Go for it. As soon as Grace gives you permission, you're good to go.

I've got a client who is very wide, very compressed anteroposteriorly. And, fascinatingly enough, whenever I put him in a supine or inverted position, he can't breathe. His nose gets congested.

Got another question that's kind of not pertaining to that.

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

Under circumstances of yielding actions, we do feel tension because load is always distributed into the connective tissues, and that's a large part of what we perceive based on my model. So whether we have a concentrically oriented muscle or an eccentrically oriented muscle, and we get to some end of excursion that is allowed under those circumstances where we do have the yielding action, that is definitely what we are going to feel. So if you have done a static stretch and you get that discomfort at the end of the stretch, that is the distribution of tension through the connective tissues that, of course, we are going to sense. So again, that's what we are talking about. When we talk about tight, we are talking about a sensation, not necessarily a useful representation for decision making until we identify joint position, muscle position, etc., and then we can determine what an intervention is. So this is a common mistake where people will say, 'Oh, you feel tight, you need to stretch,' when the reality is, if the tissue is already under tension under some circumstances—especially if I've got an eccentrically oriented muscle and a yielding action—it's like all you are trying to do is just pull on something even harder than it's already getting pulled on. It's already in an eccentrically oriented position, so it just becomes an exercise in futility. The reality is what we need to do under those circumstances is just restore the full excursion of movement under those circumstances, and then we feel nothing because under situations where we have full concentric or eccentric orientation of muscles—which would be representative of a full breathing excursion or full joint motion, however you want to perceive this—we feel nothing. We don't pay any attention to it because we don't have those sensations of tension or tightness. When we talk about weakness, we are also talking about a similar situation. I'm going to bring in the little skeletons here. Since you brought up external rotators, I'm assuming you're talking about the external rotators of the shoulders. If we get sort of a concentric orientation where we get a compressive strategy in the dorsal rostral thorax, what's going to happen under those circumstances? We are going to get an orientation of the scapula that will position—if we are talking about muscles—the subscapularis would be concentrically oriented, and then the external rotators, and we will just say infraspinatus under these circumstances, would be eccentrically oriented. So under those circumstances, because of the position of the joint, the movement of synovial fluid, and the orientation of the muscles, we have an eccentrically oriented muscle that cannot recapture its concentric orientation, which means that it can't produce force. An eccentrically oriented muscle has a much greater difficulty producing force; in fact, it doesn't really produce a whole heck of a lot of force. It's always concentric orientation that is going to produce force. So if I have a muscle that is positioned eccentrically and cannot produce force, then people are going to blame it for being weak. Then they say, 'Well, you just need to strengthen it,' and they do some sort of activity that supposedly strengthens a muscle. So you do your little rubber band external rotations under these circumstances, and if you can recapture concentric orientation of that muscle, guess what? It tests strong, which means that all you did was create an orientation in that joint that allowed that muscle to capture its concentric orientation and produce force again. And so again, this is why breathing excursion matters. This is why restoring full movement options matters because that's what allows us to continue to produce the appropriate force, move comfortably, and move without this tension.

Bill, when you said that you wouldn't put this person in prone, are we talking about all prone positions, like quadruped?

Right.

And what you want to do is actually take a look at how much pronation he's got approximately relative to the wrist. So when you grab his wrist and you turn him over into pronation, you go, oh, he's limited. It's like, get a little bit more proximal and see how far you can bring the radius over into pronation and then compare it to the other side. Because chances are he's got a radius that's bent. And then if you look, was it the picture that you sent me?

That's exactly.

This is the best I look all day and it just gets worse.

Once you're past that initial rehab stage, it's just a reconditioning element. It's like, okay, what's your fitness level now? What do I need to prepare you for? Adam can speak to this with great accuracy because that's what he does for a living. It's like you're in this constant state of reconstruction and restoration of fitness, right?

Yeah that makes sense. How does your tactic change with somebody who has already identified themselves with pain through multiple doctors or physical therapists? They come to you and they're already there. Does your tactic change?

Oh, did they?

During not really.

Okay.

Yeah. But see again, it's like we're just throwing out a theoretical point in time to have a discussion. It's not very meaningful. The idea is, when I take a snapshot in time, what's moving? Does everything move the way I need it to accomplish the task without putting stress or strain on anything in particular? If that's the goal. Because cutting off of a foot and walking straight ahead are not the same thing due to the changes in constraint at the ankle and foot. I intentionally limit motion between bones in the foot when I'm pushing off in another direction because I have to create a turn. So the compensation through the extremity is to make that turn and to drive the thorax and so forth off of the foot. Whereas if I'm going straight ahead, I have to cancel out forces or I can't go in that direction.

