in that early phase of the descent of the squat, and then as you move towards your internal rotation, chances are the squat's going to get a little bit prettier that way because you're not able to access this early phase of external rotation in your descent because you've given it up with your anterior orientation. Now, in addition to that, what you're going to want to start to do is you're going to work on your split stance activities with your front foot, with the front heel elevated as well, because now it's going to keep you in that early phase of that propulsive strategy. Allow the knee to track over the foot as you descend into your split squats, but with the heel elevated again, you're going to start to capture that early phase of your propulsive strategy at your ankle and foot. That's going to allow you to access the external rotation of the hip, and you're going to start to move through this full excursion of the hip. Throw in some Heels Elevated Camperini deadlifts and now you're going to be able to capture some of the internal rotation with that early propulsive foot as well. And eventually dropping that heel back to the ground in your single leg hinge type of activities. So we have this full external rotation, full internal rotation kind of a strategy as you move through your squat.

When we talk about directions and points in space and things, but when we talk about how we produce movement, we only do things in rotations. If we can start to see that, our problem solving becomes spectacularly easy relative to trying to think in all of these multiple directions that just create confusion. Again, I encourage you to think this through a little bit. I know it's confusing because I just took away two things that have been ingrained in your brain as far as how we do move. There's nothing special about those planes; they don't really exist. They are a resultant of the cancellation of rotation. So again, hopefully this is helpful. Alex, if you have any further clarification questions on this one, please ask away at billharmonthegmail.com. If you're angry with me, please send your hate mail directly to me. You can DM me on Instagram or throw this up and be angry on YouTube if you like. I'm totally cool with that because I know it's uncomfortable to think this way. But if we're going to solve problems and if we're going to get better, we've got to start looking at things differently. So think differently. Have a great Monday. I hope you all have a fabulous week to get it rolling. I'll see you tomorrow.

Now, if the pelvis is driving me forward even farther over this extremity and I'm hitting the late propulsive strategy, I maintain the early propulsive strategy, but because I'm moving into a late propulsive foot where I have the loss of relative motion, what's gonna happen, it's gonna start to drag the femur with it, and so now the entire system. So the whole lower extremity is going to start to behave as a single segment, and it's going to drag the femur into ER along with it. So this is where we're going to start to see lateral compartment sensitivity. So the LCL will be sensitive, the Dyslite T-Band will be sensitive and probably produce pain as it pulls against its attachments on the lateral knee. You'll see lateral thigh pain, a lot of sensitivity down the lateral thigh. And so this is the distinguishing characteristic again for medial lateral knee pain, whereas this would be where the tibial femoral ER relative to the femur is going to be medial compartment load in medial knee pain. But if the whole thing starts to move as a system, it's going to move into a more laterally loaded strategy and you get the lateral knee pain. Either way, either way, the goal is going to be to try to restore the relative motion at this segment. So we're going to have to start this from the ground up. The typical places where you're going to want to be able to do that is through that middle range. So we're going to use a lot of knee flexed positions. So again, these are your split stance, half kneeling kind of positions is where you're going to start to recapture these things. So we can utilize that relative motion again.

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.

So it's not as black and white as everybody makes it seem to be. So please, please, please take that into consideration. So thank you, Adam, for your question. Everybody have a great Monday and I will see you tomorrow.

So I hope everybody has a great Monday. I will see you guys tomorrow. It is Tuesday. I have neural coffee in hand and it is perfect. Okay. So yesterday I posted a video about shoulder impingement that's gaining in popularity on YouTube as well. But I got a bunch of comments on that. One of the comments was, hey, could you talk about forward head posture? Because a lot of us are dealing with that. And so I thought it would be a nice little tie into the shoulder. And so we'll just move up a level, so to speak. And we'll start talking about the neck and head position with this forward head. But let's be really, really clear about what we're talking about. So by traditional measures, what we're going to talk about is lower cervical flexion, upper cervical extension. And so the way we would describe this orientation from my perspective is that we've got concentric orientation of musculature on the posterior occiput going to the upper cervical spine. So that's concentric oriented. So if anything below that from C3 on down would be eccentrically oriented. If we turn things around, we look at things from the front, we're gonna use the hyoid bone as our representation of above and below. So below the level of the hyoid bone, we're gonna have concentric orientation of those infrahyoid muscles. And we have eccentric orientation of the musculature above the hyoid that goes to the mandible. The result of all of this is going to be a passive retrusion of the mandible. And these are the people that you're typically going to see excessive amounts of mandibular opening that would often be described as hypermobility. So they might have clicking with opening and closing, but they're also going to obviously see this magnified opening. And so that's a nice way to tell when you've made an adjustment of some sort or an effective change, that you'll see a reduction in this excessive opening. I think that the forward head posture has always been looked at in isolation and so the strategies that have been utilized have been somewhat ineffective because they're trying to do a piece work when this is a relationship problem that is a resultant of all of the things that happen below the head and the neck. So typically what you're gonna see with this traditional forward head posture is this is going to appear most often on people with narrow ISAs that lack the full breathing excursion. So we're gonna treat them as such. So we gotta think about the relationship of the axial skeleton to the neck, to the head, to the mandible when we're talking about how we're going to effectively work in this situation to try to restore as many movement options as possible.

