Hip hinging, sway back and hip impingement: two case studies

What would you use as a send-home exercise that will nearly completely reduce their hip impingement within about five days as a first aid? Think about it. I know what I would use, and I would use probably a doorjamb squat. Why is that? You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey, it's Dr. Sebastian Gonzales, your host for the Restoring Human Movement podcast. Thanks for joining the Movement Movement. This is your first time.

Welcome. Welcome to the show. The show is about improving ourselves as clinicians and also trying to boil down some nice common language that we can use with patients. And a lot of these episodes are patient-friendly episodes, but for the most part, I'll be honest with you guys, I started this podcast originally just going through patient-friendly stuff only, and then I started to get bored because I couldn't get deep into more useful stuff for me. And so, it was kind of like, what am I interested in? So, I like to think of this podcast as I'm trying to learn, I'm trying to learn, and I hope you guys learn along with me, more about how to get better patient outcome and how to communicate better with people.

And so, think of it as we're both hanging out of a bar, me and you as a clinician, I decided to get a Modelo, Modelo, and you decided to get a Corona, and then one of our friends came and he decided he wanted a Tecate, a Tecate. We're all doing Mexican lagers today. So, the communication is friendly. They can understand what we're talking about for the most part. So, that's what the format of the podcast is. This is going to be useful for chiropractors, PTs, ATCs, MDs, and the patients who really want to know more what's going on. So, the podcast today is going to be a little bit more case study-based, and recently, I felt very schooled by an intern, and the intern was Mikey.

Mikey, good job. You really stepped up your game on that day, and I know you're a listener to the podcast. So, we went over a couple hip or groin or, I would say, lumbar extenders, cases that had a lot of lumbar extension as a commonality between them. One person was a sciatica one, and the other one was a thigh pain when running. You know, he could really only provoke it with running. So, we're going to cover some of those highlights of those cases today as a bunch of random tangents that I tend to take you on anyways. And first, we're going to get into that personal part, which is hopefully you guys get to learn a little bit more about me as a host, and hopefully, like your host, you learn with your host.

So, we're going to get to that short story. We're going to start with the podcast today. Every year, I have a Freedom Day party, you can call it, and it's on the 4th of July. And the thing is that leading up to the event, I think I might have told the story before, is that every month, hopefully on the 4th, if I remember, starting January 4th, and then February 4th, and then March, April, May, June, July 4th, is people will get an invite from me. This year, I decided to do an audio version. If you're not on the email list or the text message list, I'm sorry. We've got to become better friends, I guess.

And anyway, so every year, people tend to come and they forget the thing called the gate code. They forget the gate code. And so, because the music's playing in the garage, we have a garage party, so everyone's kind of jamming to the music and playing Beard Eye and, you know, rowing down and so on. All of a sudden, someone will call. They'll call me and they'll shut the music down. And so, I'll talk, pick up the phone and say, what's up? And they'll say, oh, what's the gate code? You know, and oh, where do I park? And hey, where's your house? And I say, look, this was all on the email, on the email, okay?

Right now, you just did a massive party foul, okay? So, this year, I basically, on every single audio that's going to come, I'm going to repeat the gate code, okay? Gate code over and over and over and over and over again, because I don't want that party foul to happen. So, I'm going to wait, I'm going to wait until that one person calls me and say, what's the gate code? I say, you know what? You got to check your emails. Anyways, that is my mission this year, that no one calls me on the 4th of July, they just come in and have a good time. So, let's get into the show. Now, a couple of the cases that I'm talking about in, the common factor is overall lumbar extension, is that there's a lot of lumbar extension happening.

I'll give you just the rough parameters of what I tend to see, at least with these cases, when people have a lot of lumbar extension as just an overall white elephant in the room, it's not uncommon to have things like femoral acetabular impingement or groin pain. It's not uncommon to have inner knee pain. It's not uncommon to have piriformis pain or hip flexor tightness or even sciatica. So, there's a lot of things that can happen because this isn't necessarily always a disc, a lumbar disc person, because they've become a little bit more maladapted. They've started to extend some more, which couples with an anterior pelvic tilt.

An anterior pelvic tilt tends to go with an internal femoral rotation or a challenge of holding an external with some of the musculature or some of the bony anatomy, which then can challenge the knee. According to, I think there was a power study back in 2010, I think, that basically showed that the internal femoral rotation can affect the knee. The cartilage and soft tissue structures in there as well. In addition to that, there is a possibility that some of just those blatant symptoms down into the knee are contributions from the femoral nerve path. So, L2, L3, L4, or basically, I'd say, mid to higher lumbar.

