Why is it important to “do the work”? The important physical work, the work on our thoughts and minds.
We do the work to get out of the woods (physical pain, suffering due to our thoughts and emotions).
We do the work reaching out in the dark, not yet knowing which direction we’re heading, but driven by the hope that one day we will see the light at the border where the trees meet the clearing.
We do the work because we learn to enjoy the feeling of it- even enjoy the challenge of it, and the feeling afterwards; like settling into a comfortable arm-chair in front of a fire, beer in hand, after a long day’s work.
And we do the work because we are building a buffer that will serve us in case of a Black Swan- a disastrous event we can’t possible predict, but need to insulate ourselves against. A preventative measure.
In the case of a Black Swan (written extensively about by economist Nassim Nicholas Taleb in the book by the same name, a Black Swan is a rare, random, cataclysmic event that seems to happen without warning), we are forced to surrender to a power greater than our own desire for time that is ours to with what we wish. Time-selfish time, free of scheduled obligation. We cannot predict when we will be asked, sometimes forced, to sacrifice this precious, unscheduled time, time that we would rather be using for ourselves, to serve another’s needs.
This is of course an illusion. Time cannot be ours or theirs, time simply is.
But it is in these times of sacrifice that we had better hope we’ve done the work and built a sufficient buffer to weather it out.
If a family member dies. If a loved one gets hurt and needs us for support.
“Is my buffer big enough for both of us?”
There is a purpose for time-selfishness, and it is to build the buffer that allows us to be there for others when their worlds come crashing down, and our daily motions shift not to serve our own physical, emotional, spiritual needs, but theirs, as well.
This is one of the highest reasons why we do the work. We think we’re doing it for ourselves, and we are, but we are doing it for ourselves so that we can, selfishly, keep our sanity while we are asked, without predictability, to drop our routine life as we know it and cope with what’s been thrown at us.
Call it tolerance. I call it having a buffer. And I want a buffer that will last me for days, weeks, months, without tending to it, so I can survive on the minimum effective dose of self-care.
Like a spider plant that seems to thrive when you neglect it for just the right amount of time.
The buffer gets larger and, as it does, the size of the minimum effective dose (MED) gets smaller. And counter intuitively, the more time we spend doing the work on ourselves, the more time we have later to spend simply being, without worrying about the MED, or the buffer. And ironically, this time spent being, not worrying, not working intentionally on ourselves, becomes the self-care in itself. Just having the space and time to be.
To sit. To lie down. To go for a walk (what other options exist?).
But that doesn’t mean we stop building our buffer, because it’s become such a way of life now. We make time for it. We enjoy the challenge of it. Enjoy the peace of it. The honesty of it.
We keep chopping wood, and one day, as it out of nowhere, we realize we have chopped enough. The wood pile is stacked high enough, so we can continue chopping without needing to chop, for we know there are others that have not yet started- are still staring, with uncertainty, at the axe.
We chop wood for them with the peace of knowing we have enough for ourselves.
Before we start, no, this is not a post to put the B in BPS (bio-psycho-social) on a pedastle. The B could not exist without the PS, nor could we have a PS without a B. Such is the nature of all things that exist interdependently. I do not wish to engage in this debate. I also suck at debates…
Somewhere around year 2015 I’ve found myself in a bit of an existential crisis that I’m certain many other personal trainers have found themselves in at some point:
I LOVE WORKING WITH BODIES BUT I THINK THERE IS SOMETHING DEEPER I’D LIKE MY CLIENTS TO GET OUT OF EXERCISE AND THAT I’D LIKE TO ACCOMPLISH THAN COUNTING REPS.
Of course there’s more to being a trainer than leading mindless workouts and rep-counting. And I’ve never thought about my work to be limited to just that.
And as a personal trainer who does not claim to specialize in weight-loss or nutritional counselling or physique enhancement- typical things associated with my field, just what meaning does my work have?
WHY the heck am I doing this? Aren’t personal trainers supposed to help people lose weight and exercise and sweat and build muscles and all that stuff? And if I don’t place a priority on that stuff… Then what else do I bring to the table?
As I deepened my learning about the human body, began to observe what was really happening with the bodies of my clients, I began to see that strength training and “exercising” maybe wasn’t the thing they needed to prioritize.
When a client who had hip pain couldn’t do the usual “go-to” exercises, I found ways of working around the issue for as long as possible to deliver a pain-free workout, but this wasn’t enough. I wanted to have the information and abilities to address these issues with movement, not work around them with strengthening exercises that may end up more deeply ingraining their structural issues.
The more I learned and studied the human body and movement I began to view my work in a different light. Strength training and general “fitness” training lost it’s be-all-end-all power as the ultimate tool for helping people, and I realized that I needed to be doing more for the people who trusted me with their bodies than provide “exercise”.
I think other personal trainers have experienced a similar meaning-crisis, which may lead to 1) changing careers, 2) adding new skills to our arsenal and adapting the way we work and market ourselves, or 3) becoming disillusioned completely with our work and industry and lose all sense of meaning in it.
I am currently in the depths of situation #2 (only very briefly did I linger in #3….): Learning to integrate the skills I possess that go beyond strength and conditioning, re-positioning myself as a personal trainer who does more than lead “workouts”, into the realm of restoring optimal movement quality to support a wide variety of goals any client may have, from reducing pain symptoms, to optimizing physical and sports performance, to lifting heavy stuff because it feels empowering.
Today I would like to speak a bit more specifically about a fundamental piece of my operative philosophy that I find myself repeating as I learn to integrate the tools I possess: Investigating the bodies true priorities before deciding that strength will make things “better” (whatever our definition of “better” is).
As a personal trainer with understanding in both areas of strength training and biomechanics, how to balance these priorities? Is strength training with good technique enough to improve movement mechanics? Or will addressing biomechanics lead to improvements in strength that resistance training alone could not?
Obviously it’s not a “this over that” situation. It has to be both and all in any situation.
And HOW to achieve that balance is the tricky, variable bit, as no two people are the same.
Too, there is the issue of expectation and trust, when a client is looking for a type of training that validates what they perceive to be their specific limitations or goals, rather than seeking the truth of the issue, which may not be the same as how they perceive it. This is where client education, proper assessment are important, as is being able to meet the client where they’re at. If I give them something to do that is so far off the radar of their expectations, they will likely not appreciate it or see the value in it. This begs the question- do I give them what they need, or what they want?
Again, the answer is, BOTH! Always both. Finding the sweet spot for every individual. Meeting them where they’re at.
I think the art of “finding the sweet spot” is one I will be aiming to master for the rest of my life…
Finding the sweet spot
As we can all appreciate, in a holistic model of helping someone reach their goals, we have to take all aspects of “training” into consideration:
Restorative stuff: Yin (stuff having to do with homeostasis of all systems):
Possessing ideal joint mechanics*
Ideal breathing mechanics
Sleep, nutrition, stress management, hydration, blah blah blah, for healthy organs and systems function
Exercise based stuff: Yang (training you do to push your body to do stuff harder, faster, better, etc):
Strength and power training
Skills/sports specific training
I would like to argue that biomechanics are like a mesh that surrounds and intertwines all aspects of the Yin and Yang of performance, health, and well-being.
For example, having ideal and efficient joint biomechanics (movement/posture) will help with breathing, reduce issues of compression on the organs, blood vessels, nerves, lymphatic system, etc, help the body stay pain free, enhance sleep, allows for proper digestion and elimination, and improves blood flow to distal body parts and the brain to enhance cognition and emotional regulation.
Having great biomechanics also spills over into all aspects of fitness and athletic development: the building blocks for producing force and power efficiently, and will impact on aerobic fitness by virtue of having mechanics in place for efficient breathing and economy of movement. Ideal biomechanics will lay the foundation for performing specific skills better, while also allowing an athlete to unwind from their repetitive specialized movements so they can get back to training the next day. Not to mention people with more efficient biomechanics will likely have less risk of injury and will take less time off training.
What do I mean by “better” biomechanics?
I’m talking about adult human gait mechanics of the Flow Motion Model as the “gold standard”.
Some may say that the “exercise stuff”- strength training with good technique, high quality technical skills work, will be enough to take care of the bio-mechanics bit in itself, and why spend time focusing on it?
“Squatting with ‘good’ form will keep you pain free”
“Animal Flow will fix your joint issues because it is ‘natural’, variable movement”
I agree to a certain extent, but disagree that people with real biomechanical anomalies will be “fixed” by good squat technique and simply getting “stronger”, or by pretending to be a monkey and crawling on the floor. (Note, I realllly love squats and crawling on the floor…)
Moving differently is great, but moving differently is still only a work-around for a specific issue or movement being avoided, whether conscious of it or not.
Yes, working specifically on changing the way people move and time their joint actions can be subtle, focus-demanding, tedious work, requiring daily practice, patience, and trust. Most meaningful work is…
That said, addressing biomechanics won’t automatically make you stronger. If coming from an untrained state, enhancing spine and shoulder mechanics, for example, will not miraculously bring you from zero push-ups to 5, just as if you are in pain, going from 0 to 5 push-ups may not reduce your symptoms.
Do you know your priorities? In your life? For your body?
Take a close look at what values, in the physical realm, are honestly important to you. Do you play a sport? Are you trying to maintain “fitness” as you age? Do you want to feel strong? Pain-free? For health enhancement and quality of life gainz?
Many people are unsure what they want out of a physical practice, and what they value in one. They may say they want one thing, like to be strong, or to be “in shape”, but don’t have a clear picture of what that means.
“Strength” might be a means to an end- Not the real value, but an expectation for a process.
Someone may perceive that exercise and strength training will make them pain free and perform better at their sport, and come in with an expectation that strength training, like they’ve read about on someone’s blog (not mine….), is what will get them to their REAL goal, which may have nothing to do with their level of strength.
I’ve been investigating what I truly value in a physical practice for the past several years, after my forced exit from the world of dance.
My primary value for my physical practice is to comfortably, confidently inhabit my body, at rest and in motion, and possess an awareness of it that allows me to heal myself when I get into trouble with it (which is inevitable).
What secondary values do I hold that bring my primary value to life?
Strength. When I feel strong I feel more confident and comfortable in my body. My definition of “strong enough” is probably different than that of others. I have no desire to compete in a powerlifting competition, or be an elite athlete, but I enjoy the experience of being in my body more when I can do push-ups, chin-ups, squats, and deadlifts.
Quality of movement. This is fundamental to strength development and so I prioritize my movement mechanics over getting strong. Can my joints do all the things their architecture was created for? I will not push my body in training beyond the point where my mechanics can take me.
Knowing my priorities now helps me to choose how to act according to my goals. As a dancer, my priorities were the inverse, and I was pretty depressed and in pain.
What if we don’t know what we really value? Or what if our perceived goals are not in alignment with what our bodies need? And what if our goals are not really our goals, but someone else’s goals for us? Then our approach to training will be off as well.
There has to be this sweet spot where our true values come together with where we’re currently at, and our method reflects and respects this. I think this space is met when we take the time to investigate what we really value, and is defined by acceptance, patience, and trust. A falling away of the ego and expectation for what we “should” be doing.
Maybe I’m getting a little philosophical now for a blog about biomechanics… But the method we follow matters little without investigation of the “why” behind it.
So, that said, I want to share two stories from two different dancers and how they view their priorities, and their take on biomechanics vs. strength training.
I recently met up with a reader of my dance blog in real life- A dancer/musician visiting Toronto from Europe. I’ll call him Sergio.
We met up for coffee and he told me the story of his discovery of strength training and of how, inspired by Pavel Tsatsouline, the simple addition of squats and other basic strength training exercises into his gym routine boosted his dancing because he was able to move more efficiently. This is how he found my blog- searching for information on strength training for dance.
If basic strength training had these effects on his body, why couldn’t everyone have easy access to this simple performance enhancement method? A sentiment that resonates with me as well, and is why I got into this field in the first place, spending three years focused heavily on working with dancers. That’s why I wrote a book (<— available by donation right now!).
Sergio wondered why I care so much about getting into the nit picky details of movement mechanics when performance enhancement is so readily available to anyone who steps into a gym and picks up a weight and uses progressive overload.
Again, I don’t disagree with this. I’ve experienced this performance enhancement phenomenon it for myself, and many of my dance clients have, too. And, as my role as a personal trainer, people are neither expecting nor asking me to help them with specifics of joint biomechanics that they aren’t even aware are a thing to work on.
But to get someone to squat on their flat, pronated feet that don’t know how to supinate makes me feel ethically wrong, and sooner than later I feel obliged to shed light on the client’s limitation.
Yes, initially getting stronger will probably make that person feel better. But let’s go back to the squatting on pronated feet example.
25% of the bones in the body belong to your feet. If 25% of your bones are not moving in a full body loaded exercise, like a squat, for how long will squatting be the solution until it becomes a new problem? Something else is going to have to move to make up for 25% of your bones that aren’t moving. Will it show up in a few days? Maybe a few months? Years? I’m not willing to ignore that and wait with crossed fingers. (And yes, your foot bones should have some movement when you squat).
Where Sergio is at now, he is prioritizing strength training. Is that wrong? I don’t think so, because we don’t have enough information!