So I don't express these concepts very much, mainly because I don't measure them. I can't tell you where you fall on the autonomic gradient. I can't measure your blood pH in real time to determine what your other physiological needs might be. So again, I just don't discuss these things. What I do measure is movement, and what I do try to influence is movement. So I spend my time basically talking about that. So if we move through compression and expansion, we move through creating a gradient of pressures and volumes, then that's where the discussion should lie for a movement professional like myself. It's like we can discuss all these other cool influences, and by all means, study them to your heart's content. Gain as much depth as you can. I spend time doing that as well, but in the end, I'm a movement guy, and my goal is to create a model that is coherent with the physical laws and to measure the things that I can and influence the things that I can. So Ed, I don't want you to think that I've ever ignored any of those things, but again, I just don't discuss them because it's not a way that I can determine a useful outcome and create the situations that I'm looking to create, in the purple room or wherever I might be, whether I'm maybe in the training hall as well. So hopefully, Ed, that gives you a little bit of an understanding of where I'm coming from. Great question. Glad you asked it. Glad I got to express a couple things. Apologize for rambling; it's usually rather.

I have neuro coffee in hand and it is perfect as usual. Okay. Solid Tuesday coming up. Looking forward to it. Got a great question from Jeremy. Jeremy wants to talk a little bit about shape change associated with movement and how do we identify? Do we have a relative position change? Is it soft tissue? Do we have end-feel situations that can be useful? and I'm going to ramble a little bit probably, but I'm going to try to tie all of this together to give what I believe is a representative model of what is actually going on because there are a lot of things to consider. when we're talking about active range of motion versus passive range of motion and fields, et cetera. Because we have an interaction here of all things. We can't just look at things from this limited scope. And I think that some of the modeling that has been utilized in the past, it misrepresents a lot of things as to how they change as we move. So let me grab the pelvis here. Since you did ask about public shape change. So one thing that we want to we want to always understand is that all movement is shape change The hard models that we use are And the way that they represent movement creates sort of this representation that this whole bone is moving and therefore I get this positional adjustment in the acetabulum and that provides me an element of range of motion when the reality is, is that it is always shape change that is turning this acetabulum. So let me give you a for instance. So if I wanted to access active range of motion in internal rotation, the pelvis has to actually elongate anteriorly to put the acetabulum in that antiverted position to access internal rotation. However, if I'm performing passive range of motion testing on a table on a human on a living breathing human being, I am actually inducing that shape change as I move them into passive motion. So if I have them at say 90 degrees of hip flexion and I'm going to internally rotate that hip, that is me inducing the shape change. So as I push into the acetal and I turn them, I have this interaction of the tissues that surround this hip joint. I have the fluid volume in the hip joint itself that is creating the shape change or promoting the shape change that will allow that pelvis to actually elongate anteriorly, expand anteriorly, and then I can access that inter-orientation. So when I am successfully measuring normal hip inter-orientation, that's what's happening. However, if I have some form of muscle activity on the front side of the pelvis that is promoting a compressive strategy on the front of the pelvis as I move that hip into internal rotation, I still have the same interactions of tissues. I still have the same interactions of the fluid volumes in the joint and within the muscles themselves. but I have a compressive strategy that does not allow the fluid volumes or the tissue behavior that allows me to access that internal rotation. So there becomes the limitation. Each of those limitations is going to promote some form of an end feel. So if I look at viscoelastic tissues and the way that they're loaded, they behave differently under certain circumstances. So, One of the representations that I always use is silica putty because it is viscoelastic in its nature and so it behaves just like viscoelastic tissues do. And so one of the things that we need to represent when we're talking about end fields is that if I pull on viscoelastic tissues very, very slowly, they elongate under my tension. So this would be much like a yielding action that would be associated with some form of active motion. But I can actually produce these yielding actions passively under these circumstances where I load the tissues very gradually. However, if I pull very, very quickly, you'll see that the tissues become very, very stiff. And then it snaps off very, very clean. So we have to understand that certain tissues are loaded at different rates, even when we're moving someone passively, because if I have concentric orientation of musculature, the surrounding connective tissues within a reasonable range of that concentric muscle activity are already loaded. And so as I move them through space, they will behave in a stiffer representation than say something that I was loading it much slower. And I had some eccentric orientation that allowed greater movement to occur. Those tissues might be loaded slower and so I'll get a softer end feel that's associated with that. So I have to understand that I have these interactions. Again, what all this does is allows me to identify, one, what ranges of motion can I access? What strategies do I have that are limiting the shape change of, in this case, the pelvis? And then is there any other influences from a tissue behavior standpoint that might allow me to determine what strategy this individual is using from an eccentric to concentric yielding to overcoming strategy. And so again, so there's a lot of interactions here that I believe are influences in the hip range of motion. But the thing that I want you to understand is that it is always, always a shape change. And then the muscle activities, so the compressive strategies that are superficial create greater stiffness, they limit the fluid shifts. And so that's why we're going to start to see these deficits in passive range of motion because it is me that is inducing the shape change during passive range of motion. It is the individual that has to coordinate the shape change to allow active range of motion. So I think if we had to narrow this down to like the big idea of today's Q&A, is that all motion is shape change. You've got to be able to do it actively and I have to be able to represent it passively to know that I do have that shape change available to me under certain circumstances. So again, moving somebody on the table is not the same as standing up. So now we have a great activity structure to our programming to allow this person to go from Yes, we have a passive representation on the table, but can we create an active representation against gravity? And that's a whole different world, but that's why we train people. That's why we move them through these great activities is to allow them to access the shape changes themselves and hopefully either produce an element of health or performance that they seek. I realized this was kind of like a long drawn out kind of a thing, a little bit of rambling going on, but hopefully I said something that was useful for you. If not, then please ask a question. Send it to askbillharman at gmail.com and I'll see you guys tomorrow.