So, what I'm talking about in these cases today is basically, we had a few cases that came in that were, again, the lumbar extension was a little bit more than I wanted to ignore. And actually, they had to have pain with extending their back or arching their back. So, they're sway-backing a little bit. Rounding their spine forward actually was very comfortable and they had no pain whatsoever. One guy even had, again, he had sciatica and or leg pain, pain down into the thigh, or sorry, the backside of the thigh, like nervy pain. And it went away with bending forward. So, in this case, I wouldn't necessarily call it a disc-based problem.

I'd think of it as something else like a closure or, again, what's the common theme is lumbar sway. And so, if you guys have not been to any workshop that I've done, I just kind of talk first about what is the elephant in the room, all right? If someone walks in and they're limping, but they're not talking about a problem on that side of their body and they came in for a finger problem, this is kind of an elephant in the room. Why is that happening, you know? If someone came in and their head was, like, totally down the whole time and they weren't looking up at you and say, well, what's going on there?

Oh, no, I came in for a foot. Huh, that's weird, you know? Like, just note it. It's noted because it's a commonality. Whether it's related to their problem or not is a different story, but if it's related, it'll tend to present itself over time here a little bit. And so, I think the first one I'll talk about is the runner with thigh pain with running, mainly because he's the freshest one on my mind. What I would say was probably going on with him is that he, so he did have a lot of low back sway and he had a lot of sensitivity around the back, which happened around L2, L3, right around the spinous process or the midline of the spine.

It didn't go down into the leg necessarily as the standard numbing, tingling pins and needles type of thing, but he did have a lot of occurrence of both the thigh and the back at the same time. The back would tend to get tight on that side. It wasn't necessarily his primary concern. He was just kind of talking about the thigh and his back was just, it presented itself. And so, I spent a couple sessions working with him. And so, usually with this type of case, I'll try to get the glutes really engaged and working. And I'll also figure out the spine's directional preference. And it looks like if bending forward is helpful, then we'll try about, you know, 20 reps or so, like the end range loading style, and then I'll have him sending him off running again and see what happens.

Or if press-ups, end range loading and extension, lumbar extension will be helpful. I'll try that and I'll send him off running. And usually, you know, 20 to 40 reps tends to work pretty well to kind of present itself as being useful or not. This guy actually, he was one that actually grabbing his ankles in a seated position and pulling his chest between his knees, so more of an end range loading and rounding of the low back. Actually, he went out and ran the first day and he's like, oh, wow, that's like halfway better. And I was like, oh, that's interesting. Okay. So, I chose not to do any tissue work on him.

At least, we've seen him three times. I chose not to do any tissue work on him because I, through some testing, I found that there's nothing really wrong with his knee. I loaded the musculature in question. If you were talking about a muscular strain, there was nothing wrong with it. And the knee was relatively stable, no positive findings whatsoever. And so, we found a lot into the hip and we found a lot into the low back. And so, we just went with the elephant in the room. And so, I could have tissue worked him the first day, but I really didn't do much. I wanted to see if we can establish a control system for him, something he can dose out at home.

And so, I chose that at first. Now, the reason why I'm bringing this case up is because sometimes it's just really easy to go back into the basics and just not overlooking the simple low-hanging fruit. And in this case, on day one, I did show him some of that grabbing the ankle thing, but I also like to send him home with some type of exercise, which is one of the reasons I think is going to be the most helpful. In this case, people who tend to sway in the back a little bit, they tend to also have a little bit of that glute amnesia going on. Like, the glutes don't tend to help, or we'd have something called the spinal hinge, or there's hinges predominantly happening at a section of the lumbar spine versus the hip.

Now, granted, it can happen in both areas, but, I mean, both of them should be able to move. But if the predominant movement of extension and flexion has happened at the spine, then it's really not for that. It's the hips of ball and socket. It's really good at moving around, and so we might as well just push it towards that, and at least momentarily to figure out if we can get the area above to chill out and so the symptoms go away. And so I chose to give him some banded bridges exercise. And so he started to feel some into the groin. He felt some into the adductors. He felt some into the hamstrings.

And so usually through this troubleshooting process, I'll ask people, where do you feel it? You know, I'll tell them to break the band and put the hips into, or put the belt buckle to the sky, and I'll say, where do you feel it? And so usually, we'll go about five, ten reps, and he'll, something will present itself. And so it did. And so he mentioned basically everywhere else except for where I thought he would feel it. So what I'm looking for is him to feel it into the glute area, and a big old handful of cheeks start to work. And so he didn't. He felt it in the groin. He felt it into the inner thighs.