In Sergio’s credit, he is very body aware, and has a deep practice of inner investigation. He knows when something is not right for him and knows how to change when he’s stuck in a pattern that doesn’t serve him.
But while Sergio claims he has no current troubles with his body, what I think needs to be considered is what happens in 5 years if he keeps strengthening, reinforcing, his body with possible underlying movement issues that he is not aware of? After all, he IS a dancer, and I’ve never seen a dancer (or a human) who didn’t have some issues with their body.
I am a good example of how Sergio’s mindset started off great, and then went horribly wrong (or right… depending how you look at it).
I fucked up.
Here’s a story about me, because it’s my blog and I’ll write about myself when I please.
When I initially started strength training as a 20 years old dancer, I noticed right away that the extra work capacity that came from developing strength through squats, deadlifts, and push-ups had a dramatic change on my dancing. I felt like I’d struck gold. Found the “missing link”. My teachers noticed I was dancing “better” and I started getting all sorts of positive attention from them.
But what happened over the course of two years? I became over-trained (because I wasn’t planning my training schedule properly and was working out 4+ days per week on top of dancing everyday for hours), and I got injured (because no amount of squats or deadlifts in themselves could resolve the underlying postural and movement distortions my body had ingrained over the course of my life thus far).
What I needed was to address my movement mechanics to support my training, both in dance and at the gym, and in life (to get some healthy blood back into my brain, to be quite honest).
Applying myself to strength training was like fixing an atom bomb to my proximal hamstring- Using a potentially useful science in a destructive way.
Unfortunately, Google can’t assess your structure
Advice on how to address your specific movement mechanics is nearly impossible to search for online. (Maybe that’s why you’re reading this?)
This is because the same injury may manifest in X number of different outcomes and no two people will have the same experience of the same injury.
A fully “healed” ankle sprain may show up years later as a laterally flexed spine or a rotated pelvis or a knee that doesn’t extend. So one can’t just go online, type in “exercises to fix an ankle sprain“, or “exercises for my sore SIJ”, and find the solution. Because Google can’t assess that “why does my back hurt when I squat?” is a result of an ankle sprain five years ago that has now manifested itself as postural and movement distortions through the entire skeleton.
“I want to strengthen my ankles”
I will use another example of a young Highland dancer I did a few sessions with recently. We’ll call her Ally.
One of her primary goals was to improve her ankle strength to help her jumping. If you don’t know what Highland dancing is, it’s hardcore. You basically have to jump on one foot for 2 minutes straight without moving your upper body or putting your heels on the floor, all while looking pleasant.
Check it out:
I noted that one of the most important assets for a highland dancer would be the ability to create a rigid lever through the ankle, holding a supinated foot shape throughout the high volume of single leg hops they must do in their routines.
The foot creates it’s most supinated, rigid structure in the toe off phase of the gait cycle, and so for a highland dancer, being able to access the mechanics of this phase- foot supination, ankle plantarflexion, is crucial to carry over into their sport.
Crucial to this is also the ability to create a mobile, adaptive foot that can leave the rigid state when they are not dancing to allow for “normal” gait mechanics for proper recovery from training and performing. Too, the muscles of supination will only get their chance to load during pronation, and so to not access pronation limits access to supination as well.
We need both!
Too, a highland dancer would need the ability to generate power from their hips, especially since dorsiflexing the ankle is going to be limited due to not being able to put the heels down during their jumps. That said, the hips are also going to be limited in how much they can load and explode as the dancer must stay perfectly upright, limiting how much they can actually flex from the hip to generate power (glutes load in hip flexion). Much of the strength is really coming from a partial range of motion in the ankle, from partially plantar-flexed, to fully plantar flexed.
Like I said, it’s a hardcore dance form.
Getting back to Ally.
Ally already lifts weights. She can squat and deadlift more than most teenagers, and so she already has a base of strength to support her dancing. But are her biomechanics in place for her dancing to benefit from the stregnth training she is already doing?
As it turned out in our assessment, Ally could not supinate her feet- both feet were stuck pronated, ankles dorsiflexed, especially her right foot. Remember, in highland dance, being able to supinate the feet and plantarflex the ankles is kind of really important.
Her hips also did not flex. Instead of flexing her hips, her ankles dump into dorsiflexion and pronation, she posteriorally tilts her pelvis, and flexes her spine. This means she does not load her glutes when she jumps- They stay locked short.
This also shows up in how she deadlifts- Hips unable to flex, so she massively dorsiflexes her ankles and pronates her feet. Is the way she is currently deadlifting helping her dancing? Or reinforcing inefficient movement patterns that will ultimately limit how much she can progress in her dancing? I am leaning more towards the latter.
In Ally’s case, I would prioritize her movement mechanics initially over adding “ankle strengthening exercises” to her training program.
When Ally asks for “stronger ankles”, what her body is craving is feet and ankles that can supinate and plantarflex to create a rigid lever to jump on, and hips that can experience flexion to help her load her glutes and generate more power in her jumps.
In her dance training and working with her technique coaches she would want to slow down to integrate the new mechanics. For example, as we’ve been working on helping her train her demi-pointe with REAL supination mechanics in place (as opposed to type 2 pronation- ankle plantar flexion on a pronated foot), she may need to take a few steps back in her dance training to make sure she can better use these mechanics. A few steps consciously, patiently, back can lead to monumental progress forward.
In her cross training with weights, she would want to focus on integrating the changes in movement mechanics into her lifts. As we’ve been working on helping her get REAL hip flexion (instead of the exchange that is taking place at her ankles and spine) she may need to take the intensity back in her strength training to make sure she can access a proper hip hinge. All the hours of cross training she is doing with her cross fit workouts may not be to her benefit unless they are reinforcing useful mechanics.
There is a balance to find. A sweet spot in training for any goal.
Does their goal truly reflect their priorities?
Is there necessary work to be done on basic on joint/movement mechanics?
How much technical skills training can their body take with the mechanics it currently has to work with?
What volume and intensity of strength training will enhance their performance without reinforcing old movement habits that are not useful?
And how to package this in a way that inspires trust in the process?
These questions haunt my dreams.
But this sweet spot is not a perfect 50/50, or 25/25/25/25. Balance may mean 75/25, or 80/20, and this depends on where you are now, where you’re coming from, and where you’re going. And the purpose of one’s training will never be fixed, but always changing, day to day, week to week.
As in Ally’s case, as highly trained Highland dancer who already has a solid base of strength, it is my view that addressing her joint mechanics will likely have the biggest impact on her performance goal, and this point in her training. For now.
In Sergio’s case, as a highly trained dancer with no current injuries, adding in something he didn’t have in his training-Strength development, made a radical difference in how his dancing felt. Ain’t nothing wrong with that. For now….
But for both, neither solution will last the course of time. Things always need to be reassessed and adjusted based on where the body is now.
When I was a hypervigilant, chronically-in-pain person, low threshold, restorative work helped me find balance. But then after a few years of that, to restore balance, I needed to also explore the other spectrum (which I did through Hardstyle kettlebell training).
It’s more a question of constantly asking and evaluating “What’s missing that is preventing me from doing what I do better”? Where are you not supported in your training? Where are you not supported in your life?
“Overall, these exercises are much harder work than the physio I was doing before, in that I have to really concentrate on small things. Can’t just put myself through them. Have to be present. It’s good. It’s why I sought you out rather than doing more straight up physio as I kinda knew this was what was missing, what needed to come next.”
This is an from an email sent to me by a lady that I am working with after, our second session.
We’ll call her Jean (not real name).
Jean is the epitome of the perfect student of exploratory movement, and I think the quote above sums up nicely just what that means.
When the body is in pain, generally there are three main systems we are working with:
Mindset and emotions (perception of experiences, chronic negative emotional states etc.)
Organ and systems health (digestive, immune, etc)
Of course, these three become an inseparable web called a “life”.
As a body-worker, some things I can help with, and some things I can’t. For the individuals themselves, one thing they can start to work with that doesn’t cost a thing is the mindset bit.
Jean’s mindset is on point with where one would want it to be to make changes and heal other systems, and I want to use this blog post to explain a little more about what I mean by that- having a mindset to change and heal.
Because “healing mindset” isn’t this woo woo, think positive, manifest good health and meditate on being better you’ll be ok… It’s about engaging with the work.
When the standard approach fails…
Jean found me through my dance blog that I’ve since taken a break from writing on (danceproject.ca), but she is not a dancer. She is a pianist and also participates in horse riding and dog sledding.
Jean is in her 50s and has been experiencing pain for many years but had stopped seeing her physiotherapist because it wasn’t doing anything. When I first met her she expressed that she was frustrated with the care she was receiving from physio because they were only looking at the parts of her body that hurt: Her right knee and hip primarily. But they weren’t looking at the rest of her body, and Jean had a strong intuition that this was the reason things were going nowhere. She felt very distinctly that there was something going on with her upper body that was related to her knee and hip issues, but no one was looking there.
Smart lady to listen and act on her intuition.
Looking at the location of symptoms as “the problem” and stopping there is the standard approach. The approach that says, “treat the symptom”.
Luckily (I think…) for me, I never learned the standard approach because a) I went to school for dance, not for whatever it is I do now*, and b) all my most influential teachers are out of the box thinkers, who don’t ascribe to the standard approach and aren’t afraid to go against the norm, old-school movement paradigm. Maybe I’m missing out? I’m ok with that.
Jean was pleased that our initial assessment looked at her whole body, from her toes to her skull. Isn’t it nice to be treated like an entire person? Don’t you hate it when people only see you for one aspect of who you are?
*What do I even do? I dunno. I work with bodies and movement. I get people to move their joints in specific ways. I sometimes massage them, Thai style. I sometimes have people deadlifting heavy things if they want to. But the end game is always for them to have a different experience of their bodies, push their comfort zones, and access the movements their bodies are currently missing. What’s my job title? You tell me…
Ready for an AiM-style geek out?
For the Anatomy in Motion (AiM) students like me 🙂
Here is how Jean showed up (some interesting distortions):
Pelvis: Right hike, left rotation (stuck in right suspension)
Spine: Right lateral flexion, right rotation (stuck in right suspension)
Right knee: Can’t externally rotate (can’t access right suspension)
Right foot: Can’t pronate (can’t access right suspension)
The story her body was telling me was that nothing from the hip down knew how to pronate, and her pelvis, spine, and ribcage were trying to make this happen for her. Or, maybe her pelvis, spine, and ribcage were trying to stop her foot and knee from needing to pronate because it felt unsafe?
Regardless of the story I choose to attach to her structure, what I was witnessing was an exchange (something I wrote aboutHERE).
We can consider that in the phase of gait in which the foot pronates, that the entire skeleton is organizing itself to allow pronation. It’s not just a foot pronation, it’s a whole body pronation. In AiM this whole body pronation phase is called suspension.
As mentioned above, while Jean ‘s pelvis and spine are pronating, she is missing some very important pronation mechanics below: Foot pressure not getting onto the anterior medial calcaneous, foot bones not spreading and opening on the plantar and medial surfaces, and femur not rotating internally over the tibia.
If things aren’t happening below, something up top may need to do this for her. In her case, I believe this is why I was seeing the type two spine mechanics (same direction lateral flexion and rotation), right pelvis hike, and left pelvis rotation. If you can’t pronate below, something must make up for it above, or next door. A useful strategy to help her make up for a hip, knee, ankle, and foot that don’t pronate, but not an efficient way for the body to move that will stand the course of time.
Want to try this for yourself? Stand with your feet side by side and:
Put your weight primarily on the outside of your right foot
Hike the right side of your pelvis
Twist your pelvis to the left
Twist your ribcage to the right
Laterally flex your spine to the right
Not an effortless posture to hold! Feels pretty terrible for the right hip doesn’t it? No wonder Jean was having some issues, eh? But somehow this was the most efficient way her system knew to hold herself based on that tangly web of “life”.
So, we have really one of two options for how to sync her joints back up. We can:
Teach her foot and knee to pronate to match the rest of her body.
Get her spine and pelvis to experience the other end of the spectrum (left lateral flexion and rotation) to free up the opportunity for her right foot and knee to safely experience pronation.
Or, more realistically, probably do both (and we did both).
Anyway, that’s just a little bit of background on what she was dealing with to provide some context.
The mindset for healing
What I really think is beautiful to share about Jean ‘s journey so far is her mindset and attitude embracing the process that I suggested we follow.
If we come back to the quote at the top of this post, from the email she sent me, I’d like to break down what is so lovely to take from it, particularly if you are someone who has been in pain for a while, like her.
“These exercises are much harder work than the physio I was doing before”
In AiM, we try not to call the movements we do “exercises”.
This is partially because of the connotation the word exercise has for many of us.
“Exercise” brings up images of a gym, performing a set number of repetitions of a movement with the end goal of getting stronger, or more flexible, or sweating, or punishing ourselves for eating cake, or burning a particular amount of calories, or making ourselves vomit from effort, or escaping from reality, or for mental health, or cardiovascular health, or whatever our notion of what exercise is for may be.
And so the word “exercise” comes with undertones of needing to get something out of it, which is not what we’re trying to teach with the AiM philosophy. The goal, instead, is the process itself: Exploration and learning; investigative movement. To show the body a new way of doing things. Give it an experience.