And that goes for any sport. It goes for any level of activity. Anybody that stands out in anything means that they are able to superimpose something on top of what they are and take advantage of their physical structures. And so we're going to see that no matter what age, just that kids change over time. They tend to be a little bit more adaptable like I said, and so that's why again, we don't need to change the rules. The rules are the same. Just take into consideration what the kids are bringing to the table that some of the older kids or the adults don't have.

Where would you start with someone like this? So this is an extreme case and it's going to give us an opportunity to show how to move somebody out of this and recapture a lot of that full excursion of breathing and movement because this is really an extreme case. This is somebody that is sort of at the end game of the superficial compensatory strategies that I talk about. And so let's create that representation for us. I'm going to grab the pelvis, as I usually do. So if I have a wide ISA and I have limited excursion of breathing, that means that my ISA and my IPA are going to match. So I'm going to have an exhaled position of the pelvis. So the IPA is going to be wide. Now, to get to the position that Jimmy's asking about, under most circumstances, your wide ISA, wide IPA is going to have this mutated sacrum. And so I'm going to have this space posteriorly. So this allows me to be a good hinger and not a great squatter. And I can produce high levels of force. I use a lot of high pressure strategies. And again, so I'm going to typically have this orientation. What Jimmy's describing though, requires that I have this final compressive strategy where I'm actually going to bend the sacrum down. So I'm going to compress this area. And under most of these circumstances, I'm going to lose both internal and external rotations. And so again, that's just layers of superficial compressive strategies on top of the normal archetype that's going to result in that. So I'm going to lose ERs and IRs. So I have very limited excursions available to me to use for activities before I would hit another compensatory strategy. So if I was to take somebody with this posterior compression that Jimmy's asking about, they won't even have 90 degrees of hip flexion available to me unless they want to compensate. So right away I've taken a number of exercises off the table, so to speak, because I can't move them into this position because they just don't have the capacity to do so. But while it is a limiting factor, it also points my programming into a very, very specific direction. And so I'm going to hold up my little graphic here that I drew out for the camera. I have two cameras by the way. So I'm just going to hold it up there until I see it get visualized. So there it's clear in the little camera and then there's one for the big camera. So what I want you to do is go ahead and take a screen capture of that. And again, so you have a representation. So you see the blue square in the middle. Is any direction that we want to go but with limited excursion and then you're going to see the red rectangle is where we're going to try to expand movement first and foremost. Okay, so I want to have a wide ISA and I have this this compressor strategy all the way up and down. For me to try to force a turn under those circumstances is very, very difficult to do. They have limited hip flexion. They have limited hip abduction. They have limited hip extension. And then all their traditional ERs and IR measurements are going to be limited. So I have to stay within this small square of movement. So instead of a split stance type of an activity, I'm going to use a staggered stance. So my feet would be just offset. And then I'm going to drive a number of different reaching patterns or pressing patterns, but I have to use angles that are below shoulder level. So let me give you a for instance on this. So we would have a staggered stance high to low cable press, which would keep the pressing motion below shoulder level. And I'm just offsetting the feet. And so I'm going to gradually move into these turns. Because again, if I try to go too far into a turn, all I'm going to do is create this massive orientation of the whole system, which is not really a turn. It's just changing what direction that I'm facing. And I want to create the ability to actually turn and rotate. So I got my water balloon, so another visual aid today. And so I have somebody that's compressed anterior to posterior. So this is looking down on somebody. And so they're