He felt it into the hamstrings. He felt some in the back, too. He actually had to stop because some of the mid-back around like L2 area, L3 area was becoming a little irritated. And so he wasn't really using his hips to extend, in my opinion. He was using other things. And so we troubleshot this a little bit. There's ways to tinker with these exercises, because that's just one of the simplest ones to send home. And I just wasn't really getting when I needed to. I felt myself kind of fumbling around a little bit. I sent him home with a couple, way more exercises than I usually do with people, just because I wanted to make sure.

He was driving a long ways, and he was only coming once every week. And I wanted to make sure that he was able to hit his goal, because it was a timely goal. And so he came back the second time. He was great. He actually wrote down on a ledger to figure out what he felt during his mileage and so on. And so the second time he came, there wasn't really a big change. And so he had done all this stuff. He'd written it all down. He was very diligent. And so at that point, I chose to go with a different glute exercise, as well as building an anti-extension type of training. And so if you're wondering what anti-extension is, I talked to Mikey about this the other day.

And he said, well, why would you pick that for that? And I said, well, because if extension is driving this problem, we need to build the brakes for extension. And so with this, I tried to build the brakes on the front side, which would be the anterior slings. And the glutes also help out with this too. So I tried to build that a little bit. And then we came back the next time and no real big change, you know, so the third time. And so this is still a case that's pending probably by the time this podcast drops. But the third time, I was thinking, you know, like, because I remember this one time, this one time I had this knee pain.

It was like right on the outer part of the knee. And this was before I really knew much of anything, but it was probably my first experience with the attractor state principles and just smoking somebody. And then just, they feel better without having to think much of anything. So this one time I had the outer knee pain. And so it'd been, it'd been months, you know, and it really wasn't feeling any better. And I decided, screw it. I'm just going to, I'm just going to work out. I'm just going to lift. And so I lifted. I remember I did Bulgarian split squats and I just went for broke. And so I was so sore the next day.

And one of my friends wanted to go run. And I was like, I don't want to run, man. I can barely move my legs right now. You know, I just went for broke. And they said, oh, come on, go. And I said, oh, okay, fine. So I went, I didn't have any knee pain whatsoever. I mean, it wasn't the best run because I was sore and I was, it was, I was tight, but I didn't have any knee pain then. And I didn't have any knee pain ever again, at least in that spot with that condition. So I told this guy this story and I said, are you open from with me trying this type of thing with you? Because the, we can keep you in corrective exercise land all we, all you want to, but it's sometimes load just is, is a better stimulus unless just you open a try and he said, yeah.

Actually, so before I proceed on this, I should mention too, I did do a podcast probably about 30 episodes ago. I think where I talked about the block system. And this is kind of how I trained the interns. It apparently is very helpful. I just, I thought of it one day and we did case presentations. How would you, how would you address this case if this case came in, if you had to guess and it was the perfect situation for it? And so let's just say if you have like a, like the standard McGill style and, and McKinsey style low back. And so you might go, or does that be discogenic? And so you might give them a block one, which is first aid, McKinsey extension, or at least porn prop.

And so with bucket two, which is your corrective exercises, you might give them the McGill stuff. So bird dog, side plank, modified curl up with correct, with block three, which is your, um, which is your, um, your strength training or your, your, your loaded movements or your S and C. I'd say I classify this as like the Dan John bucket. And so I might give them a split squat and I might give them a deadlift from a kettlebell from a block and I might give them a single arm row. By the way, if you're wondering, um, where this is going, uh, I'm going to, I'm going to mention this for, for these cases, at least how I would see them in a perfect, uh, perfect world.

Cause I do have these written down for, um, many cases, at least that's, this is part of our intern training package. Uh, and this is what I'm actually, my workshop is going to be on this year. It's going to be case presentation and building your bucket system and knowing where to go. So with, with this guy in particular, where was I going with this shit? Um, Oh, uh, loaded stuff. And so I, I, I, I decided just to throw them into bucket three. And so we've already tried a lot of bucket two bucket one was his, was his grabbing the ankles, which I mentioned earlier, which is an easy thing. The corrective exercise is like all the ground based stuff that you see these fancy exercises and bands and shit hanging off people.

That's your corrective exercise bucket, which is a, which is a stepping stone to getting into load. It's getting into the S and C world, the Dan John world. And so we might have to cue this bucket three strength conditioning Dan John world as, um, differently based upon people's problems. And so I chose to use a landmine, uh, RDL with him. I chose to use a landmine squat. Um, and then I actually did a, uh, a bear position row, like you're in a bear crawl, but you're rowing with a strap and, uh, or with a, with a heavy band. And so he felt his glutes on glutes on the RDL, the bar or the, um, the landmine RDL.