How often do we go into an experience expecting to get something out of it, and missing the meat of the experience itself? Like going to a concert, and watching most of it through your phone to get that perfect video memory of it (done that…).
The movements are simply to immerse the body in an experience it doesn’t usually get to have. To access joint motions that are currently being avoided. To move into new airspace and dark zones where learning can happen. To open up new options for movement that had been denied. To reorganize the skeleton and resultant muscle tensions.
Per Gary Ward’s big rule of movement #2, joints act, muscles react (from What the Foot). We want to give the muscles something different to do by moving the structures they attach to, not by trying to strengthen and stretch the muscles in an attempt to control the skeleton.
To quote something Gary said on an immersion course:
“The presence of muscles that contract first before lengthening will always be present in a system that doesn’t flow.”
Some people report they feel “stronger”, or they are getting more “flexible”, or they have more energy, as a result of practicing the AiM movements, but these are only secondary to showing the body a more efficient way of moving.
How many of us have truly investigated our relationship with exercise? I did this in 2015 as an experiment and I would encourage anyone to do the same. I stopped anything that felt like exercise. I wrote two blog posts about it and the ensuing existential crisis here PART 1, and here PART 2.
Many of us are forced to investigate our relationship with exercise only when exercise has no longer become possible- after injury in particular, as was my particular case.
At this point we have a choice. To go back to the way of doing things before injury, or to try to understand that how things were being done “before” is what led to being in this state now.
“I have to be present. I can’t just put myself through [the motions]”
Not to go mindlessly, counting down the reps of the homework exercises until they’re done, but to be fully immersed in the experience.
In fact, I rarely give a specific number of reps to do. Why? Because the goal is not to get to 10 reps. The goal is to be immersed in the experience of the movement. Its not what happens when you get to rep 10, its what is learned in the space of reps 1-9.
There will be a distinct sense of “knowing” when you’re done with a “set”. You’ll feel something has shifted. You’ll feel things working that haven’t worked in a long time. Your brain and body will simultaneously say “enough!”. But to know when you’ve reached this point means you must pay attention to what you are feeling. It could happen in 3 reps, or it could happen in 12, but you have to tune in to this feeling.
In Jean ‘s case, the foundation of our process was to tidy up the coordination of the joints that were out of sync: Change the ratios and timing of pronation through her entire system, from her foot up through her spine.
It took a lot of focus and energy on her part. She had to tune into parts of her body that she had no prior awareness of and the movements they were capable of performing.
Just being able to feel where the weight in her feet honestly was through all the noise in her system proved to be a challenge.
“Where am I, and where am I not”.
Had Jean simply counted to 10 and gone through the reps without awareness, she would be moving too quickly and automatically to learn a new pattern or to feel whether she was moving the parts that we were actually aiming to move.
In the book Don’t Sleep There Are Snakes, Daniel Everett tells a story of how the remote Amazonian tribe he is living with, the Pirahã, do not use numbers or math. He tried to teach them simple addition, but they didn’t have any prior experience with the concept of numbers or adding and would not learn. What if for some people, areas of their bodies feel like math did to the Pirahã? They could learn math if they wanted to, they have the same brains as every other human, after all. But they have survived so long without it, found a way of living without math, why start now?
“I have to concentrate on small things”
We weren’t going for big sexy movements, but small, precise ones. She needed to tune into how things felt rather than just perform the motion.
Can you get your weight onto the anterior medial part of your heel?
Can you drop your right pelvis lower than your left?
Can you feel your spine bend to the left when you reach your right arm up?
As a closed system, changing one thing about the body must cause an adaptation from everything else. One degree can throw the entire system off.
If the pelvis isn’t level by one degree, everything else will be off by at least that much, probably more. If you draw two lines originating from the same point, one degree apart, how far apart will the two lines be after 2 inches? One foot? 100 feet? One degree matters, especially if there is pain present.
So for Jean to accomplish just several degrees of movement from a joint she doesn’t normally even have awareness of, or feel a change in where she is weight-bearing on her feet, while subtle, feels like an entirely different place to put the body. Off balance. It’s only a matter of degrees, but the brain starts to freak out because it doesn’t know where it is, and this is where the learning happens.
It takes so much more energy to focus on and feel the subtle differences I am describing than it does to squeeze your butt 10 times while thinking about what’s for lunch, and so for Jean, our work is hard not necessarily for the physical effort required, but for the ability to tune in, cope with change, and integrate it.
Not a “fire this muscle” approach, but a “move your structures into new spaces” one.
“I knew that this was what was missing”
“What’s missing”. In AiM philosophy, it always comes back to finding what’s missing, and claiming it back.
In Jean’s case, what’s missing was all of the above: Having her whole structure addressed, being asked to tune into her body, feel the parts she wasn’t aware of, move in ways she normally does not, access joint movements she has not felt for years, and do this subtle work in a completely present way.
I think Jean’s experience rings true for many people, certainly for myself in the past: Get hurt and go about getting treated in a way that has no expectation for us to engage with the work and be a part of our own healing process. Lie on the table and get worked on, without an expectation to do any work.
People are rarely presented an experience that allows them to heal themselves, and many people will rarely look for one because they don’t know what they don’t know.
In fact, in our first session Jean said:
“I’ve experienced body work of different sorts. But body work is something being done to me. It helps to get things to let go, to wake up things that are shut down. It does not teach my body what to do when I get up off the table. I feel like as soon as I move I’m going right back to whatever caused the problem in the first place. I need someone to teach me how I myself can get my body to swap out dysfunctional for better, consistently, and long term.”
I knew right then that we were going to get along great.
If things are not changing in your body, ask:
Are you treating it as a whole system, or as separate parts?
Are you being present with it, or just going through the motions?
Are you checking in with it daily, or ignoring it’s signals?
Are you moving with awareness?
Are you moving out of your comfort zone, accessing ranges that you don’t usually move into, or sticking to what you know and normally do?
Are you determined, trusting, and committed to the process, or feel doomed to be stuck forever?
The real healing happens in the space of engaging fully in the process. Like Jean’s begun to do.
Realizing that the process is the goal.
“It’s the sides of the mountain that sustain life, not the top” ~Robert Pirsig.
Jean always mentions how because she is “old”, she is having a hard time at making changes. But I don’t think this is true. I think she is doing incredibly well at making changes because of the attitude she has towards her journey. Its not a race after all, and it will take the time it’s going to take.
Time doesn’t heal, but what you do with the time you have to heal, will.
I recently started a small group six week program that meets Sunday mornings. I unofficially call it “Church of Core”.
Its a program designed under the premise that, being that there is so much misinformation on the internet, in the media, and from people at the grocery store on what we should be doing to “train the core”, there should be a class to help people understand the truth of how the body moves so they can make their own informed choices on what to do at the gym.
And honestly, do whatever you want at the gym. It’s all good. Do what makes you happy. Just make sure your body possesses and understands the mechanics to cope with those choices.
I wanted to share a little case study from a participant in the program who was having some issues.
Twist and shout (ow)
Nancy (not real name) is a dancer in the program. We had just finished day two, in which we’d explored sagittal plane spine movement and stability, and she asked me if we were going to look at rotational movement next, because she was having some issues that and she had a big dance workshop weekend coming up. I said, yeah, come early to church next week and we’ll take a looksie.
Nancy’s primary complaint was that left ribcage rotation caused a straining painful feeling through her left side from her pelvis up to her ribcage. This is obviously an issue for a dancer because rotating is kind of a big deal in a lot of dance movements. She got the same symptoms with right pelvis rotation- Pain and tension through left obliques. So it’s not just a left spine rotation issue, its a transverse cog issue.
In AiM, “cogs” refers to the role in gait of structures moving in opposition against each other, like turning cogs. In gait, the pelvis and ribcage have a cog-like motion in that they should always oppose each other’s movement in all three planes of motion: In normal walking, when the the pelvis rotates right, the ribcage should rotate left.
In the case of Nancy’s symptoms, it was not just a ribcage rotating left issue, but an issue with any part of the gait cycle in which her left leg is forward (pelvis right) and her upper body is swinging to the left (ribcage left).
It’s nice when things make sense like this because they sure as hell don’t always do.
Her chiropractor identified that her issue was her left external obliques. Let’s look at why her obliques might be complaining about this rotational pattern.
Obliquing, long and short
If we’re going to blame a muscle, it stands to reason that we should know if its sore because of concentric shortness/compression, or it is locked long, under eccentric load.
Left ribcage + right pelvis rotation will lengthen the left external obliques, as the left EOs rotate the spine to the contralateral side
So, we could infer that the muscle is not happy with being loaded eccentrically to decelerate left spine rotation.
In the case of many muscles strains, the tissues have become locked long and because they are already loaded and lengthened they will have trouble decelerating joint movement because they’re already stuck doing that all the dang time.
In Nancy’s case we want to know WHY left spine rotation has become an issue to manage. Why are the obliques being lengthened all the time? Perhaps there is something NOT happening in this rotational pattern that the left obliques are picking up the slack for?
Time to stop thinking about muscles
I’m not telling you what to do, but muscles are confusing and chaotic. Looking at joint motions makes things much less noisy.
To quote Gary Ward, “Would you rather look at 13 muscles that connect to the knee or look at the 4 movements it can do?”.
I’d rather work on 4 things than 13, personally.
What stood out in interviewing her body was that her right talus was positioned internally rotated, everted, and could not externally rotate and invert. The chances of her right foot being able to supinate were pretty slim. This turned out to be key for helping her access left ribcage rotation with much less discomfort.
In the Flow Motion Model™, whenever the talus goes right, the ribs and spine go left, and when the talus rotates left, the ribs and spine go right.
This is because the rearfoot and pelvis always move in the same direction in transverse plane in gait (in all planes, actually), and recall that the ribcage and spine always oppose the pelvis.
So we could infer that the ribcage and spine should always oppose the talus*.
Therefore, if the talus can’t go right, another structure might have to go right MORE in order to accomplish every phase of gait in which the right foot supinates (and that’s most of the gait cycle, FYI).
In Nancy’s case it seemed to be the spine/ribs trying to rotate excessively to make up for a lazy right talus. And what might get tired of decelerating this motion over and over? The left external obliques.
Supinate the shit out of it
So we got Nancy’s foot to experience supination with her foot tripod grounded on the floor. With a little nudging and wedging, her right talus obliged and started inverting and externally rotating. Sweet.
We then integrated it into a pattern that required her to do left spine rotation and right pelvis rotation (we chose right propulsion phase). What was cool was that as long as her right foot was supinating, she could access left spine rotation with almost no discomfort.
When she retested her rotations there was significantly less discomfort than before. Her right talus was also sitting less everted and internally rotated at rest.
The entire process took about 20 minutes. Then we hugged and went to church.
*Talus and ribcage always oppose… Except for that fraction of a second in which gait is homolateral!
Few things, I guess:
Learning to work with the FMM and AiM philosophy makes connections like this possible.
Blaming muscles for issues doesn’t provide enough useful information. I was not thinking about what muscles were tight or overworking of facilitated or inhibited while I was working with Nancy (which would have driven me crazy back when I used to do a ton of Neurokinetic Therapy® testing). Saying “it’s my oblique that’s the problem” doesn’t tell you why. Muscles react to joint movement. The answer will show in the structures, their position, and the movements they can and cannot do.
Thinking about her oblique pain in terms of concentric muscle action might not have led to the same resolution, but thinking eccentrically made a lot of sense in this case.
The “talus drives the bus”, and its useful to know how movement of the foot affects movement up the chain.
Knowing how to palpate the talus is a useful skill (that I didn’t have until very recently, thanks to “Foot Dating” on an AiM course).
It really is true that one of the most powerful experiences for the body is just to help the feet to experience true pronation and supination.
I used to be very flexible. I still kind of am. But it’s weird. It’s a slow grind to get my hands to the floor in a forward bend, but I can still bust out a middle split anytime, without warming up, provided I’m wearing stretchy pants (and I’m ALWAYS wearing stretchy pants because I made excellent career choices).
Back when I was training to be a dancer, being able to do a split cold was a useful thing (or so I thought…).
For the degree of comfort and freedom with which I could inhabit my human body, this was not a useful thing. Not useful at all.
However, I would be ignorant to blame my problems on my flexibility. The fact is I made dumb choices. I lacked respect and awareness for my body, and did not value honesty in my experience of it. I did not listen to my body. And I did not have patience for when I wanted something to change about it.
Flexible as I was, I was trapped in my body.
Well, you live and you learn. Sometimes the hard way.
I learned that my body feels much better when I don’t stretch. So I don’t stretch anymore because I consider myself not to be a complete idiot.
So… What’s your point, Monika?
“I should stretch more.”
“I never stretch, that’s probably why my body feels so tight all the time.”
“I do the hip stretches, by they just keep tightening back up.”
Stretching and mobility work are a popular go-to when something doesn’t feel right in the body.
Back in my dumb(er) days, my left hamstring felt really “tight”, so I stretched it daily, for months. Then, I strained my left hamstring while I was stretching in jazz warm-up one day. Pretty dumb, eh? Well, I was only doing what I thought was right based on the information I had, and I thought stretching would set me free.