compressed. So if I try to turn them too far, all I do is get this. And that's not really a turn. That's just a reorientation of the entire system. What I want to try to do is I want to try to create compression on one side, expansion on the other side. And if I can do that, with my activities, that's going to actually start to restore my ability to create turns in these people and start to restore the rotations. And so if you go back to the red rectangle, those are going to be activities where I'm going to start to deviate from center outward to the sides. So I'm going to start with lateral stepping. So consider if I was doing conditioning with somebody like this, we'd be doing sideways sled drags, or I'd be doing suitcase carries, because what those activities do is they could create compression on one side, expansion on the other, compression on one side, expansion on the other. And this is how I'm going to start to improve the excursions and restore their ability to turn, because once again, if I try to force this, all I'm going to do is get compensatory strategies. So staggered stances, pressing and pulling below shoulder level, lateral movement. So this is where your side lunges, your side split squats, your low step ups come into play because that's what these people need because they only have a limited excursion in their peripheral joints and so we have to take advantage of what they do have and then slowly progress them out of that. So Jimmy, this is such a great question. If you're in the rehab side of things, these are the people that you're going to want to put into sideline because we take advantage of gravity. So if I put you on your side and you're compressed A to P, what happens is, and you can see in my balloon, so I get I get all the guts falling down towards the bottom and so that creates expansion on one side and compression on the other. So sideline becomes very important. I start to build people up from sideline. So now we're talking about immature oblique sits, mature oblique sits. This would be something that would progress eventually into side planks and such if we're talking about moving into gym activities. So right away you should start to be thinking about how you're going to be able to write this program for somebody like this. It's not difficult to write the program. What is difficult is identifying the representation of what you're looking at first and foremost. And then the program kind of just writes itself because when you understand the needs of this individual, again, it becomes very, very, very easy to write. So hopefully that gives you some guidance, Jimmy. If I didn't answer your question sufficiently, then please do so. Oh, by the way, the asymmetrical ISA element of this. No different than anything else. You just have two different representations. So you have a shape change on one side that is opposed to the other. You're going to follow the same rules that we just talked about. One side's going to be able to go a little bit more into your posterior. One side's going to have to go a little bit more side to side, but the rule still applies. So again, hopefully that answers your question.

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.

I think in general, Jason, your, like I said, your final statement is correct. What we need to do is we need to look at this from the perspective of, hey, we can call a diagnosis anything that you want. We can say that there's pain in this area and never knowing why it would be painful per se. Maybe there's a structural issue that we can sort of narrow things down to where we have some sort of finding on a, on a radiograph or MRI or something like that, that leads us in a direction and maybe we can blame some things on that. But in general, if we don't have any structural abnormalities and people do have pain, we'll just never know why they have pain in the first place. So then the goal is to restore this full movement capability. So can I orient the pelvis? Can I restore the relative motion to the pelvis, which is this full excursion of breathing? And so then I get normal eccentric orientation and concentric orientation of the surrounding musculature in the hip and the groin area. So again, I think that your model might be just a little oversimplified but you've got the right concept in mind. And so again, it's just a matter of restoring this full excursion of breathing restoring the relative motion between the body segments, and that ultimately is the best shot you have at restoring health, comfort, and normal movement capabilities. So Jason, like I said, I think you're on it.