He felt them on the squat, but there's something going on. It was a little wishy washy. And then it's funny, he felt his back with the, with the rowing. And so usually the bear position, because they have the feet and hands on the ground, they're locked down. They have a lot of stability there. And I tend to cue them with your job is to not let the, not let the, the band move you. You can move the band, but whatever you do, don't let the band move you. And so he was allowing the band to move him because the spine was getting a little pissed off. So I, I, I was using that with him and I'm like, oh, this isn't working either.

You know, and so I started to look above a little bit. And so I was thinking about the hip, but then I started to look above the lumbar spine. I'm like, well, about thoracic spine. He's got a lot around right there. Like that's, so I started to go into, you know, like, like low kneeling, um, thoracic spine rotations and things like that. And I caught myself just doing a bunch of this stuff. And finally, Mikey's like, whoa, let me try something here. So he pulls the dowel, the dowel out and he has him go on a chair, seated on a chair first. So he puts the hand, the dowel on the back of the head, back of the thoracic spine in the ass crease.

And he just has him lean forward into the feet. And so he's basically just showing him the hinge from, from, from a seated position. I've done this before. Um, I remember there's one guy actually where he had pain with, um, he was, he drove and his job was to count canisters. And so he'd lean down and look up and count canisters. And so he'd twist his spine up a little bit. So I taught him to hinge. Um, but Mikey grabbed this thing out. Like, uh, he was, it was like, it was in back pocket. It was ace in the hole. He was just ready to go. And so we did that. And this guy's like, ah, I feel it. That feels so odd.

It feels so different. That is that what I'm supposed to be doing. So after that, after he did about 10 reps, we took the dowel away and we gave him a, we gave him a goblet squat in the same spot he was at. And that worked really well. Then we took it into a landmine and we load that up and that worked really well. And so after that, he ran, he had a one out of 10 pain when he originally came in with a five and the first day he was at a seven. So we didn't even load the hips a lot, but he patterned in that hinge. And so for somebody who, when we were working with him, we saw all these other things that could be happening.

Um, I think it really, if it comes down to it, if we think down with the biggest white elephant is in the room, it was the fact that he had a lot of lumbar extension. And so he also couldn't get his glutes to fire on, you know, I'd love to say we can go above. I think we should go above. This is, if we have all the time in the world, but we don't. And so the thoracic spine, although it was of interest because I was thinking, uh, with that much round, the rotation could really not be as good as it could be. And he's probably rotating at the, at the mid low back. Maybe I need to address that, you know, but I, I should have done better.

I could have done better. Mikey did a great job with him. So, um, I'm thankful for seeing that because actually in the same day we had a second occurrence of the same thing, but it was with the sciatica case, which I'm going to cover right now. Now, really quick break from the show, guys, I want to share one of the webinar series that I just put together. It is the, probably the only one I'm going to make it in the near future. And so if you guys are wondering, Hey, does Sebastian have any original content? Does that mean anything that he made that was, it's educational for clinicians, help me improve my skills, get people to loading, feel confident in cases like hips and shoulders.

And yeah, I just made this. I just made this. Um, it is all the information I know up to date. I will even reference all the people you should learn from as foundational information. Um, you're going to want it. You are going to want it. And if I was talking to myself five years ago, I would beg and plea myself to get these courses because it will really make it. So I don't do the wrong technique to the wrong person. As we, as I, as I kind of say the appropriate care will get the person where they want to go sooner than they ever thought possible. The inappropriate care will keep them coming back to your office again, really good for business, but bad for the patient.

So think about that. I want to share everything I know with you guys. And so go to p2sportscare.com. It's under the products tab and you'll find it. It is my face. My face is there. A five step of patient care series. I would start at hip. Do not start at a different one. This was recorded as a series. And so if you go into number three, like lumbar spine, I'm going to talk about things and reference things that I already showed in one and two. So you're going to miss out big, miss out on big chunks of information if you jump around. So please get one of six. If you like it, get the rest. You'll like it.

I promise. So p2sportscare.com slash products. Now back into the show. Now the sciatica case was a fun one because it was a good example of on day one how things can change from day one to day two. On day one, he had leg pain, but he was a clearly flexion intolerant back. Like the back did not want to go forward. We did seated flexion tests. So we also did seated flexion compression, just a little bit of compression. It bothered a little more. Extension was very favorable. It took his leg symptoms away. He did prone press ups. That felt way better. He was able to walk out feeling much better. We did slump tests, all that kind of stuff.

