Okay. What if it was low blood pressure? I would suck. I would be terrible.

I was doing the opposite.

Okay, so when you see the knee going in, that is the pelvis orienting into that compensatory strategy. So again, that's how he's creating the downforce. He's doing it from above the pelvis, not the best way to capture internal rotation.

She's a female, wide ISA, early thirties. She really has a wide ISA, like she really just can't close. She also has asthma, so she's not getting full breathing. It's more like she's living puff to puff. She's taking the maximum number that you can throughout the day. She has a wide ISA, they came close. She also has measures that are fairly symmetrical and more in your bias, as far as I can tell, though I recognize that I should look out for the spine. She's moving a lot on those probably, but like, almost 90 on the straight leg raise on both sides, full hip flexion. If even that, maybe it's a lumbar substitution. When she moves, she can't yield posteriorly. The activities that I've found that have been good so far, she struggles with even chopping. Heels elevated toe touch feels really good to her. Something like quadruped just holding it, she feels like her chest is releasing some tightness. But if we do something like a child's pose, she can barely breathe. She has rock hard tension here, rock hard. It feels like she's been lifting heavy for years, but she hasn't. Very anteriorly oriented.

Okay. Well, but let's not stop here. So by tradition, by tradition, so I have not measured this person, but I can tell you what her measures are going to be. Right? And then you already know what they are. So where do you have to go here? What do you have to, in simplest representation, like you don't have to take me through like the entire process. What is the greatest limiting factor right now that if you don't address your toast, like you're not gonna get anywhere?

Yeah.

Okay. Yeah. It's just more complicated.

This is an online client, so my hands-on assessment capabilities are absent with her. We rely on active range of motion and movement-based KPIs. She has a history of hip dysplasia that is radiographically confirmed. When I first started working with her about eight weeks ago, she still presented with a narrow stance and a relatively deep body weight squat, but she presented with an obliquity where she was getting pushed over to her right leg. Her chief complaint is right anterior burning hip pain that gets aggravated with repetitive hip flexion, such as running up stairs. She does a lot of beach body and Insanity-type training, so repetitive squatting and jumping really aggravates it. The initial plan of care was: when she sat in a chair and performed hip ER and IR, her external rotation looked relatively good—not a massive limitation like I've seen in some of my online clients—but her internal rotation was about 15 degrees on the right with a little bit of side bend compensation at the trunk, and 25 degrees on the left. Since then, I treated her as if she had a narrow right oblique due to her presentations at the right hip. I pulled her back on the right and gave her some middle clunkiness. Then, looking at her body weight squat, she no longer had the deviation toward the right in space. Now, I'm working her into some split stance stuff to find ways to eliminate interference with her current training that's still making her hip sensitive. She responds really well to a prone right clunkiness to turn the sacrum away from the right side, which eliminates almost all hip pinching. But when doing a left foot lead, right foot back split squat with weight in her right hand to help her turn the sacrum away from that right side, she gets anterior knee pain. My first cue was to shorten the stagger, which helped a little. The pain is in the same knee as the hip pain—the right knee, specifically the back knee. Then I thought maybe she's not getting enough IR and extension representation on the right side. So I performed active tibial translation on the right, and it resolved the issue. I'm not exactly sure what I did, but I was hoping we could discuss it because I feel like I'm close to helping her fully get into her training.

I had a similar situation to what Thomas asked. Sometimes when I have people do the dip for a jerk, they dip too deeply. This dampens the dip and leaves them with nothing to push up with, which is ineffective. So sometimes people prescribe a pause at the desired depth to develop body awareness of how far to go. The problem is that when people pause, they sometimes go deeper to generate momentum for the upward drive. What you want is for them to dip and then immediately drive upward. The pause helps them reach the right depth, but when they actually move, they continue going down.

That's a really good question. That's probably going to make a highlight. There you go.

Okay. Awesome. So right now, both of your hips are turning out into external rotation. Would you agree?

Right.

Okay, I don't have permission to show that on here then. It's a really good picture though. He looks like he just got off a horse.