That's why I would tend to start the wider ISAs in a supine position and drive some form of unilateral positioning. With the narrows, with the face down because of the shape of their diaphragm they actually benefit from the load of the guts moving superior and anteriorly. So think about an inverted lazy bear position where I have the knees elevated in quadrupeds so the hips are higher than the shoulders and then I drop them down to the elbow. So now we have head lower than hips and so now we have a much more favorable position for that shape of the diaphragm and for increasing the width of the diameter of the thorax. So that's why we would choose those two strategies. And that's why there's a little bit of difference between the wide ISAs and the narrow ISAs. If you're ever on the fence and you're not sure which way to go, do something. So again, it's always test, intervene, retest and that's going to provide you the guidance. So if you're successful in your intervention, then you can move forward. If it's not successful, then try the opposing strategy because sometimes these things are confusing. Sometimes people are very close to being on the fence, so to speak, as to whether they are predominantly wide or narrow.

And so what happens is that they'll eventually give up the opposing rotation. So we have tibial femoral ER, we have tibial femoral IR. And what we want to make sure is that our athletes have access to both of those, because that would represent our ability to move through a full excursion of knee range of motion. When you perform the traditional knee extension activity, you'll get tibial femoral ER. As you perform the traditional knee flexion, you would get tibial femoral IR. And so to have full knee excursion, we have to have those rotations available to us. So Matt, what I would say is you want to make sure that you can identify whether your athlete has given up one of those elements of tibia femoral rotation. That would be something I would say that would put you at risk because it does compromise the full excursion of knee range of motion. That would be my first priority. Secondly, as they move through their maximum propulsive phase, are they capturing this knee position and then can they reverse it as they push out of it? So at early and late propulsive phases, I want to recapture the tibial femoral position of ER. And as I move through that maximum propulsive phase, I want to make sure I have tibial femoral IR available to me.

Also posted today on Instagram, a little strategy to maintain posterior expansion on the backside for those of you that perform a lot of bilateral symmetrical exercises and are probably biased towards a wide ISA. Very useful strategy as well. Another great self-test is the back to wall flexion test. That's also up on YouTube so you can actually get to see that. If you are limited to such a degree that when you put your fingertips against the wall with the elbow pointing straight ahead and you can't get past 90 degrees of shoulder flexion without the deviation of the elbow outward, then you know that you are compressed below the level of the scapula and you need to go to the most recent Instagram post and get that posterior expansion. where I show you bending over the glute ham to expand the lower posterior ribcage because that's going to be your first step. I would also do the heels elevated bilateral squat under those circumstances to try to reestablish expansion in that area first because if you don't have expansion there you'll never get the pump handle to come up because ultimately we've got to get the pump handle to come up to get the internal rotations to come back. So expand the posterior lower rib cage first, then go after pump handle. The way you go after pump handle is through the unilateral pressing and pulling activities. So make sure you're addressing the reciprocal strategy. And again, when you're trying to create that AP expansion. So hopefully that gives you a little bit. You got a couple of tests. You got the back to wall shoulder flexion test. You got a straight leg raise test that are going to help guide what your priority should be. And then you've got this unilateral reciprocal strategy in regards to your training. So apply those.

They don't associate with other smokers, etc. And that's an extreme example. But what we want to start to look at is, okay, so what's the smallest change that you can make that takes the least amount of effort, which might be, hey, just show up to the gym twice a week. All I need you to do is get here. Right? Start with that. Just show up. Maybe just put on your workout clothes at home and change into those, right? Maybe that's the smallest adjustment that you make. And again, that's sort of like an extreme example, but that is also a potential reality. It's like, what is the least that you could do that is different and doesn't take much effort and is not painful and allows you to recognize that change is possible. We can go as far as asking people certain questions. So what would happen to you if you did make this favorable change? How do you perceive your life to be? And then they start to recognize themselves that, hey, if I make this favorable change, then I'm more likely to be happy, healthy, and successful. We can also reverse gears and we can ask a much more painful question. So if you decide not to make this change, how do you foresee your life to move forward? And again, it's a little bit more painful, but it does provide them a recognition of how their beliefs and their behaviors do influence an outcome. So I think we try to integrate them into a process. Everybody wants to create this lofty goal or these extreme behaviors or make these massive changes. And I think we have to do this incrementally. And so we look saying, where can I make the impact first and foremost on any level? The simplest change to allow them to recognize and change the beliefs that are actually limiting them and promoting the behaviors that are interfering with their progress.