My client came in the other day saying that his shoulder felt “tight”, and, “can we do some stretching for it?”.
Another client comes in every week with low grade back pain that she describes as “tightness” but that it’s fine because she just stretches it out with yoga (to which I question, if that “works” then why do you show up every week with the same back pain?).
In the case of the “my shoulder is tight” client, his shoulder didn’t need stretching (because the area in which he felt discomfort was locked long, not short). But we did a thing that I labelled a “stretch” (to get him to him trust me), and afterwards, when he felt better, I then explained to him that it wasn’t actually a stretch and why what we did worked. That’s my sneaky way of getting around arguments over movement paradigms: Don’t take it from me, just fucking feel it in your body.
My point is that stretching will lengthen a muscle, but it doesn’t necessarily teach that muscle anything. In the words of Chris Sritharan:
“We’re not trying to stretch a muscle, we’re trying to give it something to do.”
I want to make the case that how much motion a joint possesses, aka, stretching things to increase flexibility, is less important than other factors, like, understanding the context of the movement, the intention for the movement, the timing and ratios of movement, and the specificity of the movement to your body’s needs.
If flexibility and stretching were the solution to the body’s problems, then contortionists would never have issues. Ever. But they do. Explain that for me with stretching logic.
I want to make the case that before trying to provide more novel movement experiences and manual therapy we ask better questions. It more useful to ask questions like “why is it tight?”, and “what movements am I avoiding?” than “what stretches should I do?”.
In fact, this blog post sprung from my feeling exceptionally insufficient at the skill of asking questions.
What’s the truth about what the body needs at this moment? Is that muscle feeling “tight” because of length or shortness? And what will set the body free, at this moment in time, from the habitual things it is doing that are keeping you “tight”?
Set the body free
In my mind, the body craves freedom.
Stretching may or may not be part of the process, but the end goal is to set the body free.
Freedom to move the way you want to. Freedom to sit on a plane for 10 hours, and not be crippled fro days afterwards. Freedom to take risks with your body without fear. Freedom to take up a random sport and have the basic body mechanics to perform it without injury.
Freedom is having options.
My favourite definition of freedom is from Krishnamurti’s book Think on These Things. I feel that his definition applies particularly nicely to the body, too.
Per Krishnamurti, freedom means:
Not to want to BE anything more than what is. To be free from ambition.Acceptance of the “tightness” or soreness or whatever our bodies are experiencing. Not seeing the body’s limitations as a drag, but as something to be curious about and explore.
A state in which we are are not acting out of fear or compulsion, not needing to cling to a sense of security or protection. Sometimes we stretch out of compulsion and fear, because it makes us feel like we’re doing something useful when we don’t know what else to do. That’s what I did with my hamstring.
Not to operate based on traditions or do something just because other people are doing it. It is often part of the tradition of various sports/movement forms to do things a certain way, i.e. stretch a certain way, warm-up a certain way, and so we keep doing things that don’t help us simply because it’s the way things have always been done.
To be able to understand who you are, and what you are doing, moment to moment. Moving with awareness, not just mindlessly going through motions. To be aware of all the moving pieces of your body, and even to be aware of the parts of your body you are less aware of…
And,not just to be able to do or say whatever you want, or go wherever you wish, but to understand what is happening, and why. Without awareness of how your body is capable of moving, and NOT capable of moving, freedom is not possible. An example is a client of mine who ignores when her elbows hurt, yet she performs exercises that make her elbows hurt, just adapts them by moving around the issue- bending her elbows when they should be straight, flexing her spine when it should be extended. Even though this is keeping her stuck with sore elbows, she would rather do this than face the issue and understand the root of it. Another example could be an elite level gymnast who can move in ways that most people can’t, but by choosing to be extremely mobile and highly skilled mover, what other, more fundamental options has she limited herself of that may be keeping her below her true potential? The same is true for being stuck in any specific posture or trained way of moving.
Freedom, therefore, by this definition, is more related to understanding than it is to acting. More awareness, less “solutions”.
I believe this is a massive tenet of the Alexander Technique. AsLaura Donnelly, my friend, a dance teacher, and Alexander Technique teacher (also my editor for Dance Stronger), recently wrote to me in an email (as it relates to people wanting a quick fix to be free of pain):
‘…They want something “to do” to “fix” what they perceive is wrong. Not understanding that the thing they think is “wrong” is likely just a loud communication from the body. They also don’t understand that sometimes what they need “to do” is “not do”.’
BOOM. Before jumping on Google for the latest stretching/yoga/mobility flows, just stop what you’re doing and check yourself. Go quiet in your body. What’s it actually telling you?
As expressed by Byron Katie in her book Loving What Is,
“I don’t let go of concepts, I meet them with my understanding and they let go of me”.
The same holds true for the body as for the mind. Meet the body with your understanding, the information you receive will set your free (if you do the dang work!).
The most useful information you can have about your body is:
Where am I? Where am I not? (your center of mass is where?)
How can I move? How can I not move? (what ranges, planes of motion can I/can’t I access?)
Where are joints stuck open? Where are they closed? (compression/decompression based issue?)
What is locked long? What is locked short? (muscle tension or shortness based issue?)
In Anatomy in Motion we use a systematic process to find out the answers to these questions: What movements and positions the body is and is not currently accessing. But it’s not a process of “doing”, it’s a process of “checking in”.
But to make sense of this information, we need to know what our context for understanding it is.
What the f**k is my body telling me?
Information is useless if we have no context for it.
Check out this flow chart I drew:
So what do I mean by context and intention for movement?
Let’s talk context first.
Whether you’ve got missing parts, extra parts, or fused parts, gait happens
What I love about Anatomy in Motion is that the context is so clear, specific, and relevant to human bodies: The gait cycle. The perpetual movement cycle of a closed system.
Before we did any other learned movement, we taught ourselves to walk. It was hardwired into our brains. We didn’t have to watch anyone learn to walk and imitate them, we just did it because it is a part of being human.
Soccer is a trained skill. Dance is a trained skill. Walking, on the other hand, is a context we all inherently understand at some level. Whether your number one hobby is, like mine, nerding out on gait mechanics, or you take it for granted on a daily basis that you have legs, we all “get” walking on an unconscious level because we’ve all put in the time teaching ourselves to do it.
What blows my mind is that with each step you take, every joint in the body has the chance to move in all three dimensions. Every single joint action your body is capable of performing happens in the time span of two steps. If that doesn’t blow your head off… go read something else.
That said, walking isn’t contemporary dance. The total range that each joint goes through isn’t that big, it just needs to be big enough for whatever the demands of your life are.
In gait, many joint actions happen on a very small scale- like the total movement of the tibia per step, which is something small like 10 degrees. That said, every degree of motion matters. If one degree changes, everything else has to adapt to it. And I would argue that the ratios with which joints are moving against each other matters more so than the total range of motion they possess.
This is why stretching to get more flexible doesn’t always help people move better.
Muscles react to joint motion, and if we don’t change the timing and ratios of the joint movements themselves, the muscles will not get the stimulus to do something different. They will stay stuck short, or long, or cranky, and stretching won’t change a timing issue.
I am a good example of this. I used to be a lot more flexible and move a lot more shittily. Life was not better when I was more flexible. Just because I had 180 degrees of hip flexion didn’t mean it was coordinating in the appropriate ratios at the right times in gait. In fact, my hips had no fucking clue what they were doing.
May 25th 2017 marks the day I discovered what real, honest hip flexion feels like. How the heck have I been walking for all these years bypassing hip flexion? Never. Going. Back.
Stretching doesn’t teach timing.
What’s more important: How much my hips move, or how they move in relationship to everything else? There’s that context thing…
You can lie on your back and pull your shin towards your face, but that won’t necessarily teach your hips how to flex and hamstrings to load in context of ideally timed gait.
Let’s talk timing and ratios.
Timing infers understanding of when a particular joint motion should happen in gait (or any movement pattern). If we know when it happens, we also know what other joint actions should be happening at the same time. And so we can change the timing of joint motions by coupling them together with other joint motions that should be occurring at the same time in a given phase of gait creating a whole movement experience.
The body, genius that it is (much more intelligent than our conscious minds which got us into trouble in the first place), is hardwired to recognize a useful movement pattern, and will naturally choose the movement option that feels most efficient. This is Gary Ward’s 5th law of motion from What the Foot:The body is hardwired for perfection.
By ratios I mean how much one joint will move compared to other proximal joints within a given context (and moment in time).
For example, in the transverse plane, at no matter which point in the gait cycle, the talus, tibia, and femur should all start their journey of rotation- internally or externally, at the same time.
However, the talus has much less potential movement than the tibia, and the tibia less than the femur, and the femur has less movement than the pelvis sitting on top. While all joints are moving in the same direction, there is an ideal ratio for how much each bone should be moving against the other for optimal efficiency.
What can easily happen is the joint(s) with the least amount of available motion can lock up, and other structures move more to make up for this. So is there an issue with timing or with a ratio? They are same same but different. An issue with a borked up ratio is going to result in a timing issue.
Meet Person X
To go deeper into this example, let’s say that as Person X walks, they have a talus and tibia with no rotation, a femur with just a tiny bit of movement, and a pelvis and spine that rotate way too much to make up for it. Maybe this is causing the individual some hip and back discomfort, limiting their squat depth, or something like that. This is a hypothetically scenario, but actually, Person X is a real person I’ve worked with who has a tight back and limited squat depth.
So what do we do?
Before we start to stretch and mobilize the ankle and hip, and stabilize the pelvis and spine (the standard approach), we want to consider how we can help the body to redistribute the ratios of movement in these joints in a more ideal way in context: How do these structures coordinate in gait, and how can we change the timing?
Let’s ask the flow chart questions for our person X example:
What is the incongruence?(What’s the raw information?):Talus and hip not externally rotating to re-supinate the foot while spine and pelvis rotate too much.
Where is it happening? The primary structures involved are the talus, tibia, femur, pelvis and spine (but we still want to zoom out and consider the whole body)
When does that happen? (in the gait cycle): “When” refers to a phase of gait. The talus is not externally rotating from it’s pronated state which begins to happens in the transition phase of gait (aka mid-stance for non AiMers), and continues to do so through to toe off. So our “when” could be transition.
How is it happening? (what does the global strategy look like? What’s the exchange?): Whenever person X takes a step, the foot doesn’t supinate from a pronated state. The talus doesn’t externally rotate, the femur doesn’t externally rotate, and so it looks like a spine rotating back and forth as the leg is stuck rotated internally. The talus and femur have exchanged movement for the pelvis and spine.
Why is this happening? (intention for limited talus/femur ER): This comes from the individual’s history. Person X experienced an inversion sprain to their ankle a few years ago, and, because rear-foot inversion and external rotation always couple together, externally rotating the talus into supination is associated with past injury, making the ankle feel vulnerable. So to make gait possible, the clever body has decided to change the ratios: Instead of talus externally rotating into an unsafe space, the pelvis and spine will rotate instead. Useful short term to protect the ankle, not useful long term for the compensating structures. Not a liberated experience of the body.
This leads us to another key aspect of understanding movement: Intention.
Intention for movement
Movement does not happen for it’s own sake, there is always a goal, as is the case in Person X’s locked down talus: Protect the ankle!
I reach my arm out and grasp onto a cup of coffee, not for the sake of moving my arm, but because I wish to drink the coffee to bring my sludgy, morning brain into a state of greater alertness, aka baseline (I am sad that I need coffee to get to baseline). I care more about the sensory experience of having coffee that results from the arm movement than I do about the arm movement itself. No coffee, no arm movement.
This is true for all movement.
Why would the body choose to lock down a joint, like Person X did with their talus? Why did my left hamstring get so dang tight? Because it is serving us in some way. If it wasn’t, it would happen. These solutions, however, can become our problems if we leave them long enough.
After an injury, the intention of a movement strategy is often to protect a vulnerable area. But it can also be because of a learned movement pattern that was useful in a sport, or a habitual way of moving and holding one’s self for any number of reasons.
To go deeper into WHY the body is doing what it is doing should be a prerequisite for stretching anything. But I never learned that until it was too late.
Things became much more interesting for me when I started thinking this way. The word “compassion” also came to mind. A challenge to really understand the experience of each Person X in front of me. To really understand myself.
The level of WHY, after all, is where all the good, interesting, change making, liberating stuff happens. At every level.
I think there is so much value in getting deeper into this philosophical space. Not everyone will agree with me on that, and I was even told once after a movement session I held (for the IADMS conference last October in Hong Kong) that I was being too philosophical.
If we are not inquiring into our thought process behind helping people to change their patterns, then we are missing something huge. We are missing compassion. We are missing the desire to really understand the people who are trusting us with their bodies.
Helping people to set their bodies free requires helping them to develop an understanding of how they are moving and holding themselves. This takes patience and honesty. It takes, on my part, an understanding of the intention behind the way they are currently moving, and to do this, I must ask better questions. I must be clear on the context, and specific in how I provide an experience for them to access ways of moving that they currently are avoiding.
As Gary Ward once put it:
“[AiM is not] novel movement. I see AiM as a specific investigation of the whole system, which when scoped out should give you the information that helps you 1) understand why the person has X pain, and 2) help them be rid of it”.
