You're welcome. It's very helpful, very insightful. So I'm doing a lot more traveling and I picked up on your podcast and I was listening to, I think it was episode 10 when you were talking about client relationships and you mentioned something about making the, like not personifying the pain in somebody when you're dealing with them. Can you expand on that a little bit more and like how you avoid that?

Tough call. I think that the easiest thing to do under these circumstances is not to worry about it. So the number one priority across all aspects is the static element, right? And this is also a bias from being an exercise guy, right? You think about all the creativity that comes from movement, and figuring things out from that perspective and problem-solving from that perspective is really, really powerful. We know the impact of exercise on the brain. So number one, there should be a foundation of movement and activity that should be standard. When I went through elementary school, we had three recesses a day. And now I actually believe in having success for the elementary kids.

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

Right.

So let's assume we have normal relative motion. If we had to make a division once the talus starts to move towards the internally rotated position, so plantarflexion, adduction. Once that starts to move in that direction, you're moving towards the middle phase. Because theoretically, and again, this is totally theoretical, when the heel strikes the ground and the foot goes to flat, before you would load it, before you would put any weight on that foot, the talus is still kind of dorsiflexed and abducted. Got it.

So I just look at the synovium as I would a laceration of your skin, right. So they poke holes in a structure that is supposed to contain the fluid, right. And the way that I move that fluid through the joint determines how well that joint behaves, right. And if I poke holes in it, I've just altered my ability to manage the volume of fluid that's in the joint and how I manipulate the pressures inside the joint, right. And so one of the concerns that I have early on is that fluid that is either within the joint that I need for the normal behavior of the joint, and then the fluid that is around that joint that restricts my ability to move that joint, right. And I don't want to create irritation because the more swelling I have, the harder it is for me to get range of motion back. So in the initial post-surgical phase, it's like, well, we'll talk about these because that's kind of where it shows up the most, I think. But my concern is that I don't have an intact synovium when I do stand up on it, right. And that's going to alter my ability to manage the joint like I normally would, so it doesn't behave normally. So am I creating more irritation? Right. So do I have a stronger inflammatory response? Am I irritating structures that aren't supposed to be touched at rest? Am I allowing them to touch? It's like all of those things are my concerns with this early phase. So being on your back for 10 days after a knee surgery doesn't do anything negative other than help me manage the swelling. The grave concerns over getting strength back after a knee surgery are ridiculous. Strength is the easiest thing in the world to regain. Fitness is easy to reacquire. What's very, very difficult is to manage a joint that's not intact, right. And so again, I'm using the typical 10 to 14 days for tissue healing that would be associated with, like I said, you get a laceration of your skin, they sew it up, and they say we'll take those stitches out in like 10 to 14 days. So I figure if all the tissues are the same, they're probably going to heal very similarly. And so I just use that window to manage the swelling post-surgery. It doesn't mean you can't get up and go to the bathroom. It just means don't be spending a bunch of time on your feet thinking that it's going to be helping anything, right. Because the more swelling that anybody has after a surgery, the harder range of motion is going to be. So I think it's a little bit more important to be protective in that early phase.

And so what we're going to eventually see then is we're going to see a lot of activity in this lower area. So you're going to get a lot of superficial activity from, say, lower glute max. Upper glute max is going to be compressive. Adductors are going to be compressive in the front side. So you have something that does not have a lot of excursion in the hip joints. When you see the loss of the straight leg raise, the really limited toe touches, you know you've got a lot of muscle activity down through here. You also have the compressive strategies as we said. So here's the end game in this situation. So take every superficial strategy that we can imagine when we're talking about pelvis and rib cage. And so we got somebody that's pretty much squished, kind of like that. Okay. And then the last position that they're going to get into is actually going to be in inhalation compensatory strategy. So every other superficial strategy is a compressive strategy for exhalation purposes and a maintained position against gravity in the upright. And so the last thing that they're gonna do is they're gonna bend forward at about T8. So right at the base of the scapula, they're gonna bend. And so they're gonna have that kind of an orientation on the spine. And so this is actually inhalation. So they're actually grabbing the front of the pelvis with rectus abdominis. They're grabbing the front of the pelvis and pulling upward. So they're pulling upward on the pelvis. And so they bend at that T7, T8 area on the spine and that is an inhalation compensatory strategy because think about it if I squeeze with everything on the outside I still have to have a way to get air in. Okay, but now you have somebody that has zero rotation so they're getting pushed into the ground they're trying to push themselves up with all these compensatory strategies which is why this person is living in the world of pronation. So you gotta take gravity out of the equation because that's where the biggest struggle is. So if you try to do anything in these upright positions with this person, at least from the get go, you're probably gonna see a lot of struggle because they cannot expand. So the best strategy to utilize in this situation is put them on their sides so start working inside line so we start about talking about shifting the pelvis from side to side doing that inside line doing the same thing with the upper thorax so those of you who have any skills in the PNF realm are going to be very, very useful for this person. So the scapular PNFs, the pelvic PNFs inside lying are money in this situation.