In PT school, we don't really learn how to quote unquote measure things like tibial internal and external rotation. You can look at it in isolation, right? So if you take somebody to 90 degrees of knee flexion, right? So that's where your constraints are lessened. So like you do your anterior drawers and all that kind of stuff in that position because because the constraints are lessened in that position. And that's looking at it in isolation. Michelle, what I would say is that the most important thing is that you have the full excursion of knee range motion. So you think about this. So as I flex the knee, the tibia internally rotates on the femur. And then as I extend the knee, it externally rotates. So if you have normal knee extension, you can make an assumption that you've got enough tibial external rotation. If you've got normal knee flexion without resistance, then you can make an assumption that you've got enough tibial internal rotation. It'll be like if you get down on like in tall kneeling and then sit down on your heels. Okay, you would want to me that could do that right and and and so that is that is a passive that like that's at the passive constraints. I have a user goniometer other than to prove to to students that they're horrible eyeballing measurements.

Because it's basically like you're integrating everything from all parts of science and all parts of the universe to come up with this universal theory of everything pretty much and we just supply it in the...

What were some of the final activities that you were doing with them?

These are more just like clarification questions about risk exam. Um, so you like to use that opposition test. Is that am I more likely to have an increase in ulnar deviation if I don't have full pronation?

Yeah.

Yeah.

But that same topic, right? With people that may have a belief that their diagnostics does not back up, right? Oh yeah. They're still feeling something, right? And like, you still have to validate their concerns.

Absolutely.

When we talk about an anterior orientation, that'll be representative of movement in this direction. So now I'm going to show you this from the front. But what you have here, Matt, is someone that's anteriorly oriented, but they're anteriorly oriented on an oblique axis. So it's going this way. So what it looks like is that this side is actually more forward when the reality is it's just turning to the right. And again, you're just orienting the pelvis on this oblique axis. Now I'm going to turn this around so you can actually see this. If you pay attention to the ischial tuberosity, what's going to happen is you're going to see that ischial tuberosity move up in that direction there as the pelvis tilts forward on this oblique axis. And so what we need to do is we need to utilize exercises that are going to bring this ischial tuberosity down in the opposing oblique axis. And so let me give you a list of activities that you might want to consider using. 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, which will also help you achieve these same positions. The idea is you have to push backwards to the left on an oblique angle. So that's your exercise selection for this type of an orientation. Because again what you're looking at is this tilt on the oblique axis versus a true anterior posterior axis.

Right. So the compressive strategy actually, as we say, it's like squeezing the toothpaste from the top down. You get this compressive strategy where you don't get the sternum pump handle like you normally would. And of course, that's going to impact everything from scapular position to neck position and then the resultant shoulder range of motion that you've already measured.

Pre kiddos. That's kind of a big deal too. We'll eventually talk about how that works.

I don't think you need to be thrown on a table to figure this stuff out. But what I do think you need are some sort of physical active measures that you can recognize that will allow you to identify where you are in the process. So maybe it becomes something as simple as a toe touch variation, something as simple as a split stance variation, something as simple as your squat pattern. And then you say, okay, what am I giving up? Because I will offer you this, that if you drive your deadlift hard enough, you will give up your squat pattern. It's inevitable because they are in conflict with one another and so I'm not talking about a powerlifting squat pattern I'm talking about a legitimate like yes, you'll tuberosity of a heel kind of a squat because that is representative of a totally different end of the spectrum in regards to how we acquire movement. So your deadlift is a compressive pattern, your squat is an expansive pattern. And so what you want is some measure of adaptability between those two extremes that provides you enough health where you go, I'm okay, I can accept this as my capabilities or do I need to skew in one direction or the other? So if your training skews you towards this highly compressive a hinge type of training, you have to decide whether that's okay for me because the better you get at that, the more you're gonna give up your squat pattern. And I would offer you this is that, so when we're looking at a self measure or a gym measure that helps us identify whether we're giving up a broad spectrum of adaptability, that that squat pattern is gonna probably be a biggie because it represents your ability to expand where everything else compresses you. So when we talk about pressing, when we talk about heavy pulls, when we talk about deadlifts, all of those compressive strategies limit your ability to expand on the backside of your body where that deep squat represents your ability to re-expand that area. And so again, I don't think you need to be thrown on a table at all, but I do think you need to be able to recognize this, when am I giving something up?

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?

You see it? Then move her into it and move her into it with some measure of control out of it quickly. And then progressively increase the rate at which you are applying the IR into the ground. So this is an early IR problem. So it's like going into the cut problem. Cause she's using, she's trying to use a max P out of the cut strategy going into the cut. That's why she's twisting the machine.