I feel that I had to write this blog because the ideas I wrote so strongly about here are the very things that I currently am not doing well enough. I get so caught up in trying to read someone’s structure and find the solution that I forget to ask “why are they like that in the first place?”.
Meet them with your understanding…
The other day I worked with a lady who had a spine that was completely laterally flexed and rotated to the right. I thought I knew right away what was happening, when in time that happens, and what I wanted to do with her, but I realized only after our session I didn’t ask why. Our outcome was successful- her spinal curve straightened up within a few minutes and her pain decreased, but what now? Without knowing why that happened, where do we go from here?
Or maybe it doesn’t matter. Maybe the story isn’t important. But this doesn’t ring as true.
I suppose my conclusion, and lesson for myself is to slow down and ask more useful question.
(This isn’t actually a “principle”, but what I feel to be a useful way of thinking.)
There are lots of stories of quick fixes on the internet. Stories of people who have been in pain for years, and then, in one minute become completely pain free. Stories of magic treatments and “voodoo”.
Naturally, when people are doing well they want to share it. Nobody makes Facebook posts about how much their lives suck and how bad they are at their jobs. Actually… Some do. But for the majority, we want the world to see how awesome we are, and so we rarely share the challenging cases where things didn’t go so well and what we could have done differently.
We also don’t always hear about the follow up story to these “miracle fixes”. Were they able to maintain their new pain free state? How long did the fix last? What are they doing now to make sure their bodies can manage the stresses of life and not get hurt again? How might they have needed to also change their lifestyle for the long term?
And importantly, not all cases are quick fix, minute-miracles.
Most cases go something like:
“I keep getting X worked on, and it feels better initially, but then it hurts again in a day or two.”
“When I do the exercises I feel better afterward, but then get worse again as the day goes on.”
“Nothing has helped so far. I don’t think anyone can help me with X.”
I personally was not a miracle fix. My body was all kinds of wrecked from years of treating it like shit, and my mindset was fixed in a doomy place, reluctant to change.
Some therapists made my pain worse, some had no effect, and some admitted to me that I was complicated and they weren’t sure what to do (I appreciated the latter the most). Some therapists didn’t give me exercises when I asked for them, and some gave me exercises that I didn’t do.
Then there were treatment strategies that made my body, as a whole, feel much different, like I was moving in a positive new direction, but still didn’t take away the pain I was experiencing daily.
Many cases, like mine, are long hauls uphill. In these cases, it is easy to give up, lose hope, and resign oneself to being in pain forever.
What is the difference between these “miracle fixes” and people like me?
We don’t learn much from the quick fix. But from the challenging uphill cases we can learn a lot. I’m more interested in the intricacies of the uphill journey through pain. What sets these people apart from the quick fixes?
In contemplating this, the word tolerance comes to mind and I’d like to explore that thought a little.
BE LIKE SISYPHUS
I have had those sessions in which a client has experienced the “miraculous” one minute fix. For example, years of knee pain gone after three reps of one movement. What happened? Did we accurately reintroduce a missing movement that the body was craving for to feel safe? If yes, why does this work for some people, but not others? Is it a matter of “not the specific movement that person needed”? Or is there more at play? (there is indeed much more at play with pain.)
I don’t know. I can’t explain the mechanism for instant pain relief. What I do know is that what is most important is not to stop there, not to consider the work “done”, but to keep going with the process. Keep building up the body’s tolerance.
However, most of the people I work with who come to me with some kind of pain symptoms, do not experience the “instant fixes”, and are climbing a mountain, starting to feel like Sisyphus.
As I wrote about HERE, being completely pain free may not even be the most useful or realistic goal to strive towards. Not to feel doomed to always be in pain, but an acceptance that things will not ever be “perfect”. That you can’t go back to the way you used to be, but you can move into something different that you might like the feel of better (after all, the way you used to be got you to where you currently are…).
That said, I believe that everyone can move forwards from where they are now and have a more positive experience of their bodies if only they commit themselves to a path with patience, trust, and compassion for their journey, whether that takes five minutes or five years.
For those of us climbing the mountain in seeming perpetuity, I believe that the “tolerance principle” is an important one to keep in mind , and, in the words of Robert Pirsig (who recently left this world, may he rest in peace) “It’s the sides of the mountain that sustain life, not the top.”
Indeed, as the mountain metaphor suggests, it is the journey that matters more than the goal, especially because when it comes to pain, we don’t know what the “top” of the mountain feels like. If “free from pain” is the “top”, what happens when we get there? Isn’t pain a part of life that we are sure to move in and out of constantly?
Better to commit to the hike as a never ending process than be sad that the top of mountain is hidden from sight by the clouds. The terrain will change from rough to manageable, the weather will change from torrential downpour to pleasant sunshine, but yet the hike will not end until the day you die. (That’s meant to be a positive comment, not an ominous one, by the way…)
THE TOLERANCE TOTTER
I feel that the analogy of a teeter totter works well to illustrate the tolerance principle. I illustrated the teeter totter of tolerance below. Enjoy this excellent piece of art by me (if you can read it, sorry for the scribblez):
On the left side of the tolerance totter sits all of the factors that contribute to someone being in their current, lousy predicament.
If the teeter totter is tipped to the left, those factors weigh more heavily in determining how the body will feel: A state of fragility, low tolerance to the activities you habitually perform, and to the random and mundane stressors of everyday life.
Actively engaging in the factors on the right hand side will also reflect in how your body feels: Probably, but not necessarily, a lot less lousy.
To make sense of how your body is doing, we need to consider:
For how long has X been hurting? A matter of days, or of years?
For how long have you been receiving treatment? Has this treatment been objectively effective?
For how long have you been modifying your lifestyle based on your triggers for X? (And are you aware of your triggers for X?)
For how long each day do you do exercises to help X compared to time spent doing things that provoke symptoms of X?
Have you actually stopped doing the things that provoke symptoms of X?
From 1-10, how willing and open are you to changing your lifestyle to unravel X?
From 1-10, how much do believe and trust in the process you have started to unravel X? (assuming you have started…)
The answers to these questions will add load to either the left of right of the teeter totter, towards fragility or resilience, and, to a certain (I would say large) extent, it is very much your choice which side you stack.
To tip to the right is the ideal scenario. Get Resilience Dude nice and fattened up. He’ll take care of you.
What I feel is worth noting is that in the case of the tolerance totter, we do NOT want equilibrium.
Equilibrium is a false sense of tolerance. While it can indicate you’re on the right track, you are still only resting at the middle of the teeter totter. In this state of equilibrium things could easily tip either way depending on the stimulus.
Pain may be gone and your body might feel fine as long as nothing changes in your life, but the structure of your body may still be set up in such a way that if you do go for a 10km run, play a bit too enthusiastically with the grand kids, or go through a divorce, the teeter totter could easily tip to the left. “But I wasn’t in pain anymore! I don’t know why X started hurting again!”.
The tolerance had not been built. The symptoms had disappeared, but the work was not done. The work, in fact, is never done.
A state of high tolerance requires that the teeter totter tips to the right, which creates a situation in which more and more load must be applied to the left side to even get it to rest at equilibrium. In a state of higher tolerance to the things that used to formerly wreak havoc on your system, you can take more risks with less chance of adverse effects.
So beware the state of false tolerance in which symptoms have begun to drop away. Understand that the body is happily in its balanced comfort zone. A new stimulus to the system in the form of a stress or a challenge may easily tip the scale to the left.
DON’T BLAME THE COUGH…
This recently happened to a friend of mine.
He had a previous back injury that didn’t bother him anymore. Then he got sick with a terrible cough, and this coughing was enough to flare up some old back symptoms that he thought he was done with (flexion based pain. Coughing is pretty high force spinal flexion).
He had not built a sufficient tolerance for this kind of stress. His body had adjusted to the habitual movements and activities of his daily life, but was not prepared for the intensity of a bad cough. He was still moving around an issue hidden a few layers deeper than he was exploring. He had found a comfortable state of equilibrium, but a cough pushed him to the left.
This is often what happens to people new to exercise, who did not realize their bodies were so fragile until they started doing something different with them.
According to the tolerance principle, a robust system needs more than equilibrium, but for the scales to tip massively to the right, away from symptoms, towards resilience.
How? You do the work.
As the saying goes, “Before enlightenment, chop wood, carry water. After enlightenment, chop wood, carry water.”
LET’S TALK ABOUT ME
My own chronic pain began when I was 15. Although, at the time, I didn’t consider myself to be “in pain”. I was good at ignoring it, and felt young and invincible. I didn’t get any physiotherapy for my issues and when I did go to a physiotherapist I brushed off the exercises as unimportant, “I’m not in that much pain anyway, I can work through this”.
It only took seven years, until I was 22, for everything to catch up to me. My body’s tolerance for anything was rock bottom at that point.
For those seven years I received little to no treatment, did little to no form of nourishing movement, I kept doing all the things to provoke my symptoms (dance and some other questionable forms of exercise), I was not willing to change, I did not believe I could change, and had no process or people to trust. My body’s tolerance for any additional stress was low.
This is why I injured my neck in bed one morning. That shit shouldn’t happen.
So at 22 I made it my personal mission to overcome and understand it all. I really had no other option.
Part of my process required that I put in the hours of work to make up for seven years of neglect. Seven years is a lot of hours of abuse to overcome. 61320 hours to be precise (and it takes about 10000 hours for mastery… Consider me an expert). No wonder, now, five years later my body is just starting to feel like pain-free days are the norm, not the exception.
Just now, at age 27 it feels like I can skip a day of movement practice and not feel like shit the next day- I’ve built a small amount of tolerance.
It is my view that when the number of nourishing hours tops the number of destructive ones, then things can start to change.
That said, I don’t think it’s just a matter of time spent, but also of quality of nourishing experience presented to the body. Much like building any skill (and I do consider building resilience to be a learned skill), 10000 hours for mastery means 10000 quality hours, or, if the quality is high, it may take much fewer hours to master a skill.
It is important to keep in mind that I was unraveling my body almost entirely on my own from a place of zero education. I didn’t have the funds to pay for treatment, so I took it upon myself to find ways to nourish my body. For this reason, it took many, many attempts before I struck on something that was truly helpful for my body. Though I was putting in a lot of time, the quality was low. This is why it is so important to get help from someone you trust and invest in your education to accelerate the process.
This is also why I believe some people can have the experience of pain dropping away in five minutes rather than years when they work with someone skilled. The quality of the experience counts, and, if it is exactly the experience the body has been looking for, the effect can be dramatic. It’s not just about moving differently, but moving specifically. Specificity will trump novel experiences in the long term, in my opinion.
This does not mean that in five minutes the teeter totter has tipped to the right forever, but that the path forwards is now much more clear, and, should you do the work, you will benefit and build the tolerance to liberate your body.
So in order for tolerance to increase, we need to multiply quality and quantity of nourishing movement experiences:
Tolerance= MT x MQ
(in which M is a nourishing movement experience, T is time, and Q is quality. Don’t ask me to define quality… That’s another blog post)
When you find yourself doing an activity that would normally provoke X symptoms, but it does not, then you have some evidence of increased tolerance.
If one day you neglect to do exercises that normally you would do everyday to keep your body feeling good, and yet notice no return of X symptoms, there is more evidence of increased tolerance.
The issue is that many of us stop shortly after crossing the equilibrium threshold feeling that we’re “done”. Or, we give up before reaching equilibrium because we believe the solution must be some sort of quick fix, that for us to be on the right track, the decrease in pain must be instant.
Sometimes it is, sometimes it isn’t.
It took me five years to come to this place of understanding my body at a deeper level, and not being in daily pain, yet still I know the work never ends.
I keep chopping wood.
There is so much we don’t know about this topic. Let’s leave it at that for now.
What I hope for most of all, is to improve my ability to communicate these ideas with the people who are climbing the mountain in a way that makes sense and inspires trust, patience, and compassion on their journey.
If joint X is doing too much Z, then joint Y may need to do less Z-ing to balance the system.
This concept is certainly not unique to the body. This happens at all levels in nature, and, interestingly (I think…) shows up in our actions and personalities, and it was in Adam Grant’s book Originals (one of my favourite books I’ve read so far this year) that he noted how people who tend to take risks in one area of their lives will balance that out by being risk averse in others.
That’s the exchange. And its intention is to serve us, whether it ends up causing us pain or not.
The other day I was working with a lady we’ll call Fiona and we found a pretty interesting correlation between her left foot and her right lung. I’d like to share this story, as I thought it was a pretty cool example of this idea of “exchange” in the body.
Here’s what was going on with Fiona:
Fiona has a high arched, rigid, inverted left foot that doesn’t pronate. Part of this is a condition called Charcot-Marie-Tooth disease, in which a common symptom is the stiffening of joints and atrophy of muscles, which can worsen over time.
When Fiona tries to pronate her left foot, it everts: The whole thing tips inwards without a lengthening of the plantar and medial surfaces of her foot.
There is no opposition: Her 5th metatarsal lifts off the ground, and you can see light under her lateral arch. Not ideal.
We can help her foot pronate with a bunch of wedges, and if I manually guide her rearfoot into eversion. Otherwise, no weight ever goes onto the medial edge of her foot and that arch stays up. Her pelvis is also shifted to her left foot, and that is where her center of mass lives, contributing further to the inverted shape of her left foot.