And so he was very much discogenic symptoms, very classic discogenic symptoms. And so he came back about two weeks later, and he no longer had back pain. For the most part, the sciatica was very intermittent. He'd gotten down to, I think it was about 25% of the time when it was pretty consistent prior to. So he was much better. He was happy. And I said, when do you feel pain now? And he said, only when I stand. And so I'm like, how about when you bend forward? He said, no, it's only when I stand. And especially the longer I stand, the worse it gets. And so I clarified with him, and certainly was with standing, standing upright.

And bending backwards tended to irritate his back a little bit more. And so in these situations, usually what I'll do is I'll just go straight to a retest. I'll test out the same series that I tested before to see if he is indeed an inactive disc now. It's not really a disc that's active and generating the problem anymore. Now it's just a past thing, and he's got some nerve irritation, which is not a big deal. It's just we just have to reduce it a different way. And so in these situations, I'll typically go in a little bit more into a test of a round, but more a round under support. And so I'll do something called a buddy squat, which is the Dan John original.

And so I'll grab them with their hands, and I'll say, just let me take the weight of your body and just go ahead and slide your hips between your feet and put your butt to the ground. If it hurts at all, you can stop, but for the most part, I want to see you get down there and just relax and breathe and chill. And so we get down there, and they're usually at a, in this situation, they're usually at about a zero. And they're like, wow, that feels really good. Great. I think that we're on to something now. So he would be then, at that point, we flipped the switch a little bit. I took all those press-ups away, which usually I'll clarify with people.

Well, look, I only give you the first aid that I give you for five days to ten days because it is first aid. Again, bucket one is first aid. Bucket one is first aid. I keep telling them, bucket one is first aid. Because they'll get married to that idea very quickly, and if they do, they'll end up with a whole different type of problem than they originally started with, although it might not be the same problem. And so in this case, I started taking it away very quickly. All right, and so the next first aid I did was one that's a little bit better, I think long-term, and it's a doorjamb squat. So you have them put the hands on the doorjamb or on a pole in my office, or you can do a goblet squat, and you just sit down there into a nice chain-smoking, relax for five minutes if you could, but you don't need to.

About one minute is enough type of squat, and just relax. And it should feel like a zero, and all we're doing here is we're just chilling the nerve down. Now, granted, we can do some type of a neurodynamic solution like an opener or something like that, and yeah, you could. But sometimes I just, I mean, personally, I just go with what the patient's symptoms show me sometimes. And so I could have chose the other one, but I chose this in this case. And so anyways, he was now out of the woods at the disc, and now we just got to chill the nerve down and just get things moving again is all. So he had been in twice, and finally the third time, which was the other day, which Mikey was with me again, and so we had already gone through a lot of the bucket one.

Again, bucket one the first time was press-ups. Bucket two the second time, which I changed, ended up being doorjamb squats. He did get some bucket two stuff. He got some corrective exercises. First day, he got a bird dog. He also got a side plank. He got walking, and the second day, he got a, I think we did modified curl-up as well as bucket three. We did split squats. And so he was still having a pretty hard time finding his glutes, I'd say. When you cue him into a hinge, he feels his quads. He likes to squat when he is being taught to hinge. Every movement is very squatty. And again, I talk about that elephant in the room.

It's like, hmm, we can't get him into a hinge. I really want to get into a hinge, and then I want to load that hinge as quick as I can. So I was coaching him through what I call the frozen skater, which is still a bucket two. It's still corrective. There's not really a lot of load with it, but you can challenge it a bit. And so when you advance that thing, it's a single leg RDL. And so I had him do a skater for a while. He said he was really having some problems with it. Like he just couldn't really get, he didn't hurt. He just felt like he wasn't doing it right or didn't feel it. I just feel like his quad was really working a lot.

And we can see his low back round quite a bit into it. So there wasn't a lot of hinging involved, at least at the hips. And so we kind of took that away. And I took him to a goblet squat. I said, maybe we can get, this is not necessarily hinge, but I can get the glutes into a deeper position on this. And so I'll take him to a low box. Just give him like an 18, 20 pound weight, something like that, just as a counterbalance. And so I took him into that and I thought, you know what? We can access the glutes in the deep rings. Let's just try it this way. I'm just going to bypass the hinge because this is really hard to teach right now.

And so we did that. And so he did okay on that, but it still wasn't, I still kind of wanted the hinge a little bit. I don't know why. It was just me. I just wanted the hinge, all right? But I got distracted again, just like the last time. And I thought, man, okay, so the thoracic spine, there's a lot of, there's a lot of rounding there again. He can't rotate through that thing. He can't extend through it. Maybe I just take him through the thoracic spine series, which again, it's not a bad thing, but it is at the low hanging fruit. And so I got distracted. I went down that route. And so Mikey steps in.