That's so great.

Well, in many ways, you're developing both skills from a physical perspective. If it is a motor planning thing to a comprehensive ability to be able to follow directions and be able to apply that to their skill set. Absolutely.

I like that Feynman quote of, I'd rather have questions that can't be answered than answers that can't be questioned.

My father's a tailor. So this isn't super random. We've been making masks for people. One of the things we use for filtration are certain vacuum bags. So there's a company called Festool that makes super fancy sanders where you can sand and there's no dust. The vacuum sucks up the dust. They have a really nice bag. And so we use those bags as liners for the masks because it filters out 93% of particles.

So I think that in some regards it can help put bumpers up and keep you safe. It provides you a foundation of reasoning. Right and again because we're working in probabilities that may help you narrow some probabilities. So, but having more models to use and to be able to filter information through allows you to narrow those probabilities much more quickly. Right. And that's why we can't negate that element of science. Right. Always improving our understanding of that. Like I said, it just helps us make better choices, select better interventions, and then hopefully make a better outcome.

finding different ways to communicate even though we can't really be physically there. And then aside from that, like also understanding what's essential and what isn't, not only in what we do as practitioners, but what we do in everyday life.

But once you understand the principles of how we're applying this to the internal forces, the versatility of the box squat is only limited by your imagination. If you have any questions about the box squat or any other exercise for that matter, please send them to askbillhartman@gmail.com or follow up with me on Instagram or in the comments below. Now, I have a couple of questions that I wanted to go through today for today's Q&A. Both kind of interesting in different ways. First one comes from Jason. And Jason says, I recently saw a client with a 90 degree ISA that did not move at all. Additionally, he had limited shoulder and hip internal and external rotation, limited shoulder and hip flexion, no hip extension, and a lordotic posture. Given these measures, I found it difficult to decide whether I should treat him as someone compressed or expanded as these measures seem conflicting. First and foremost, let's clarify something about this 90 degree ISA thingy. There is no normal. Everybody has their own idiosyncratic infrasternal angle. Some people are really biased towards an exhalation axial skeleton with a compensatory inhalation strategy and some people are more biased towards an inhalation axial skeleton with an exhalation strategy, and that's what makes these wise narrows. It is a guide to direct you towards a strategy of influence to make favorable changes in their adaptability. So when you're presented with something with a 90 degree ISA that does not move, the goal is to create a dynamic ISA. If you have manual skills that are allowable in this situation, that's where you would want to go first. You want to try to get this thing to move. I would compress one side and try to expand the other and then vice versa. If you don't have manual skills, what you can do is take advantage of a glute ham raise pad, have people assume different positions over top of the pad which creates a compressive strategy and then promote expansion on the other side using breathing. In the remainder of those strategies, you're going to focus on expansion in the dorsal rostral area. And then you want to do some form of reciprocal activities where you're pushing or reaching with one side at a time. So any activities like supine arm bars, one arm at a time would be useful. Anything that's in an offset position will be useful. So anything in a split stance, anything where one arm is moving forward, the other arm is moving back. You want to start to think about those types of activities where you're promoting the ability to turn. But again, everything that you need to be focused on is driving expansion. In most cases, you're going to want to make sure you get that dorsal rostrum because that's what's going to allow you to achieve your flexions. The second question is from Matt and Matt asks, I'm wondering what your thought process would be for recapturing normal conditions for someone with a pelvis that is anteriorly tipped on one side only with a wide ISA presentation. The right ilium seems to be pulled forward by the iliacus and the lower rib cage on the same side looks to have an oblique that is not pulling the rib cage down fully during exhalation. What you actually have here is somebody that's got a pelvis that's tilted on an oblique axis. So the right side is not necessarily forward as you believe. The pelvis is anteriorly oriented, but it's anteriorly oriented on an oblique axis. The pelvis is turning to the right. You need to utilize exercises that are going to bring the iliac tuberosity down in the opposing oblique axis. So you're going to do a right supine arm bar. You're going to do a mountain climber with the body inclined at a 60 degree angle with the left knee to chest. You want to do right shoulder rolls. You're going to do backwards crawling. You could use a Jefferson variation on a left front foot elevated split squat. You could use a right leg forward rear foot elevated split squat with the left hand holding a low cable. You could do a high to low cable press and a stagger stance with the left foot back. You could do a right to left cable lift. The idea is you have to push backwards to the left on an oblique angle.