Out of curiosity, I wanted to check in with her breathing to see if there was even fill between her right and left lung. And guess what, it was her RIGHT lung that filled more. This did not make sense immediately, (and I will explain why momentarily).
Even more interestingly, after mobilizing Fiona’s left foot, her lung fill became even- The left was now expanding to the same degree as her right.
What. The. Fuck. Eh?
This is where my mind went blank because I wasn’t expecting that, and it doesn’t really make sense. But it kind of does if you know the Flow Motion Model™, and how to use it to work out the possible exchange taking place.
If we think structurally about the lungs filling, the shape of the ribcage will have an influence on this. If the ribcage is open on one side more than the other, the structure of the ribcage will dictate that more air can fill the side of the ribcage that has more space.
For example, a right laterally flexed spine will open the left side of the ribcage, and, if you stand up, put one hand on each side of your ribcage, and try breathing in that position, you’ll feel the left side of the ribs expanding more as you inhale.
Here is an excellent illustration of this, by me, Monika:
If we now think about WHEN each lung will have an opportunity to fill as the ribcage expands in each phase of gait, we can start to put this information into context.
What can Fiona do, and what can’t she do, and what might be the exchange?
Pronate her left foot
Shift her pelvis to the right
Shift her pelvis to the left
Fill her right lung
In gait, the left foot will pronate in left suspension (foot flat), and, at that point, the pelvis will have already been shifted to the left.
In the moment the pelvis shifts to the left in gait, the spine will be laterally flexing to the right. This is what screwed me up: I was expecting her left lung to expand more as a direct result of her CoM shifted left putting her spine in a right lateral flexion, and getting more air filling the left lung. But what was happening was really the opposite.
This led me to explore how her spine could be part of this exchange with her foot.
In left suspension, the spine will ideally be laterally flexing to the left, towards the pronating foot. However, Fiona can’t or won’t pronate that left foot, and so, what if she was laterally flexing to the left in excess to make up for a left foot that won’t pronate?
Spine pronation > foot pronation.
Completely plausible, as with her spine laterally flexed to the left, the right side of the ribcage will be more open allowing more air flow into the right lung. After having her foot mobilized it was possible for her to access left foot pronation more easily. With a left foot that can pronate on it’s own, it is possible that her spine now does not have to pronate her foot for her, and is able to rest in a more centered place and allow for equal fill in both lungs.
This sparked an interesting conversation between Fiona and I on breathing exercises. Yes, it can be useful to use specific exercises to train the breath, but what if the breath could be more easily influenced at an unconscious level by making changes to the structure? Something to be considerate of, indeed.
Last week I saw three different people with externally rotated knees. In particular: Three externally rotated right knees that don’t internally rotate, causing the individual some grief (not just at the knee, but definitely at the knee).
I remember Gary Ward saying something to the effect of, if you keep seeing the same thing over and over again in your practice within a short period of time, check to see if it’s not your OWN issues that you’re projecting onto your clients. Have been guilty of that in the past.
Just to make sure I’m not full of shite, I stand up, check out my right knee, and, lo and behold, it appears my right knee doesn’t fully internally rotate. Actually, both don’t. Well damn. However, my right knee internally rotates a lot more easily than my left, so, maybe my awareness, despite my imperfections, is helping to keep my perception honest. In any case, the important lesson: Whenever you see a bunch of the same thing, check to make sure it’s not just YOU.
I would like elaborate on a few observations I noted in working with these three individuals, aka, how not being able to internally rotate a knee can potentially wreak havoc on the body.
Some stuff they had in common, in particular:
Missing an effective propulsion phase of gait
Feet turning out in gait, aka, the “duck walk”
Rock solid, toned up, tibialis anterior
Low femoral external rotation
Limited right trunk rotation
Are you ready to get excruciatingly technical? Hell yeah!
Propulsion- The phase in the gait cycle just before the foot picks up off the ground prior to swing in which the pelvis is travelling (propelling, if you will) forwards, the extending hip fully decompressing, and the foot is in a maximally supinated , rigid lever position. To create this rigid lever, the knee also needs to be locked in extension in order to anchor the foot to the ground so that the pelvis can travel forwards, allowing the hip to extend and load the hip flexors for the next moment: Swing.
Getting to propulsion effectively is important.
However, in all three of my funky-kneed individuals, propulsion was just not happening.
In propulsion, the knee will be in its end range of extension. For this to happen, the femur twists externally on top of the tibia, locking the condyles together into it’s “screwed home”, comfy position (home= comfy). This creates a position in which the tibial tuberosity is rotated medially of the femur, giving us an internally rotated knee.
Knee extension = knee internal rotation in an ideal situation in gait.
If the knee can’t get “home” to internal rotation and extension, as was the case for these three individuals, then the rigid lever to propel off of will be compromised, and resultant shite: The hip won’t extend, swing may be compromised, and all the muscles that load up in propulsion (psoas, iliacus, distal tibialis anterior, peroneals, distal hamstrings, distal FHL, adductors, to name some biggies), will not get their chance to lengthen.
Internally rotatable knees= Happy hips that can extend.
FEET TURNING OUT IN GAIT
That funny “duck” walk thing. I used to do that. And then I stopped ballet…
A little experiment you can try. Standing bilaterally, turn your feet out. Can you feel which way your talus is now pointing? If you are a normal human being, you should feel that feet out= sub-talar joint axis (STJ) pushes in. The opposite is true if you stand with your feet pointing inwards- STJ will point out.
Feet pointing out in gait is often a hint towards a foot that can’t pronate, and an attempt to give the STJ an opportunity to point inwards.
In pronation, the STJ axis will orient internally of the 2nd toe (usually wayyy more internally than that). But what if the foot can’t pronate? Or, what if pronation has become dangerous for some reason, and the body has needed to find a way to work around it?
Turning out the feet is one work-around: Feet out, STJ pushes in, medial arch gets to open, brain thinks it is “pronating”, but without actually pronating.
In gait, pronation and knee external rotation happen at the same time. This means that, in the case of the already externally rotated knee that doesn’t internally rotate, pronating the foot may feel dangerous because with the knee already externally rotated, there’s nowhere further to go if the foot pronates.
If the foot does pronate, the knee will reach end range external rotation (XR) too quickly and that may not feel so good. As a strategy, the body needs to find an alternative way to get a bit of “pronation” through the foot, and tan easy way to do this is to turn the foot out so that the talus can feel like it’s pointing in, and the medial arch can open. Not ideal. Definitely a work-around, but better than not being able to walk in the short term.
If the knee was able to internally rotate, this would free some space for it to move into external rotation as the foot pronates, rather than immediately crash into end-range. The change in timing allows pronation and external rotation of the knee to couple together safely.
In the case of these individuals, reintroducing knee IR was a foreign, but nurturing experience.
SAGITTAL: Short (note, this is passive shortening, as gravity does the job of dorsiflexing the ankle and pronating the foot.) FRONTAL: Long TRANSVERSE: Short
So, in the case of our friends with externally rotated knees and rock solid tib ant, what does this mean? Few theories for the increase in muscles density and hypertrophy:
Length tension: Being used excessively to decelerate a joint motion. For example:
Tib ant decelerates the arch lowering in frontal plane to manage over-pronation (aka shin splints). Slowing down pronation will serve an already externally rotated knee by preventing it from rotating further, and tib ant may be working overtime for this.
Ankle may be plantar flexing too quickly out of late swing in an attempt to decelerating sagittal plane ankle motion into dorsiflexion, and block over-pronation and thus, more knee external rotation.
Short, overworking tib ant: Concentric muscle tone. Some examples:
Not being able to lengthen and load tib ant in sagittal and transverse plane in the previous phase of gait, propulsion, the tib ant will have to contract excessively on swing to dorsiflex the ankle to clear the ground (or turn the foot out).
An externally rotated knee may be attached to a foot stuck in pronation and ankle stuck dorsiflexed, which will shorten tib ant in sagittal and transverse plane.
If a high varus angle of the foot is present as an attempt to slow pronation and knee external rotation (as this increases the distance the 1st met must travel before it hits the ground), this will contract tib ant in frontal plane.
I’m sure this is not a complete list. I am, of yet, not sure which one of these is the most true for each of my three individuals, but what matters more than the story I choose is the “what will I do next”?
LOW FEMORAL-ACETABULAR EXTERNAL ROTATION
In order for this to make sense, we must distinguish between femoral rotation (FA: femur moving in acetabulum), acetabular-femoral rotation (AF: acetaculum moving on femur), and hip rotation (the orientation of the space between the two bones).
Until I understood this distinction, and a lot of it has to due with timing, hip mechanics fucked with my mind. I blame PRI. Just kidding… I blame my limited thinking, conditioned by previous PRI training.
Curiously, in all three individuals, the right hip- the same side as the externally rotated knee, was more limited into external rotation than their left. Why could this be? (and yes I am aware that this is a left AIC pattern…)
When the knee is externally rotated, the hip can be either internally rotated (IR) or externally rotated (XR), depending on which phase of gait we’re talking about.
There are two phases of gait in which the knee does XR: Suspension and early swing. Both are pronating, and knee bending phases. The distinction: In suspension (closed chain), the hip is in XR, while in early swing (open chain), the hip is moving into IR from maximum XR.
In either case, if you were to freeze time at the moment the knee is in XR, the hip would appear to be in XR as well. In one case because it is really truly in XR (suspension), in the other, because it is still in a state of XR but moving into IR (early swing).
PLOT TWIST: In suspension, though the hip and knee are in XR, the femur in the acetabulum itself in internally rotating.
How can an internally rotated femur be labelled as externally rotating hip?
Suspension= FA IR + AF XR + (*some timing stuff*) = Hip XR.
Remember the femur and the hip are not the same thing. The femur is the bone, the hip joint is the space between the femoral head and the acetabulum.
*Aforementioned important timing stuff*: In suspension, the pelvis is rotating away from the suspending leg (AF XR) as, just prior to hitting the ground, the leg was in swing. The leg swinging rotates the pelvis away from the swing leg (creating AF XR), as the femur also rotates externally (FA XR). Then, as the first met hits the ground and foot starts pronation, the femur begins to rotate internally, initiated by the talus as the foot begins to pronate. However, the pelvis is still rotating away (into AF XR) faster and farther than the femur is rotating internally, which creates a global position of hip external rotation.
Clear as mud, right?
Early swing, by contrast, is simple:
Early swing= FA IR + AF IR = Hip IR
So, when the knee is in XR, the femur IS internally rotating regardless of what the hip is doing. When the knee is in XR, the femur is internally rotated farther that the tibia.
Knowing this, it makes sense to feel a limitation in femur XR on the side that has an externally rotated knee.
This also makes sense as a contributing factor to why propulsion wasn’t happening: In propulsion we need hip AND femur XR along with knee IR.
LIMITED RIGHT TRUNK ROTATION
Having an externally rotated right knee and limited right trunk rotation are not an absolute coupling, but it was curious to see it in all three individuals this week. It was pretty interesting example of the clever body making adaptations above to accommodate something below (or is it something below adjusting for a structure above…?)
In two of the three, the same situation was going on:
In gait, both had an observable left trunk rotation. Ribs were going left-center-left-center, and never making it to the right.
BUT, in a bilateral stance, the opposite showed up: Both had an inability to rotate to the LEFT. What the f***. I was not expecting that.
Why would someone rotate left so much while they walk, but not at all when isolating ribcage movement in bilateral stance?
My operating theory is, what if they were already rotated left, and in which case, there is nowhere else to go. You can try this in your own body. Stand with your shoulders rotated to the left. Now, try to rotate them more to the left. Doesn’t get you very far, does it?
So why would the body choose to put its thorax to the left, and how does this relate to a right externally rotated knee?
Remember, knee XR happens twice: Suspension, and early swing. In both those phases of gait, the spine and ribcage will be rotating, wait for it….
TO THE RIGHT (as per the Flow Motion Model™)
What if the body is avoiding right spine rotation because the knee is already in end range XR? More right trunk rotation would potentially require the knee to XR further, and that would probably not feel good on an already externally rotated knee.
We can look at it from another perspective. Maybe the left trunk rotation is what is trying to create right knee IR. In all (but one) phases of gait in which the right knee is in IR (transition, shift, and propulsion), the spine will rotate LEFT. (the exception is right heel strike, in which the trunk will be rotating to the right, even though the knee is in IR).
So, right trunk rotation couples more with right knee XR, and left trunk rotation couples more with right knee IR.
So which is it? Using left trunk rotation to attempt to IR the knee? Or avoiding right trunk rotation to protect the right knee from excess XR? The answer will be “both” until we know for sure.
In any case, working on reintroducing right trunk rotation and right knee IR will be a nourishing experience. Hopefully… (so far so good).
Yeah, I guess I have a few.
I’d better take care of my own right knee just in case I’m projecting my own problems onto people. Will put that on the to do list for today.
Is this right knee external rotation a PRI pattern? Part of the lef AIC pattern?
These three individual cases also had other different things going on. This is not the full picture and not meant to be taken as an absolute. I just like to write out my observations on the shit I see to make sense of it.