So the typically the sensation that you're going to be feeling under the stretching circumstances is going to be load on the connective tissues. The question is, at what point in the excursion? So eccentric orientation buys you position, the yielding and overcoming stuff is the connective tissue behavior. So if you feel that tension, you're going to be bumping into connective tissues. The question is, is it yielding or not? And that's going to be dependent on duration of position if there's a load on it, the rate at which it's being loaded. If I have a lot of concentric orientation, I have a lot of instantaneous load on connective tissues, and so it will behave more stiffly. It'll be stiffer than the yielding action that would be associated with the elongation. Again, that could be just a time dependent phenomenon. But I think that under the circumstances you described, you may want to just invest some manual stuff at that point. Right? Does that make sense? Do you see how it kind of fits?

So I think I need to create an exercise selection chessboard. I have some representations in my head, but I need to put them down on paper. You mentioned when Luke was talking about progression and exercise selection, you had configuration bias for force production and propulsion as main factors. Are there any more you would add to that?

How would you do that?

And so you guys are PT so we can have this conversation. So there are situations where in most cases when people present with some sort of mechanical pain, they are applying force into a very, very small area. So somebody walks in with knee pain. That's a knee result. It's not a knee problem. It's a knee result because they're using that area more aggressively or for longer duration than we would prefer them to. So the load's not distributed. There are situations where we can accidentally do something that distributes that force elsewhere. And then the pain goes away, but we created a second problem. The way I always talk about this is like you're a golfer and you got a swing fault and you go to the golf instructor and they give you another swing fault to get rid of your swing fault. And so this happens in physical therapy all the time where we actually need people to feel better, but we didn't provide the solution that would be the best solution where we reestablish relative movement capabilities, connected tissue behaviors where they can actually distribute all of these forces effectively. So we don't want to fix a problem with another problem. And that's what you were talking about. It's like, yeah, we demonstrated higher performance, but now I created a second problem that we're going to have to manage.

Hang on, here's what you did. You moved faster forward on the right and you slowed down on the left.

So you would say the turtle. Their IR windows are smaller. I mean, they have to IR to go forward, right? They have to push into the ground and go forward.

Absolutely. Great description. So let's think this through from foundational archetype to the representation that you have now. If I start with my narrow ISA archetype, my bias is towards external rotation. So I would have a situation where I have this counter-rotated relative ER position, which will retrovert the acetabulum. So I'm biased towards ER. Now, what you've described at the knee is that the patella is in a position of IR, with relative tibial ER. And you noted that the distal tibial looks like it's in IR. So here's what you've got: ER at the hip, IR at the knee, ER at the knee, and IR at the ankle. This is significant. If I'm biased towards external rotation, that means I have yielding action on the posterior side, which should hold me back towards my heels and lift my arch away from the ground. But if I'm walking and have to go through the middle propulsive phase, which requires IR, while being biased towards ER with a pelvic position biased towards ER, how do I put force into the ground? I have to create a compensation to produce that force. So I'll take my ER pelvis and tip it forward. By anteriorly orienting the pelvis, I can put more force into the ground without changing anything. Traditional lumbar extension is internal rotation, forced into the ground. If I'm a narrow ISA biased towards counter-rotation, that's actually lumbar flexion, which means I might go above that level and use a lower thoracic strategy to tip the pelvis forward from above to create the anti-orientation. If I'm using the lower thorax to create internal rotation, I'll use a posterior lower pelvis strategy in the same way, producing ER at the proximal femur. So I have hip ER, no hip IR. My IR is coming from above the lumbar spine and below the level of the trochanter.

I actually quickly have another cervical patient much older. She is hyperkyphosis and in the thoracic region increased lordosis cervical wise. Same thing, having lots of like debilitating neck pain, but she's that different situation where she's just so expanded in the back. She's also all of her pain is on the right side and little history, she also had a bilateral mastectomy.

Or is this an exercise you're thinking of?

Anterior knee, like dead in the middle.

Oh, wonderful. OK, well, OK, nice. That did a very good job of cementing. I feel very equipped to creatively choose activity, but with clear criteria.

Yeah.

And then come back to that. Yep.

God just said that they presented in one extreme, take them to the other extreme.

Dampen the forces just from the standpoint that like, I don't want them moving that quickly. Correct. I'm picturing like the on the overcome out like that's not the part like if I'm introducing a change direction for the first time like that part really wouldn't scare me in a sense, or I think really scare them, it would be like going into it and loading it, which I think like speeding that up might scare them.

Yes, I was hoping you'd bring this one out. Good. All right.

Okay. But as soon as I initiate the squat, I have to move. So I'm going to start to move, and that's going to be actually a late representation.