We can take our global expansion-compression strategy that we talked about, which grossly describes movement, and we can move that to the local level when we talk about concentric and eccentric orientation. So let's use the hip example again. If I expand the posterior hip, that's eccentric orientation. If I compress the anterior side, that's concentric orientation. So I take this global representation of expansion and compression and can look at that locally because it's going to be the exact same strategy. The universal principle is when nature finds something that works, it repeats itself, and so this is one of those elements. We could use this as a fractal representation of movement where I'm looking at it at a smaller scale at the joint level and I'm looking at a macro scale when I'm talking about global movement of the body. Then we want to finally talk about the overcoming and yielding action of muscles. What we need to understand is that if I have a concentrically oriented muscle, that position of the muscle—so we're taking a snapshot in time—means that it would be shorter than its resting position if it had full excursion from its full extensibility to full compression. Again, we could think of that as the traditional concentric contraction being a shortening contraction. What I want you to look at it as is a shortened position relative to its middle, wherever that imagined middle may be. So it's behaving in a shortened position. When we talk about eccentric orientation, we're talking about the opposite. Eccentric actually means away from midline. So an eccentric orientation would be a muscle that is positioned longer than its imagined middle, wherever it may be if it has full excursion. So now I can describe two different positions of the muscle. Again, as a snapshot in time, I can describe its length, but now I need to describe what it's trying to do. If it is limiting motion, then I would describe that as an overcoming contraction. That would be a muscle that is attempting to shorten to limit motion in the opposing direction. So if I use my elbow and position myself at 90 degrees of elbow flexion and brace here while trying to pull this way, that would be an overcoming contraction. If I am trying to hold position against the resistance that's trying to move me, that would be yielding. So in both circumstances, the arm doesn't have to move, but my intentional strategy is different. If I was positioned in a lengthened position, that would be an eccentric orientation. If I was trying to shorten it and was being successful or just attempting to shorten it, that's still an overcoming contraction. If I am moving in that direction, yielding contractions allow movement to occur. That means it's giving way and allowing motion to occur. That would be a yielding action.

You will have to increase your ability to utilize an exhalation strategy because that is how we increase our ability to produce force against loads or gravity or whatever it may be in regards to dynamic activities. So you're going to have to determine what key performance indicators you're going to monitor to determine when your compressed exhalation strategy is becoming so predominant that you begin to lose something of importance to you. And so now if we're working with a regular client who is concerned primarily about health will monitor some element of their mobility that would be indicative of when they start to lose that variability that we would associate with health. So we would do the same thing with an athlete if that athlete requires some movement capability to perform their sport. So that's how we know where that ceiling is. Drew, I can't answer that for you. You're going to have to determine what your key performance indicators are that are the most meaningful to you and then monitor those over time. There's not a black and white answer. A lot of people want black and white answers to these things and there just isn't one. Everything is about gray. Everything is about individualization. So if you have any questions about what are the most important KPIs for you then feel free to ask another question because I think this is a really good thread of questioning that a lot of people don't really understand. They just think that everything is good for everything or everything is bad for everything when we're playing a lot with great areas here. So thanks Drew for that question. Figure out what your KPIs are and then we'll go from there.

What you may be dealing with is someone that cannot reorient the knee to allow normal knee flexion to occur. So heel to butt knee flexion is actually a really decent test that you could use to identify whether they're able to reorient the tibia or not. And then you can look at isolated tibial internal rotation, external rotation measures, and you can identify any deficits there. If you do have full heel to butt, but you have limited tibia femoral internal rotation, then you've got some serious eccentric orientation on that posterior medial compartment that's allowing a volumetric expansion on the anterior medial side of the knee to occur, and so you're going to have to address that to sort of untwist the knee if you will, and allow that tibial pyramidal IR to return and restore normal knee mechanics. But Marcos, I think you are absolutely on track with what you're perceiving, assuming you've got confirming tests that give you that information.

And then that's how we decide whether this is a good thing or not so good thing. So thank you for that question. My next question comes from Tyler. Tyler asks, how would you approach working with a patient that was diagnosed with a condition related to central sensitization, such as fibromyalgia or complex regional pain syndrome? Are there any specific compensatory strategies you have found that drive central sensitization? So let me address the second half of that question first. And I'll just give you a big fat no. I don't think that there's necessarily any compensatory strategies that would lead to anything specific in regards to that central adaptation. But as far as any diagnosis, I think we always have to consider the fact that the entire system is always involved. And so with any diagnosis with any situation because the nervous system is involved, I think there's always going to be an element of central sensitization. The question is, is there an adaptation or is there rigidity in the system that may skew the influence in one direction or the other? So when we talk about CRPS, where we know we have most likely some form of immune system influence, we definitely have a central issue, definitely involves the brain. So we have situations under those circumstances where that might be the predominant influence. Now we have to look at a whole different set of strategies from spatial and perceptual strategies or desensitization strategies. In all cases, movement is obviously part of this, but again with something like CRPS where we have such a strong autonomic influence, those are the toughest people to work with. But let me offer you this: if you look at the delayed onset muscle soreness literature, you will see that there is a component of central sensitization under those circumstances. And so when we're working with these people, it again doesn't eliminate any particular strategy that we may use; however, we may have to emphasize different aspects of our treatment repertoire. Where again, with CRPS, maybe we're using a mirror. If we're looking at CRPS, we're looking at graded motor imagery concepts to help us establish new perceptual influences that will hopefully favorably influence those patients. So again, in every case the central nervous system is going to be involved. In every case, all of your sensory systems are going to be involved. In every case, the movement system is going to be involved. The question then becomes is how much of each is representative as the predominating factors, and that comes down to your processes to how you evaluate someone and then how you introduce each element that influences the system. So once again, I hope that this is a really, really good question, but it's a really tough situation to try to influence under certain circumstances. But understand that every system is involved at every time, and that's the important thing to understand.