Part of the solution for all three of these individuals was to work on “transition” (AiM movement) to experience knee IR. All reported that it felt “weird”, “good”, and “I never do that”. No shit you don’t!
Knees are pretty cool. For a joint with only two planes of movement, amazing how overlooked its mechanics are. It only took me 4 times through AiM to start to get a grasp on the knee. Maybe after my 6th I’ll understand shoulders.
This blog post is entirely a thought experiment. None of this may be true. Take it all with a grain of salt.
I recently began working with a very talented professional singer/vocal coach we’ll call Louise (not real name). Her primary goals were to improve her health, movement quality, and strength, aka, my favourite kind of person. She also enjoys geeking out about breathing and her super interesting feet, which makes her my very favourite person right now (not that I play favourites….).
We’d had a good chat about breathing before our first session (my fascination with it, her need to have good control of hers for her profession), and so I was particularly curious to see what her breathing habits were like, among other things.
A few interesting things have come up in our work together so far that I’d like to share as I attempt to make sense of the relationships between breathing, spine, and larynx mechanics in my head.
Belly breathing vs. “ideal” diaphragmatic breathing pattern
I would imagine that singers pride themselves on having good diaphragmatic control, but, much like Tiger Woods’ swing, there is much that can be improved upon mechanically even if you perform at a high level and kick ass already.
Louise is very good at using her diaphragm as a breathing muscle, but, and this is a big BUT, she uses it at the expense of maintaining any tone through her abdominals, which shows as a belly-pushing-out breathing pattern rather than an “ideal” diaphragmatic breathing pattern that could create greater intra-abdominal pressure (IAP).
Belly breathing IS diaphragmatic breathing- The abdominal excursions with inhalation are due to the diaphragm descending (contracting), but, the belly moving forwards, and only the belly, is indicative of the contents of the abdomen moving forwards without abdominal or pelvic floor eccentric co-contraction. This forwards movement is not going to be the best way to create “support” through the midsection, both for singing and strength training.
An ideal diaphragmatic breathing pattern involves, upon inhalation, both the belly and chest moving anteriorally, a posterior lateral expansion of the lower ribcage, and the pelvic floor descending as the organs are pushed down by the diaphragm. Not only the belly moving forwards.
A nice way of visualizing it is a 360 degree expansion of the thoracic (ribcage) and abdominal cavity, much like an umbrella opening, or a balloon blowing up. The balloon doesn’t just expand on one side, unless it’s a fucked up balloon.
If the belly/organs are pushing forwards, it is likely because there is no room for the abdomen to expand to the back (posterior-lateral expansion), and the pelvic floor down (descending), and so the only place for the organs to move is forwards (not ideal).
The excursions of an ideal diaphragmatic breath will appear to be smaller than those of a belly breath. Part of this is due to the abdominal fill being redistributed in a 360 degree fashion, and air flow also expanding the upper ribcage and subclavicular space, which creates a more evenly distributed fill, rather than the prominent belly breath. This “smaller” fill (volume of air) with the more ideal diaphragmatic breathing pattern will initially feel as if you are not getting enough air. This may be simply because the fill shape feels different and freaks out the nervous system, but could also be because belly-breathers often breathe in excess of metabolic demands (see G: Gasping for Air), whereas an ideal diaphragmatic breath will get more oxygen with less total air volume (let’s not go down that rabbit hole today…).
The posterio-lateral expansion that allows for the 360 filling can only happen if the abdominals (transverse abdominis- TVA, and internal obliques- IAOs, primarily) stabilize the ribcage: Eccentrically loading to slow it from lifting up and flaring excessively and the belly from pushing forwards.
Needing to counterbalance the organs being displaced forwards, belly breathers tend to get pulled into lumbar extension pretty easily (I would know, because I’m a recovering compressed-spine belly-breather), which makes it even more difficult to maintain any abdominal tone with inspiration due to the lengthened state of the abs, and compressed state of the spine.
To summarize, a belly breathing pattern does use the diaphragm, but not as effectively as it could, as the abdominals are not doing anything to generate internal pressure and muscular support. The big movement of the belly means that:
Minimal expansion of the thoracic cavity will not decrease the intra-pleural pressure as much, meaning that the lungs will not fill as deeply and efficiently with each breath, reinforcing the need to take bigger belly breaths to feel like the lungs are filling “enough”.
It will be more difficult to create pressure within the abdominal cavity (IAP) due to decreased TVA, IAO, and pelvic floor support, the foundation for spinal stabilization with movement and, importantly for Louise, support while singing.
I believe it will be useful for her to train herself out of the belly-breathing pattern and into a one that uses more abdominal co-contraction.
Training to hold onto an “air reserve”
In other words, training to create a functional hyperinflation just in case the need for more air should arise while singing. I can understand how holding onto a “reserve” would be useful if you have a long phrase or note to hold, or you accidentally neglect to breathe at the most effective time and need to push your air a bit further.
But there is a consequence to this, as training to hold on to extra air over months or years can have the effect of creating a more chronic hyper-inflated state- Excess air in the lungs, diaphragm and ribcage stuck in an inhalatory state, with an inability to completely exhale.
Why is this an issue?
Over time, hyperinflation alters the position of the ribcage, and puts the diaphragm in an even further disadvantageous position to breathe from: A state of perma-semi-contraction (that’s a word…).
Louise noted that she has a difficult time exhaling completely in our breath work, and would quickly feel the urge to breathe in deeply. She struggled to get her ribs to move down and in to an ideal zone of apposition (ZOA), or exhalatory, depressed (anteriorally tilted) rib position and breathe without flaring up her ribs with each inhalation (which would lose all IAP, aka “support”).
Because the diaphragm lengthens and ascends with exhalation, when more air than necessary remains in the lungs over long periods of time, it can become difficult to get diaphragm to get to a fully lengthened resting state. Because muscles must lengthen before they can contract, this makes an ideal diaphragmatic inhalation near impossible, spinal stabilization difficult, and compromises IAP generation.
Holding a “reserve”, or, a functional hyperinflation, does make sense as an adaptation to her “sport” of choice. However, if left unchecked, it will keep her from using her breath as efficiently as she could be, as being stuck in a perpetual semi-inhalatory state impacts on her quality of both inhalation, exhalation, and internal pressure regulation. Perhaps this is a deeply ingrained part of the singing training tradition; much like passively overstretching is part of ballet training tradition- Practices that can lead to compromised performance, but no one is taught a better way of doing things.
Here is some excellent art by me, illustrating some of the silly “traditions” I ascribed to as a dancer:
Louise and I discussed that owning the full spectrum, i.e. full inhalation and exhalation, rib flare and ZOA, diaphragm contracted and relaxed- would help her to find a more “centered” place with her breath and body, and decrease the reserve of air she needs to hold on to, which would decrease the chronic hyperinflation over time. Doing so would also help her to fill her lungs more efficiently and better use her diaphragm for it’s spine stabilization function, creating higher intra-abdominal pressure, which will come in handy when she needs the support for singing the higher tones without going in an “airy” head voice.
As an inexperienced singer, my thoughts are that the reserve training is probably useful, but the minimum possible amount of trained hyperinflation to get the job done is desirous.
The reserve is similar to packing for a long hike: You want to pack as little as possible to make reduce the weight you’re carrying but not starve. Hiking without a bag at all would be ideal, but not realistic (unless you have someone trailing you with your food and water supply in a helicopter).
After the hike, you can take the bag off and unwind, and, after singing and over-breathing a bunch, it is also a good idea to unwind.
Another important thing to note is that, if Louise does try to sing with the breathing patterns we are discussing as more “healthy” physiologically, she may experience a temporary decrease in her singing abilities, which, may not be desirable if she has to perform. This is comparable to taking away an athlete’s functional adaptations. For example, if a dancer needs a lot of flexibility in her hamstrings, and stiffness in her feet, and we take this away because it is not “healthy”, she may suffer a decrease in her dance technique. Similarly, if we try to make a sprinter too mobile, they will lose the stiffness which is in part necessary for them to generate power and speed.
There is a sweet spot, which, I believe exists within the exploration of the spectrum: Can you inhale and exhale? Can you play at the extremes without losing sight of “center”? And can you play with the bits in between without losing sight of the edges?
Ultimately, I believe that working on the diaphragm + abdominal control, deeper more efficient filling of lungs, and being able to exhale more fully will provide her with more options for how to use her breath, and more opportunities to unwind from the stresses that singing can have on the body.
Stiff spine and effect on larynx control, tone, and pitch?
Degree of spinal mobility and neck positioning can have an impact on, and be impacted by, breathing and ability to use the larynx effectively (and visa versa). This is something I am just starting to put together, and may need to revise this section later. Bear with me now and please correct me if I’m wrong.
Louise is stuck with a fairly flexed thoracic spine that doesn’t know how to extend, and a extended cervical spine that doesn’t know how to flex. As a strategy to extend her thoracic spine, Louise retracts her scapulae together excessively in an attempt to create spinal motion, a common strategy for stiff spines that I frequently see.
For singers, being able to flex and decompress the C spine is necessary to modulate the quality of their voice. This is due to the larynx, which houses the vocal folds, being located around level C3-C6.
The larynx is suspended from the hyoid bone, which is what Gary Ward (author of What the Foot) has classified as a “dangler” (technical term). This means that its gross movement is primarily due to the movement of another proximal structure (for example, scapulae are also danglers, suspended on the ribcage, the jaw is a dangler, suspended from the cranium). In this case, the hyoid is closest to the cervical spine and skull and so hyoid, and thus, larynx, movement can be mapped based on C spine and skull movement.
The hyoid also has a pretty cool connection to the scapulae via the omohyoid muscle (which I just learned about yesterday). This means that there could be some tricky strategies going on between Louise’s hyper-retracting scaps, stiff spine, and hyoid/larynx, that may have an impact on her voice.
Another thing worth noting is the the closing of the glottis to increase sub-glottal pressure, sometimes known as the Valsalva manoeuvre. This allows greater building of air pressure to stiffen the abdominal cavity and is useful to protect the spine for higher threshold activity, like lifting heavy things, but also at lower thresholds it serves to stabilize the spine during simple limb movements. Some people may tend to overuse the muscles of the hyoid/larynx to create this stabilizing pressure rather than being able to use their diaphragm and abdominals (TVA + IAO) effectively for IAP, which can mess with the larynx’s role in air pressure modulation and resultant vocal quality.
For someone like Louise who does not use her abdominals effectively to create IAP (as a belly breather), she may be overusing her hyoid and larynx musculature to create it, or, locking into bony end range at her C spine, in an attempt to create a sense of stability, which will impact on how well she can also use her larynx to modulate her voice.
What all that means is that one’s potential vocal range and ability to modulate pitch and tone is somewhat dependent on spinal mobility, internal pressure regulation, scapulae movement, as well as freedom of hyoid movement (to dangle).
Where things get interesting is when we look at how larynx movement can affect pitch and quality of the voice:
However, as Louise has explained to me, the movement of the larynx may have more to do with the quality of the voice, regardless of the pitch, due to how it modulates air pressure. A higher larynx will tend to raise the air pressure and make the quality of the voice less airy, and so is useful for getting high notes to sound less “heady”.
Here is yet more excellent art by me:
When the larynx tilts forwards over the cricoid (anterior tilt) and raises, this lengthens and tenses the vocal folds to create higher pitches. However, altered neck position and resultant muscle tensions can limit this anterior tilt.
Here’s where things get more fuzzy for me. I have read that relying on moving the neck and skull to move the larynx is not as effective as being able to use the intrinsic muscles of the hyoid itself to move the larynx to modulate pitch and volume.
A lower resting position of the larynx is said to be more desirous and healthy than an elevated one. I suppose this makes sense as this means that should one need to push into a more headier voice, there is actually somewhere for the larynx to go. However, I would also reckon that too low is not great, especially if stuck there. Like any other structure of the body, I suppose the holy grail is to find “center”, and to do this we must also know the extremes.
When it comes to using intrinsic muscles of the larynx, I am not entirely sure how to train this because I’m not the one who’s a vocal coach with the experience in that domain. However, I can imagine that unlocking the neck and spine mechanics, breathing mechanics, and ability to co-contract abdominals, diaphragm and pelvic floor to create IAP will free up the muscles of the hyoid and larynx to perform their vocal manipulatory role more effectively, which will have a spill over effect into vocal training.
Here’s what’s currently going on with Louise:
C spine stuck extended= Larynx stuck in posterior tilt (potentially)
Skull stuck in posterior tilt= Larynx descended (potentially)
Because movement of the c spine is also quite dependent on movement of the thoracic spine, we must also looks at Louise’s current set up:
Thoracic spine stuck flexed= C spine stuck extended= skull stuck posteior tilt= larynx stuck in posterior tilt and descended (as in the lovely picture on the right I drew, above)
This could potentially be impacting her range and comfort into higher notes, but also into lower notes, as her larynx could be hanging out in a descended position all the time with nowhere lower to go (and indeed, she admits lower notes are tough for her to hit).
Because Louise attempts to extend her T spine by squeezing together her scaps, the more she sings with this as a postural strategy, the more she may experience shoulder and neck tension as she attempts to create a more elevated, anterior tilted larynx position for higher notes by tensing her shoulder blades, with an extended C spine.
