Okay.

My question is in regards to the visual presentation of people when they come in, specifically regarding their femur and pelvis position. Some people are 'dumped forward' with a lot of valgus, while others are 'dumped forward' with bow legs. My question is essentially what determines whether they do that. Is it strictly the ISA and the relative position of the ilium and the sacrum, such as nutation versus counter-nutation? Or can someone with a relatively counter-nutated position go through the nutated position and dump forward into femoral internal rotation? And then if their weight travels more forward, can they present back into a weight-pulsive position?

You can't squat deep. We'll put 500 pounds on the bar and I'll shove you down.

Is there any position where you can capture that medial foot position with the heel moving towards eversion? What are you talking about? Like, like this? Any position? Like, I'd like, all I'm saying, I'm asking is: can't you is there anywhere? It how you position your foot or your leg to capture that medial aspect of the foot? Maybe when I'm in like a mid-stance. So if you can do that, if you can do that, all right, then then you know you can you can capture the position of the foot that you need. What you might need to understand is what position are you landing in in regards to the left foot. So if you've got a left side that is landing and moving very quickly through mid-propulsion towards late propulsive, then you have connective tissues that are behaving very, very stiff. So they're stiffer. So what you might need to do, and again, not having examined or seen you move around, but what you might need to do is teach yourself how to recapture this early propulsive representation. And so now we're talking about not just heel-elevated activities, but your whole foot elevated on a ramp kind of a thing. So if we were talking about your split squat, okay, that we started with. What you're going to want to do is you go left foot, lead, split squat, foot on a ramp. So the whole foot is even on the ramp, okay. And then you're going to want to start to superimpose some internal rotation on top of that. So we're talking about the contralateral load. See, you're already reading my mind. Or you're talking about a band that's pulling your knee outward to hang on to the internal rotation, because what's probably happening is that you're landing in an ER representation, you're landing in a late propulsive strategy, and you're not capturing that delay moment, the early propulsive representation on that left side, because that's where you superimpose the internal rotation, okay? If you can't capture internal rotation, that's step one, because remember the late propulsive strategy is an external rotation representation, but it's pushing that side forward. It's turning your sacrum away from that direction, right? Because it's trying to keep that left hip forward, not wanting it to come backwards. So in most circumstances, you're gonna have to capture that early representation, okay? Okay. Does that make sense?

Less time would be a faster rate, yes.

Unfortunately, there are many people that pursue things that they're not physically designed for. And then we end up seeing them in the physical therapy room because they're doing stuff that again, they just weren't meant to be, right? And they may pursue them or they want to pursue them or they enjoy certain activities, but can't do them. It's just that you have to start to recognize it's like, you know what, maybe this isn't what I was cut out to be. Like, you know, some people should be marathon runners and not offensive tackles. I mean, we could look at that extreme, but now let's look at the small gradients in between. It's like we have differences that we have to respect. And so your job is to figure out, okay, based on your physical structure, if you want to do this activity, what is going to be the best way for you to do it, the most effective way for you to do it and the safest way for you to do it. And that's why this job is hard.

Okay. So I'm playing within that middle ground. When I'm doing a Campo because of the two foot contact being more evenly distributed, it's not evenly distributed but more so than the kickstand. I'm going to get more relative motion within the pelvis and I'll be able to make a better turn where I'll be able to create the delay strategy more on the heavier side, right? So there's a low distribution difference in this that's going to prevent the turn. Did I help?

If you want to just narrow it down to that selection, I'd be cool with that. But don't forget about all the other stuff that is considered connector tissue, because it all behaves the same way.

Yeah, right. So it would be relative too. So you might see like somewhat limited on the right, but more limited on the left if you're that pushed. Okay, got it.

OK, yep, I'm familiar.

The patient has a history of knee surgery on the same side, so I checked range of motion. The hip seems to actually have really good mobility. Internal rotation was a little bit limited.