That's my proxy measure for the entire system. And so that's what I monitor or try to influence. The hope is that whatever element or whatever subsystem within the system is the limiting factor is also addressed by the interventions that apply with the understanding that every sensory input is always an influence. Every movement is always an influence. Breathing is always an influence. And so we have to consider all of those elements to some degree. But I'm limited by my scope of practice. And so again, I have to use my proxy measure as a measurement of all systems that are taking place. Like I said, you hope that with your intervention that you're addressing that subsystem or element of the system that is either too rigid to allow adaptation or you're able to promote another adaptation that can overcome that limitation and then restore whatever it is that we're trying to restore, whether it be a movement or a subjective perception that is why the patient comes to you. Typically it's going to be pain under my circumstance. And so that's kind of how I look at things. And that's why I always say that I don't really know why they get better because number one, I probably can't really identify as to why they had the problem in the first place. But my hope is that it's represented in the movement system because that's the system that I actually have the most influence on based on my scope of practice.

Compensatory strategy or vice versa where I have an inhaled axial skeleton and you use an exhalation compensatory strategy. But we're talking about thoracic outlets specifically. What we're looking at is the area of the rib cage from above the second rib and above T4 in the back. So this is sort of like if you looked at the cap on the thorax, this would be that area there. And so you're looking at a compressive strategy primarily anterior where you're pulling the manubrium down as an exhalation compensatory strategy. And in doing so, we reduce the space between the clavicle and the upper rib cage. And so that's where that compression takes place. That's where you lose the full excursion of the neurovascular that comes from the neck and in the upper quarter down into the upper extremity. And so then the way to alleviate that is obviously to reverse these compensatory strategies. So what the ISA is, it leads me to determine what the sequence of compensatory strategies will be. Because if I have a narrow ISA, they tend to use a predominant anterior compressive strategy first, and then move to the posterior compressive strategy, whereas the wide ISA will start with a posterior compressive strategy and then move anterior. Ultimately, though, if I had a wide ISA with a thoracic outlet problem or a narrow ISA with a thoracic outlet problem, they're at about the same level of compensatory strategy because it does involve the same structures of the manubrium and the influence on the position of the clavicle, which creates the compressive strategy between the upper rib cage and the clavicle itself. And so again, ultimately the reason that you would want to identify the ISA dynamics is to determine where you are on these compensatory strategies, and then that determines what intervention I'll use to alleviate and try to restore this full excursion of breathing so I don't have to rely on the compensatory strategy that's causing the compression in the first place. So again, that's why I would use the ISA. I don't use it as a particular diagnosis. If it became a shoulder pain, neck pain, or hip pain, I would still be looking at the ISA because it's going to lead me in the direction of what compensatory strategies you're using that's creating this compressive strategy in the first place.

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

Watching all your videos with great interest, I'm trying to grasp the big picture of inhalation, expansion bias, exhalation compression bias, and the compensatory strategy one would use when they have either exhalation or inhalation bias. So let's talk about the very first compensatory strategy that's available. So if I am exhalation biased, that is due to physical structure, which will eventually hash out on some level. But for now, let's just say that you're going to have somebody that's going to be exhalation biased or inhalation biased. So if I'm exhalation biased, I have to figure out a way for me to breathe in against that strategy. And so let's talk about the infrasternal angle a little bit, because that's where this infrasternal angle stuff gets really, really interesting, because it is the first and the easiest way for us to determine what the compensatory strategy is. And it's probably the first and most important compensatory strategy in the human because it influences the capabilities of the thoracic diaphragm to allow us to breathe in. So if I'm exhalation biased, I would normally have a down bucket handle position of lower rib cage. But what has to happen is I have to be able to breathe in some way, shape or form. The first compensatory strategy is to allow that thoracic diaphragm to move. So if I'm exhalation biased, I cannot descend that thoracic diaphragm unless I eccentrically orient the abdominal musculature, which is closing down the bucket handles. So I will release that. I will eccentrically orient external oblique as an example to allow the ISA to open, and this allows the diaphragm to descend in someone that is biased towards exhalation. If I am inhalation biased, I have to figure out a way to exhale. And so I will use the musculature that would close the ISA and pull the bucket handles down. And so the first compensatory strategy, again, that's easiest for me to evaluate, is the lower rib cage because that's where the greatest capability to compensate is. And so as they exhale and they close the ISA with the external oblique, that allows me to exhale against that inhalation bias.