He's like, hey, hey, hey, I got this dowel. I got this magic dowel. I'm going to take this magic dowel. Put this on the back of your head, the back of your mid-back and your butt crease. Sit on this chair. Yeah, yeah, good. Mikey's really chill. Like he'll offer you a cup of water. Like if you stand still for like about five seconds, he'll offer you a cup of water because he's a cordial guy. So he teaches him this and the guy's like, oh, that's different. And so he went back into the skater and he felt it better. He felt the glutes there. He went back into the squat. He felt it better there. So I'm sure you all kind of know that the hinge or the hip hinge is kind of like the start of the actual deadlift or the squat.

It's kind of like the start of the squat and then you kind of descend a little bit more. So the natural break in the hip. So we had trouble getting him to do that until Mikey stepped in and did that stuff. So those are two cases where, again, like I guess my takeaway with this is I was starting to overcomplicate things and I've caught myself over the months. I've been fortunate to have a lot of people who are extremely coachable and I could just blow through a lot of stuff really quickly and I sent them home with a little bit more of a comprehensive program than other people. And then other people I start getting distracted about like, oh, that one didn't work.

That one didn't work. And so it's not uncommon to get a few of the exercises which don't work and you have to keep scaling them back. Some people it's, it feels like you're pulling teeth and I know I can get better at this stuff but sometimes, and I know this is a, this is I guess a side thought is that I think I need to do a better job of talking to people in the beginning about, okay, I'm going to show you, I'm going to go through a series of exercises with you. You don't need to know them all. What I'm doing is progressing, progressing you and regressing you at will because you're showing me that you're good at, good or bad at what you're doing.

And so sometimes they'll get hung on that, hung up on that, on the idea of, oh, well, this one exercise, I should do, I can do this one. Just let me give a chance. No, no, no. Let's just move on. And so they get determined to try it and to, to like beat the exercise and do it, but we don't necessarily need to give them something once it won't, they won't succeed at with home. So I need to be clear about that. But this whole experience is just a reminder. I just need to be a little bit more in tune with what the goal is. The goal is the goal. All right. The goal is to get the hips working before tangenting onto the thoracic spine, at least in these cases.

So I should have been more keen about that. And this, I guess that second takeaway was talk to the person so I can, I move through some exercises quicker. And the first case was, he was very good at that. I didn't have to talk to him about it. He was just like, okay, at the end, I trust that you're going to tell me what to do. I said, yeah, we will. But we burned through like about five, five to six, seven exercises in that, in that setting just to troubleshoot before we actually landed on one that works. And then Mikey got the one that worked. So, since I have a little bit of time on this podcast still, I got through this quicker than I thought I would.

What I should probably cover here is, I think, when I've been teaching my interns, I think I've gotten better over the months. I guess it's been less than, I guess it's been more than a year now, maybe. I've gotten better and better, I think, anyways. And I think our conversation the other day, Mikey, I think was really good with, why would you pick that over that? I mean, this actually, Mary Lou was, I guess, the starter of this conversation, and me and Mikey continued it, was, we were talking about a case where they had, I guess, stenosis, quote unquote. They had lumbar stenosis. And so, I don't know whether they had a stenosis or not, but their back felt much better when they just rounded their back.

And so, she was saying, well, this is interesting because it got better, so what do I do with that? Like, how do I use a corrective exercise with that? Which one do I pick? And I said, well, which one facilitates more resistance against more extension? Which one puts the brakes on extension? And she thought about it for a little while, and we actually had a case come in later that was similar to this. It wasn't necessarily stenosis, but it was extension-based pain. And so, we were having a discussion there with me, Sarah, which you guys heard recently in the podcast, and there was Mary Lou there.

And so, I was doing notes at the time, and I was partly listening, and I heard bilateral back pain that improved with flexion. Sarah heard single-sided back pain that was worse with extension and lateral flexion towards. And so, when we finally came down to it, Sarah picked one, I picked one. And so, Sarah picked, why don't you challenge the opposite side, anti-lateral flexors, basically. If you had left-sided low back pain worse with extension and left lateral flexion, then why not try to challenge the right-sided musculature that stops more lateral flexion? And so, she chose a right-sided side plank.

And I said, that's a good idea. I'm like, I heard bilateral, so I would do just a hard plank, like a hard style plank, to get the anterior wall against anti-extension. And so, somebody came in, single-sided low back pain, could pretty much bend forward. It was a pass-flexion tolerant person or disc person that came in, I'd say, about a month and a half ago. And so, he could bend down forward, no problem, but there's still some pain with extension. And so, I said, look, why don't we just try it? Go ahead and do the side plank on the other side, let's just see. And so, he did it, and then we stood up, he bent forward, he's like, whoa, I can touch my toes now, right?