Yet another interesting piece of Louise’s puzzle is her high arched, stiff, inverted feet. In the foot map of the body, developed by Gary Ward and Chris Sritharan of Anatomy in Motion, the metatarsal rays (1-5) are seen to be correlated in structure to the ribcage and thoracic spine. In Louise’s case, they share the same shape: Flexed (rounded) T spine with arched (rounded) feet- Both stuck in primary curves. As we attempt to teach her feet how to pronate, or, “extend” through the arch, it will be curious to observe what this could free up in her thoracic spine and ribcage into extension and impact on her breathing and neck alignment.
Louise and I discussed how a diaphragmatic breathing pattern can help to mobilize the spine: An inhalation will slightly extend the lumbar and thoracic spine, exhalation flexes them. Could her belly breathing pattern be the main contributing factor to her stiff spine via never quite mobilizing her T spine? Or, could her stiff spine the be major contributor to her belly breathing pattern? I suppose it will be both until we know for sure.
The vagus nerve (cranial nerve X) is intimately related to the processes of breathing, vocalizing, and the striated facial muscles, making singing what Dr. Steven Porges may consider a “neural exercise”: One that combines the various functions of the vagus and serving as a portal for ventral vagal stimulation, and easier, quicker access to parasympathetic state of health, growth, restoration, and positive social engagement. Porges has described that both singing and playing wind instruments are ideal examples of neural exercise to “tone the vagus”.
Having just finished reading The Polyvagal Theory prior to working with Louise, I was curious about how singing could be used as a method of neuroregulation (which is one reason why I also wanted to study it). However, I was also curious how could this be affected by some of the inefficient habits I’ve observed in some singers, like poor breathing patterns, hyperinflation, over-breathing, spinal immobility, and poor internal pressure regulation, all of which in themselves can be correlated to a state of inhibition of the ventral vagal brake as stressors on the system, increasing sympathetic, fight or flight activity.
For example, a state of chronic hyperventilation (breathing in excess of metabolic demands, which can easily happen with the amount of mouth breathing involved in singing) could contribute to inhibition of the ventral vagus and increase sympathetic activity. Too, a state of chronic hyperinflation (common for singers who hold onto their reserve and never practice complete exhalations) is related to sympathetic activity due to the resting inhalatory (contracted) state of the diaphragm and exacerbated by the correlated extended position of the spine and ribcage.
In order for singing to be a portal for increased ventral vagal activity, do the mechanics of breathing need to be “optimal”? I’m sure they don’t need to be perfect, but for how long can one sing with inefficient mechanics until there is a negative effect? What is the sweet spot?
In other words, is the vagal stimulation via the act of singing- coordination of the various structures innervated by the ventral vagal branch, a sufficient counterbalance for these “non-ideal” breathing and postural habits (as we’ve been discussing in Louise’s case)? Or could enhancing the body’s fundamental mechanics, helping to make singing and breathing make singing less of a strain to the system, transform singing into an even more nourishing experience? And, much like an athlete stuck in a pattern of training that could be leading them to injury, does the act of singing in itself serve as an escape from noticing the poor habits associated with it until it is too late?
For me, dance was an escape from “reality”, and I imagine singing could be an escape for some individuals. Though I was a good dancer, I had shit for fundamental movement mechanics. Though I felt “good” while I was dancing- the escape into the flow state of the music, the movement, and my body, I was using this feeling an escape, and I ignored the symptoms of this (everything hurting). Eventually, ignoring the symptoms that dance was no longer nourishing me began to hurt enough that the escape was no longer even a possibility.
Could singing be similar? Do singers burn out the bodies in the same way that dancers and athletes do? Curious…
I’m probably just thinking too much. But if I don’t write down my thoughts here, they will fester and rot in my brain.
It is lovely to reflect on the interdependent nature of all structures of the body like this. Lovely to attempt to map it with the Flow Motion Model (FMM). I am still questioning a lot of what I just wrote, especially the stuff about the larynx movement. If you know things that I don’t, I want to hear them.
Louise is an incredible singer already, but she has been noticing an increase in “support” while singing since working together. She also has had the realization that maybe she doesn’t need to take as big of breaths as she does, doesn’t need to hold onto as much air as she does, and can sing just as well, if not better, with healthier breathing habits. Apparently, what she’s been working on with me has also been useful for some of her students, too.
Very cool stuff. I’m interested to see how things go for her, both with singing, and her movement/strength training practice.
Louise is also my vocal coach, and I’m sure I will be pestering her to go into agonizing detail about the use of breath and larynx while trying not to embarrassmyself singing.
Apparently, I have now agreed to be the terrible singer in a terrible ukelele and brass band. My only condition was that I get to keep the beat on a triangle, and that we perform only Wonderwall. Watch out, Toronto.
Tracy (not real name) is a lady I first met while she was waiting to get knee surgery (meniscus repair). We began working together to help her build strength and prepare her body for the procedure.
That was NOT the kind of surgery Tracy got… I just like/am traumatized by that video.
I am writing this piece about Tracy because it is a lovely case-study of a few things:
a) How someone who is relatively unfit can see a surgery as an impetus to get in shape, address movement mechanics, and go on to hike in the mountains pain free 6 months later.
b) How surgery can sometimes be a very good idea, not only because it can reduce pain symptoms, but that is can sometimes reveal the true underlying cause of WHY there was an issue in the first place.
c) How learning to pronate the foot, and removing an arch supporting orthotic can be a major piece of the knee-pain puzzle.
d) How focusing on symptoms prevented me from seeing the root cause of the issue as quickly.
At first, it was Tracy’s left knee that bothered her (primarily with flexion), and she was scheduled to get surgery in a few months.
In an assessment, her center of mass was shifted to the right, and she found it very difficult to shift her pelvis to the left, which, made perfect sense at the time, her left knee being in pain, wouldn’t you want to shift away from it?
As part of our process pre-surgery, my goals for her were to see if we could help left knee flexion feel a bit safer by exploring the mechanics of weight bearing on her left leg (learn to pronate and supinate the entire foot, hip, knee- lots of suspension/transition). Her goals were also to build full-body strength, to be in better condition going in to the procedure.
Two of our outcome measures were kneeling on her left knee, and a quadruped rockback (putting it into deep knee flexion).
Week by week as we plugged away, she noticed some good changes in how much range of motion she could access pain-free, and felt stronger over-all going into the surgery (that was April 2016).
I had my doubts about surgery. I always do, as it is a last case scenario- Avoid unless absolutely necessary. However, in Tracy’s case, the surgery was a very, very, good decision.
As it turns out, her left knee wasn’t the issue. It was just making the most noise. The squeaky wheel gets the grease, as they say.
What should have tipped me off from the beginning was that in our initial assessment I was drawn to give her the AiM right “strike” exercise (replicate the phase of gait at which the right heel first hits the ground), which significantly improved how her left knee felt in both outcome measures. Not perfect, but not bad for a few minutes of work.
Why did an exercise for her right hamstring help her left knee? In Tracy’s gait, a stand out feature was that she did a massive side bend to the right but never left, which seemed to be a counterbalance help her to get her center of mass left but not right. So to me it seemed logical to get her to do the opposite and see what would happen: Left side bend, right heel strike, effectively shifting her mass off of her left leg, getting it onto the right.
(To be honest, I can’t quite explain why I was drawn to right strike… There was more information at play than just the ride lateral flexion, but right strike seemed like the shape her body was craving).
In hindsight, I probably should have followed that thought process further, earlier on, rather than spend so much time working on the left knee mechanics.
WHY exactly did right strike seem to help her?
What in particular about that movement was so useful?
But I got sucked into the symptoms. That, and I had just learned a bunch of cool stuff about knee mechanics and wanted to explore that. Very selfish of me.
That said, the work on left knee mechanics did come in handy as she rehabbed her knee, so, I suppose it’s impossible to say that I “should” have done anything differently.
So, Tracy’s surgery was successful, but, it became very clear what the root of the left knee issue was after the procedure.
After the surgery, her left knee felt great. Rehab went smooth, and by June I began working with her again to continue strength training. It was at this point that her right knee started bothering her. The left knee felt better than ever- she could kneel on it, do a deep knee bend without pain. So why the issues on the “good” side?
From the start, there were hints that Tracy had trouble weight bearing on the right (right strike being helpful), but these were drowned out by the noise from her left knee. Now, however, it was clear to see that she could not shift her center of mass to the right.
To me this was strange. Generally, after an invasive procedure, people will have issues weight bearing on the side that was operated on. But Tracy had no problem with that.
Was the reason her left knee got beat up because of a long standing inability to weight bear on her right leg? And why was she having trouble getting her weight to the right?
Here’s what we found…
Tracy’s right knee was not externally rotating with flexion. A go-to to check in with when there is knee pain- Is the knee rotating is is flexes and extends? As the knee flexes, the tibia and femur should both rotate internally, but the femur should rotate farther, creating tibial external rotation under the femur (knee ER). Tracy’s femur and tibia stayed stuck together, the femur never quite getting internal of the tibia, flexing with an internally rotated knee. It was likely that the two bones sticking together, not gliding smoothly, was what was causing her knee discomfort. That would certainly create a strategy to avoid weight bearing on the right.
Tracy also has a bunion formation on her right foot. I hadn’t been able to see this before because I was too focused on her left side. Doh. Note to self: Don’t chase symptoms. Bunions can be seen as a functional adaptation, for example, to stop pronation. Pronation and knee flexion/ER happen at the same time in gait, and so the bunion could have formed to stop the knee from bending and externally rotating by blocking the foot from pronating.
Tracy had also been given an orthotic years ago to support the arch of her right foot to block pronationand keep the pressure off the tender bunion, which, in my opinion, seemed to be compounding the issue, not solving it.
Right knee not externally rotating= painful knee
Pelvis shifts left, but not right = not able to get mass onto right leg because of right knee feeling unsafe to flex
Right bunion= blocking pronation and knee flexion
It’s nice when the information lines up like this.
THE NEXT STEPS
In the words of Gary Ward, we proceeded to “pronate the shit out of” her right foot.
The next paragraph is for the dedicated AiMers.
The method we chose was a modified suspension in which we could simultaneously:
decompress her bunion
pronate her foot
flex the knee and externally rotate her knee
At first, I simply got her to bend her knee as I guided her tibia inwards and pulled on her first met. This decompressed the bunion, opening up the medial side of her foot, and encourage some dorsiflexion and abduction of the forefoot, allowing her foot to pronate. We also needed to wedge the lateral edge of her foot to close the space between her lateral arch and floor, helping her to feel her full foot in contact with the floor, and to experience a real pronation, not eversion.
Then, to encourage more knee external rotation, I got Tracy to rotate her pelvis as far to the left as she could, to maximally internally rotate her right femur as I blocked her tibia from rotating further medial than her big toe, helping her to get her femur to internally rotate beyond her tibia, and creating knee external rotation.
Then, I stopped pulling on her toe to see if she could pronate without my manhandling, and we used a medial forefoot wedge to help her foot get frontal plane opposition.
There was no knee discomfort during this process even though she was bending her knee farther than what would normally reproduce pain.
Tracy is a woman of very few words and, when I asked her how it felt, she told me it felt “good”.
After this, we got her to try some step-ups, something that was bugging her knee to do, and there was no discomfort. Yay!
DITCH THE ORTHOTICS?
It was clear how pronation was a nourishing experience for her right leg, yet she was wearing an orthotic daily that prevented her from accessing it. I am often tentative to ask people to try removing their orthotics. Many people feel unsafe without them, even when they could be keeping them in pain.
Fortunately, Tracy came to this conclusion on her own. “So… Maybe I should take out my orthotic?” she said. I told her, “Yeah, try it. If it feels awful and dangerous and your knee hurts you can always put it back in, but try spending some time without it and see what happens, as an experiment”.
Typical… The solution is often to remove something, not add more, just as there is nothing you can buy to make you better, more complete, but so much to gain in letting go.
The following week I asked how things were feeling without the orthotic. Woman of few words says, “Fine”. Any knee discomfort? I ask. “Nope”.
Tracy is a rare kind of person to work with.
Laughing as she moves into spaces where her body feels off balance and falls over.
Determined to try everything I ask her to do, completely trusting the process.
Smart enough to suggest taking out her orthotic before me trying to persuade her to even consider it.
For every woman like Tracy, there is a client who refuses to face their issues head on, choosing to move around them, not trusting in themselves or in their guide, opting for passive therapies entirely or simply ignoring the issues as long as they can.
Writing out this case study helped to cement a few important lessons for me:
Remember to ask why is the body doing what it’s doing. Ask, how is this serving the individual? Ask the 6 questions: What is happening? When does that happen? Why is that happening? How is that happening? Where is it happening? and, What if we…?
Remember not to get sucked into the symptoms. Interview the whole body.
Surgeries aren’t all bad.
Change can’t be rushed. People will be ready to take away crutches like orthotics when they are ready, and when they see the value in it.
And lastly, I wanted to write this to remind myself to enjoy every second of working with people like Tracy, because not everyone is as open to trying the weird shit I ask them to do as she was. People like me, who recommend to train your feet to pronate and throw away the arch supports, are the minority.