Okay.

We decided we're actually going to have a conversation between the two of us. People probably think that we spend all of our time together, but we don't. We're like two ships passing in the night because of how our schedules work. I was literally thinking that same phrase at the same time, which is funny. We talk and communicate, but eleven years in, we've made a lot of mistakes and done some really good things. Now we can bring value to other people, which was my intent with putting this together. We start with our story because many people have a misperception about how to start a business like this. They see where we are 11 years in but have no idea where we began. Nobody knew who we were initially. People knew who you were because you had a big following at T-Nation and were associated with Eric. You released Magnificent Mobility, then I came into this. I'm not sure when you moved down.

From a performance standpoint though, you may be biased towards one type of heel strike or foot strike rather over another. And so when we think about some of the slower speeds, what you're probably going to see is you're going to see this almost an essential element of heel striking first just because of the speed of performance because as you look at faster and faster runners you're going to see that the foot strike because the ground contact time is reduced that the foot strike is going to have to change to allow the propulsive element to continue so the faster you go you're probably going to see people get biased more and more towards a mid to forefoot strike and so if we look at the extreme I think I got a question about sprinters here. Yeah, so I'm going to kill two birds with one stone here. So this first question was from Tim, and I think that it was Alex that asked, can we talk about the propulsive phases applied to sprinting? So let's combine these two questions. So the slower I go, I'm going to heel strike, and I'm going to roll over the forefoot as you would think. So I'm going to go through all phases of early, mid, and late propulsion. With sprinting, especially at top speed, what you're going to see because the ground contact time is so brief, I have to hit this maximum propulsive phase. The propulsive foot is actually a pronated foot. So what you're going to see in a top-level sprinter in many cases is it will appear that the heel doesn't actually make contact with the ground. So the cool thing about this is this matches up with some of the shoe research is that maximum pronation actually occurs as the heel breaks from the ground, which means that maximum propulsion would be at that moment as well. So in a top speed sprinter, when the heel doesn't make physical contact with the ground, they're probably still in max propulsion. So again, I think the running speed is going to play a major role in what type of foot strike you're going to see and what is optimal under those circumstances. So Alex and Tim, I appreciate that question and hopefully I gave you enough information to satisfy your needs. I'd be happy to kind of flesh this out a little more but again, so to wrap it up let's consider running speed one of those primary parameters as to what type of foot strike you're going to use but in addition we have to consider all the things that are above, but that's a big long conversation, I think.

We'll move towards pronation, which is my propulsive phase. And I will resupinate the foot at end range. So I will have activities and exercises and elements of performance that will emphasize one of these phases or another. If I can identify where the limiting factor is in performance, I can then select the appropriate activities with the appropriate positions to emphasize each of those propulsive phases. And so we have this endless array of exercises. And once we can identify where these limitations are in our propulsive capabilities, the exercise programs kind of write themselves. And so this is a really huge topic that we cover at the intensive, especially during the practical component, because a lot of people think that there's some sort of standardized exercise progressions when the reality is, is the progression needs to be individualized towards the client or the athlete that we're working with in regards to what do they do well, what do they not do well, and then what is our intent? Are we trying to emphasize something that they're already good at, or are we trying to work on a weakness or a limitation? And so again, as we look at this from the beginning of the propulsion to the end of the propulsion, there's definitely things that we need to emphasize. But just to wrap that up, remember that early propulsion is moving from an inhaled state towards an exhaled state. The maximum propulsion is where I am maximally pronated through ground contact and I move again towards the inhaled state towards the end and I can again self-select the activities that would be most appropriate for each of those phases. So hopefully that gives you a little taste of what we're talking about and I'd be happy to expand on those if you have a very specific question on that.

And that's where the fountain of youth is. And we did drink from the fountain of youth. And so I think that's my secret—I have somehow taken advantage of the magical waters of Ponce De Leon Park. It has preserved me from getting gray hair.

Oh, okay. I would be shocked and amazed if we didn't talk about golf, young man.