And then, he couldn't bend backwards, so there's still some pain with extension. And so, I said, well, try that hard style plank like I wanted then. And so, we did that, and then he could bend backwards and forward. So, we don't know what the hard plank would have been, would have done in isolation, because we did the side plank on the other side. But, it was a good, it was a good conversation to stimulate why, or facilitate the idea, why are you using a corrective exercise? What's the point? What are you trying to do? And so, when me and Mikey continued this conversation, he said, why would you pick that?

And we went down the bucket system, or the block system that I have on the Google Drive for my interns in the office. And it says, like, one of them is the example of hip femoral acetabular impingement. Like, true one. Let's just say, what is a first aid you would pick? And so, their instructions are to not read what I wrote, but I want you to just pick one first aid. And so, they do. And I said, pick one or two corrective exercises. And then, what would your first bucket three or strength training Dan John exercise be, and why? And there's not a really wrong answer in this. There's just semi-right and probably provocative.

Because if someone comes in and they have groin pain with hip flexion, and you gave them a deep squat, then that might not be the most useful thing at that point. So, we played this game. And so, he did very well. Mary Lou did very well. All the interns who have gone through it have done very well. But it is very thought-provoking. And so, I challenge you guys right now when you're listening, what way, and we're not allowed to use manual therapy in this case. I'm not saying manual therapy or adjusting is not needed in these cases, or any other type of passive care is not needed in these cases, but what would you use as a send-home exercise that will nearly completely reduce their hip impingement within about five days as a first aid?

Think about it. I know what I would use, and I would use probably a door jam squat. Why is that? Well, we think about the mechanics of Scour's test or Fadir's test, and it's usually hip flexion, internal rotation, and adduction. Adduction? Abduction. Cross midline. Whatever. I don't even remember which one that is. But crossing midline, and so it's basically, the mechanics are thought that it's you're impinging on the acetabular rim on the femoral neck. Neck or head? I guess it's neck. And maybe there's a cam or a pincer or whatever, or maybe there's not. And so when you find those mechanics, when you finally test somebody, if you haven't already, dynamically test them.

By the way, all in December, December, the first week of December last year, I already have a video series on this. So if you guys are looking for it, it's all on there. Just go on there and just go through the, you're going to get a drip campaign of all it. You're going to get a bunch of emails about how to dynamically test. And so when you find your first one and you have them fill their belly, if you put their guts into your fingers, once you put their fingers in their belly and you're in a Fadir's test and their symptoms go away every single time, you'll find out, holy shit, why is that? And so I believe it's the posterior pelvic tilt or the pressure of the belly that you're putting inside the belly wall.

Like the anaconda strength, or I guess in DNS, they would call that the intra-abdominal pressure. I don't know what's right, but either way, I found that when you actually put them into a non-effortful door jam squat or goblet squat, they feel okay. Now, if they couldn't do that, I'd put them into a frog pose, not an aggressive one, and have them breathe into their thighs because it simulates that offloading position. Now, if they put effort through that, I've met a lot of crossfers, you get them into the deep part of the squat and they feel that groin pain right there. And so that's provocative for it.

That's because they still have that anterior tilt because they're trying. Tell them to don't try. Just sit there. First aid is first aid because it's first aid. You're supposed to let it chill so you can build it back up. So, think about that. Now, based upon that, what corrective exercise would you give? Like, you can't just throw shit at the fan. What corrective exercise would you give? By the way, keep this in mind. Not everybody needs first aid, but it's nice to have it. It gives them a nice safety net. So, with the corrective exercises, I might go with a bridge, like a really aggressive bridge.

Or, because that'll posteriorly tilt, or I might help, I might use the belly wall to help out. And I might do a hard style plank. Get them really to smoke those areas and have them retest. And I'll help them dose it out at home. Now, if we're going to do a loaded exercise again, remember the whole point of corrective exercise is a stepping stone into getting them into normal everyday movement, which is foot on ground. Like, we don't crawl around like babies all the time. We don't do bands and shit. Like, those are good intermediates, but as soon as you can, put them under some load. Not a lot of load, just enough that they're going to simulate life.

What exercise might you give them? Now, I've been back and forth on this one, at least with true hip impingement, mainly because if you take them into a deep squat, like the door jam squat, but with some load, they might be too much load and they might tend to anteriorly tilt. However, if you actually get them into elbows in between the knees, it externally flares their hips. And so, they usually don't have that impingement in there, but you can get them through a full squat pattern and smoke them quite a bit and they don't have a problem. Now, could I deadlift them? I could. I probably would do a kettlebell deadlift with them from a block.

