorly they get pushed forward and then um what happens if you get this this ER orientation all the way down to the ground and so these are the people that they're on the outside edge of their foot there they'll have an inverted um calcinius they'll have an inverted look to their calcinius they may be bowed you know and so um all you gotta do is look at it at a really really good powerlifter with a really really strong sumo deadlift and you'll see kind of the same orientation yeah she said she mentioned that he was he was pretty duck-footed like like feet thrown out and then like so i like i

And well, I should just make Austin talk about this when we talked about this yesterday, because he had the same scenario, I believe. Am I correct? Yes, sir. Yeah.

In most cases, it will be very difficult for somebody who is legitimately a wide interacetabular angle, so very horizontal acetabular angles, to create what you would consider any kind of posterior orientation of the pelvis. The amount of bending that would be required would be very, very difficult. But a lot of times you'll see these wide people and they will just be flat as a pancake across the backside, especially in the pelvis. And so it's not the sway that you would typically see with the pelvis with the narrow ISA because the orientation of the sacrum doesn't allow it. So I would have a nutated sacrum. And so to have what would look like the traditional sway back where you have the pelvis swayed underneath and they're almost standing in hip extension, you'd have to have a counter-nutated sacrum to acquire that kind of appearance. And so in most cases, they're pushed, like I describe it as, they're just pushed straight through between the two femurs. And so it becomes this really aggressive kind of internal rotation. So, if I'm starting wide like that, and then I compress that—this is, you see how the sacrum moves as a unit here, Matt? Under these hard compressive circumstances with the ISA, it does not orient as such. It literally just bends. So from here down, the sacrum bends underneath. And I have MRIs and functional MRIs that actually show this. And it's pretty hardcore. Like you get like a 90-degree angle bent through the sacrum. So again, there's a lot of compression here. And so where we'd have a narrow ISA, there would be counter-nutated and they look like they kind of just sway under like this. So these wide people kind of push straight through like that. Right. Okay. And so, how does a wide person get so externally rotated? This is how they just get so compressed posteriorly, they get pushed forward, and then what happens if you get this ER orientation all the way down to the ground? So these are the people that they're on the outside edge of their foot. There'll be an inverted calcaneus, they'll have an inverted look to their calcaneus, they may be bowed. And so all you gotta do is look at a really good powerlifter with a really strong sumo deadlift and you'll see kind of the same orientation. Yeah, she mentioned that he was pretty duck-footed like feet thrown out, and then—

I asked her that and then I was saying, Hey, what does this toe touch look like to kind of make sure that like where if he's actually posteriorly tilted or if he's in the position that you were describing.

So, because of all the concentric activity that you've got on the backside, it's like these are the people that they won't even approach 90 degrees. Very, very limited. You'll try to move them through like a traditional measurement of hip flexion and somewhere around 60, 70 degrees, the knee's going to deviate laterally because there's so much compression on the backside of the pelvis. And they'll be the same orientation in the thorax. Side-lying is very useful because somebody that's this compressed goes from that shape to that shape. And so you need some form of lateral compression and there's no muscles that do that. And so that's a nice easy way to initiate some of the anterior-posterior compression. You just use gravity to your advantage to help you spread out front to back.

So as you compress that backside and synovial fluid starts to fill the front portion of the joint capsule, would as that gradient gets harder and harder or bigger and bigger, does it get harder and harder to then pull back all the synovial fluid?

So actually this is a really good question. The thing you want to try to recognize here though is that if I have this posterior lower compression, I already have a scenario where I've got the anterior compression already in play. And so now what happens? So think about pushing the femur straight into the acetabulum and getting this uniform distribution of synovial fluid around the joint. And what that means is it becomes very, very stable. So I'm driving it straight into the acetabulum. So it's not a matter of shifting synovial fluid into your posterior. It's all the way around the joint. And so under those circumstances, it doesn't move. I have ER or IR. Because if I had a gradient, I would have motion in one direction or the other, right? There is no gradient anymore. That's what happens under these circumstances. They get so compressed. And the acetabulum, because of the compressive strategy that's anterior and posterior, the acetabulum starts to face a little bit more sideways.

And literally you just drive the femur right into the hip socket. I don't have any of this. I just have straight in, like I'm just squeezing it into the joint.

You're saying usually that person who's super posteriorly compressed is also compressed anteriorly. What is the reason for that? I'm thinking like, if you're pushing somebody so far anteriorly, you kind of need a new muscular strategy to be able to keep the femur from going so far anteriorly. Is that where the, so it's like, almost like a co-contraction type strategy.

So if you want to call that co-contraction, I'm totally cool with that because you've got stuff going on anteriorly and posteriorly. You're more likely to get the posterior compression to be towards the base of the sacrum, which pushes you forward. And so I don't fall on my face, I got to push back with the front side. And then my last strategy is to bend the sacrum down and underneath to kind of squeeze everything together. And now I don't go forward or back. I'm just stuck in the middle. And so you get your waddlers, your people that waddle when they walk. They look wide too. I mean, they've got the wide pelvis, they'll have the wide thorax, et cetera, et cetera. And so the reason that they waddle is because they no longer have any turn.

With the split squat, we can take this foot and tibia through the entire propulsive phase. However, people are biased at one end of the propulsive spectrum—either early or late. I can manipulate the split squat to recapture the opposing strategy or the one they may be deficient in. The key advantage is that the front foot is never fully loaded. Research shows that in a standard split squat with both feet on the ground, the weight distribution is slightly forward, with about 55% on the front foot and 45% on the rear. Elevating the rear foot on a bench can shift this to about 85% maximum front foot load, but the load fluctuates throughout the movement. This allows me to gradually introduce load through the front foot while achieving the goal of moving the tibia through its full excursion. If the front foot is elevated on a box, the load shifts even more posteriorly, moving the center of gravity backward. Both heel elevation and full foot elevation bias the foot toward an early propulsive phase, but the difference lies in how much load is placed on the front foot and how much tibial excursion occurs. With heel elevation, the bias toward an early propulsive strategy prevents reaching the end position of propulsion.

This allows me to maintain a more posteriorly expanded orientation of the pelvis and of the thorax because I'm biasing my foot towards a concentric yielding strategy. So these are for the people that have difficulty with posterior expansion. So another exercise that you may have chosen for this person would be like a heel's elevated goblet squat. So these are people that cannot yield, they cannot delay the propulsive strategy on one side so they're constantly pushing one side forward we want to make sure that we bias that side backwards so we can use a heels elevated version to emphasize that that yielding strategy and hold them back towards this early propulsive strategy. If I want to improve their excursion to move through So I might have somebody that's biased towards this early propulsive strategy. I wanna get them to the end of this propulsive strategy. Now what I'm gonna do is I'm just gonna put their front foot up on a box. I start in early, I've deloaded the foot and then I'm allowing that tibia to translate all the way through. And then it's just a matter of progression. Like I said, I can bring my foot back down to the ground that immediately increases the load and I continue to train this tibial excursion or I continue to try to hold them back. with the heel's elevated version. So, like I said, you can see that there's multiple ways to do this. It's just a matter of understanding that the principles behind it take the same exercise, keep tweaking it. There are other ways that we can manipulate this split squat farther up when we talk about the pelvis, but that's for a later video.