Well, okay, I'm exaggerating for a fact here. That's a ridiculous assumption that she's doing 500 pound squats. Why does she have to do a horizontal plank? Why does she have to get down on the floor, put her forearms down on the ground, her toes on the ground, and why does she have to do it that way? Because if she has to use a compensatory strategy in that position to execute the activity, it's too hard. It's too difficult. So it's not that we can't use this position. We just have to put her in a position where she can execute with a minimum of compensatory activity. So it's just an elevated version. In all accounts, whether we be, okay, you ever start your, okay, herniated disc patient, you ever have one? Awesome. So the goal is to get them into neutral spine and stabilize them there, so they can manage the disc pressure and you develop strength on top of that, kind of makes sense. Would you put them on the ground and put them in a side bridge first day? No, sometimes you literally just lean them against the wall and that's enough muscle activity for the day. Like that literally teaches them, you get them to neutral spine, you teach them to start to create the shape. But with a minimum of load, because they can't manage the load because the only way they can manage a load is to create a compensatory strategy. Same thing here. It's like, I don't have any issues with the activities as long as she has the ability to capture that neutral spine position, like, let's put her there, but let's put her in a place where she can actually manage the forces.

Yeah. You'll see people that live on their pinky toe. Those are the people who hide it under their fourth toe. You're seeing that people's pinky toe puts on the ground and they've got a little toe that kind of tucks under and hides.

Yeah, that makes a lot of sense.

OK. So now we've got to figure out where all this compensatory ER showing up. I would agree that you probably have to yard the tibia because when you make an isolated adjustment at the knee, you can alleviate the symptom. Are you solving the problem? No. So where else is the compensatory ER?

That was my question, like the differences between how you're going to adjust between wides and narrow. It's not going to be the same way.

Yeah.

The end of merit and training.

Because there are a lot of those. Right. And then you start chasing a whole bunch of stuff and you have no idea what the process you were doing was.

Depends on which hand you got the weight in.

Makes sense.

Extra.

OK. And so that is a version of the end game of the AP compression, right? That was crazy.

So, would there be any benefit in—when we've got people that obviously have other things going on that are going to make them compensate to get into these positions? Is there any localized benefit to allowing, so if we can get the relative bones to move into the position the way that we're hoping to, we're going to get some tissue yielding and at least have the capacity to move into those positions at a local level and then approach the more global aspect of, you know, it could be, for instance, using a plyometric or cross-training or whatever the other activity is that we're trying to get the hip using. So what I'm asking is, if we use that in conjunction with the other things, is there still, there's still a—I'm still trying to configure where I'm still trying to get in my head where there might be a downside to that. I understand using it in isolation, but using it in conjunction with other things—

Yeah, I got that. And then go ahead. The other piece that this could be total coincidence or maybe related, and that's kind of the other piece of the question is: They also lose their back foot, meaning like there's no drag mark to go with it, because it starts to drag but then it pops up. And I didn't know what, like, are they losing that back foot because like they can't get into IR on the front leg. They enter the stance instead and that dumps the pelvis this way, taking the back foot off.

Awesome. You get it? Thank you.

I come behind them to the anterior. I capture the muscle at the ISA, and then I turn them. So they're going to turn on the diagonal for me. So they're going to create this helical orientation this way. I'm going to guide the muscle activity to get it to turn with it.

Okay, now I understand. So if you look at this picture here, let me see if I can blow this up. Yeah, there we go. Can you see, just look at the lower extremities.

Oh yeah. I set up, but I mean like they go forward with the left and then they go to the right. Yes. Yeah.

Ah, yes. Because if you think about what you just did, you took away a point of contact on the side that you're trying to delay. And so if I bring the knee up and I take away the contact on the side that I'm trying to create the delay on, that potentially becomes more difficult for me to actually hold on to that strategy. So if we're starting somebody out, I would probably want to keep that foot in contact with the ground and just raise the opposite leg into the loaded position. A little bit easier for me to hang on to the strategy that I'm trying to utilize and challenge that strategy. Like I said, once they've evolved that, now I'm going to pick that knee up and I'm going to say, okay, I need you to be able to turn into a loaded representation on the other side on the ground. So now they're actually pushing off the ground with the right side to create the loaded strategy, right? So it's a little bit more effortful, okay? You understand? It's going to be a little bit more effortful to hang on to the left side delay, because it's going to be really easy for me to push off that right foot and just orient everything into a left-facing direction, but not the loaded strategy. You see the difference. So the principle is very solid execution. There's the challenge. And that's where the experiment takes place. So you're executing based on principle. And then you see what happens to determine what the best strategy is for you in regards to the actual execution of the exercise.