But, I find that with deadlifting, unless you do something like a med ball one or a goat bag one or really teach them to hand tension, their belly wall gets really saggy. You can't see it under the shirt because they're usually wearing shirts in your office. And they'll really lumbar spine extend, which is good for, I mean, it's fine for protecting the disc against the load of a deadlift. But, it really doesn't help out with the anterior tilt and why that person is in your office today. And so, I tend to not go to the deadlift right away on these people unless they show me that they're really competent.

Like, these cases I mentioned earlier, I probably wouldn't do it on them because their hinge was fairly inadequate. But, I might take them through the Mikey style one and just take them through that with no load and just see if we can get them to pattern it out. Now, again, like I said in the beginning, there's no true perfect way, but you should have a plan. You should have a plan with tendance to work. In another podcast, I mentioned that you should be able to reasonably say, let's just say with a first aid, reasonably say someone should get better. Like, I'll give myself, like, those would be nice to myself.

I want to, they should be 50% in like 10 days, two weeks with only doing my first recommendations. I just feel confident in that with most cases of certain types. Now, if someone came in with like a metatarsal pain, I don't feel confident. I'm not that good with feet. So, it's just, I feel confident in certain ones. And so, you guys should feel confident, too, in what you're recommending. And same thing with that corrective exercise, the bucket, too. You should feel confident in what you're recommending. And you should feel like, okay, this is going to work for this person. If you don't feel confident in it, you need to really think about reverse engineering, why you're recommending what you're recommending.

I think I said that too many times. Either way, think about it, okay? And so, by the way, this podcast was not intended to be a big pitch in my workshop, but you really should come to my workshop. The workshop is going to be fantastic. The doctor one, which is a CE one, is April 20, I think it's April 25th, 26th. It's already missed early bird special, so early bird was already out there, but that's a two-day thing. There's CEs involved for California only right now, but if your state is eligible, then I'll petition for it, but you've got to give me a lot of heads up. And the student one is May 30th.

Again, you guys have already gone past early bird discount. And funny, the thing I've noticed about, and this goes with sales of care to patients or to students or to doctors or whatever, if there's no deadlines and there's no urgency, people don't do anything. So, I'll let you guys know ahead of time that I don't care about the money of what the full thing is. What I wanted was everyone to pay early bird, you know, if you were going to come. If you're not going to come, it's fine, too. But I was comfortable with the early bird, but I just want to see that everybody's going to be here. I want to know how much steak to buy, really.

But I thought at least going over the bucket system would be a helpful thing this year because it's challenging to put the things together. I even struggle to teach it. I struggle to really lay out the ideas that I think will work with people and explain it to not only patients but to students and other clinicians, too. You know, I had a conversation with one doc that he's very smart. He asked me, I asked him about a patient that I was having trouble with, and he said, so what's the diagnosis? And I said, stenosis, stenosis, I think. And he's like, okay, you sure? And I'm like, no. You know, I think, I think, I don't know.

I'm having trouble with him, so I don't know. And he's like, so if you don't know what the pain generator is, how are you supposed to treat this patient? You know, so you got to know, like, you got to know, you got to know what the plan of attack is. You have to know the diagnosis. You have to know the way to chill the sensitizing structure down. You got to know how to introduce load in an intermediate way, which is going to be your corrective exercises. And you have to know how to then get them foot on ground, build some confidence, and get them just to explore life and have fun. And so I'm hoping that my teaching style is improving.

And during the workshop this year, I'm going to do case studies like we're going to do hip impingement. We're going to do neurogenic-based hip pain. We're going to do neurogenic-based knee pain, as well as flexion intolerant spines or disc problems. We're going to do facet problems. We're going to do sciaticas. We're going to do shoulders or non-responsive rotator cuffs to see what we should be trying, how to load a shoulder. And so we're going to cover a lot of that kind of stuff so everybody has a good idea how to really use exercise within your practice and not feel like it's just a foreign thing.

Actually, I should share some of the feedback that I got from last year. They said, well, you know what? The way you taught it is good, but I'm so used to doing my way that I don't know how to patch it in. I said, look, you're right. You're right. I need to do a better job at that. And so this is going to be a little bit more coordinated. Actually, it's going to be a lot more coordinated. And I'm going to share with you guys how to actually get everything streamlined into your office so you can actually troubleshoot these people and know when to implement this type of care. So as always, thanks for listening to the podcast.

I'll see you guys next week, and thanks for being part of the movement.