And this is the position that allows the lower cervical spine. So we're talking about C3 and below to turn. So if I have something that cannot turn the lower cervical spine in one direction, chances are you've got a compressed dorsal rostral area on the same side. You will see a deficit in overhead reach, the inability to flex the shoulder and turn the lower cervical spine in an ipsy lateral, same side direction. And so we have this direct relationship that is involved with dorsal rostral and lower cervical. When we talk about the upper cervical spine, it should turn in opposition to the lower cervical spine. So again, if I have an upper cervical deficit, I need to make sure that I have a lower cervical spine that can turn in the opposite direction. So again, I can use my overhead reach, my shoulder flexion measurement to help me determine whether I have lower cervical spine rotation or whether I have an upper cervical spine deficit as well. So keep that in mind. So think dorsal rostral first, I have to have the capabilities there. That's going to free up the lower cervical spine for rotation. So as I inhale the dorsal rostrum, I must have an inhaled position of the lower cervical spine, which is lower cervical spine flexion, and then upper cervical spine extension. And that's going to allow me to restore all of those movement capabilities. So hopefully that leads you in the right direction, Misha.

Okay, so now let's talk about approach because under many cases, some of the things that she's already been through will be defaults for many therapists or practitioners. So what did you go with?

Did you do the split shift kind of thing?

So, was that a reasonable sacrifice? And so this is, this comes down to, okay, am I training this guy for a combine, you know, like the, the dog and pony show of the combine? Or am I training this guy to be successful as a field athlete? And so again, you just got to make those decisions. But again, for guys like you and I, where we've already compromised an element of health, it's like, how much farther do we want to really go here? And then what are we using as our guide to determine, I probably need to alter my strategies, change my goal or my intent? And then, again, continue to monitor. So the strategy doesn't change. It's always going to be evaluate, intervene, and then reevaluate and make sure that I'm on the correct path. And so, you know, if you're doing seven sets of 10 with your kettlebell, okay, what's the byproduct of that? You know, what are you measuring to let you know that, okay, I can still do this because that feels good to me because I get to train, but did I just sacrifice something? And so what you need to do is you need to come up with those key performance indicators that are going to be your measures of this is what I cannot give up.

Well, what's the goal? It's real simple because you kind of said it. If the goal is to maintain the ability to create the differential, then the maximum load would interfere with that. But what if I'm trying to increase the peak force output at the turnaround?

All right. My least favorite book in the whole world is Seven Habits of Highly Effective People. So Chris White has actually corrected me: 'Begin with the end in mind' is in chapter two, not chapter one as I thought, but I was wrong because I don't like the book. Anyway, what you want to do is set her up in the position you're trying to acquire and move her out of that first. Don't try to move her into it and out of it. Put her in it so you have access to the position. Set up the connective tissue behavior and then start to create the impulse out of that.

There you go. This whole gravity thing works.

Yeah, yeah, yeah.

You twisted this more than this. The relative position here is ER to here. I see. If I turn away, I increase the ER here, no matter what you think you're doing here. Because again, people stare at their hands and think the wrist doesn't move separately from the forearm. Yes, it does. The forearm doesn't move separately from the humerus. Yes, it does. The humerus doesn't move separately from the scapula. Yes, it does. So where is the relative motion?

Exactly, yes.

Definitely. And so this is where that nice tubular shape that you get on narrow ISAs after about the third set of stuff, and it's like their ribs disappear and then they look like just a big hot dog laying on the table where they have this nice cylindrical representation. Yes, I know what you're talking about.

Let's see.

Or two, try and push the proximal end into IR.

Where was her ER? Her ER was through the lumbar spine. I'm sorry, ER space. Up to the side.

Yeah.

How long ago was the Tommy John?