Piriformis syndrome while running: a case study in nerve pain

And so this is typically where I talk to patients about the three boxes of what we're going to do. As long as they're not married to the idea of something, usually they're okay with this analogy. So number one is I provide number one first aid, okay? First aid is stuff that you don't do all the time, all right? You do it for about five days, maybe a couple weeks based upon what your problem is and if you tore the scab open, and then you start to get away from it. So that's block one. Some of the suggestions are block one. Block two is your corrective exercise. And this is the stuff that you usually see silly little videos on, on Instagram.

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 everyone, it's Dr. Sebastian Gonzales, your host for the Restoring Human Movement podcast. Thanks for joining the Movement Movement. Today we're going to cover a case study again. As you noted, last month I covered a case study, and this was based upon the idea that I asked the listeners what they wanted to hear. So hopefully you guys were on board with the listeners that spoke up, and they said they wanted to hear some more case studies.

And so if this is your first time to the podcast, welcome. This is about a 45-minute-to-hour, sometimes a longer format. So we call this long format, and so it's going to take you through a little bit of a discussion. Now, the purpose of this podcast is to actually blend the line between patient and doctor communication. The hard thing a lot of times, at least for us on the medical side, is to explain things in a pure, simple way so that you guys can improve. And so if you're a patient, a lot of times it's hard to understand what the heck we're talking about, and also we actually struggle sometimes to understand what you're talking about.

And so we're trying to improve the communication. Think of it kind of like we're at a bar, and me and another clinician and a friend. Let's see, this friend today is a, we're going to go with someone working at The Habit, The Habit Burger. Love Habit Burger. We're all having a beer, and so we're talking about piriformis syndrome, and you're like, what is that? And so, good question. So we're going to break this down a little bit easier. So, also to be the first time in the podcast, I tend to share a little bit of a short story about myself, mainly so you guys can understand who your host is. Because if you're going to follow along this journey about learning more and more about how to improve care with people like this piriformis person we're going to talk about earlier to come here, then I hope that you like me as your host.

And so, just like Jay Leno or Conan O'Brien or Howard Stern or whoever your host is, hopefully you just like the host. And so, I just share a little bit about myself in regards to short story in that manner. So, we will get into that right now, and then we will go straight into the case study, and this time it is with a piriformis pain runner. So, I'd mentioned in a different podcast that I've been up Mount Whitney a couple times, and so there was one time that we went up, and actually both times, we did stay at this little cove area in there because we did a multi-day thing. We went to Constellation Lake, which is right below the high camp, and we would use it as our base camp before we'd actually go up to the very top of the mountain in the next morning.

And so, we'd camp there, and it was by this little creek, and luckily we've got the same spot both times. Most people kind of stay up at the high camp, I think is what it's called, or base camp rather, because I think there's like solar toilets and stuff up there, and so it's a little bit more comfortable. And plus, it's closer to the trailhead, so you can just go straight up in the morning. And so, but we camped there amongst these granite boulders and these little big, these big old squirrel-looking things there were called marmots, and they would jump into your shit and probably try to take your shit.

But there was this nice little quiet cove there of this, kind of like a bubbling brook that was like, it was really wide. And by wide, I mean probably about like 50 yards wide, and there was rocks all amongst it, so you can hop amongst the rocks and go to different parts of it if you need to. And so, there was also, it was surrounded by like the whole lake, and that bubbling brook is surrounded by like boulders. And so, there wasn't really a big shoreline, it was mainly boulders. And so, between boulders, there was also nooks and crannies. And so, we went fishing there. And I brought this little fishing pole up and had a lure mainly, and so we went in the main lake and caught probably about 15 fish in an hour.

Like, it was a lot. We did return them, but it was a lot. It was the most fish I ever caught in, actually, second most fish I ever caught in an hour. And so, good success there, and we went to the brook. And so, these fish were like dumber than rocks, and I went amongst a little, two boulders that were on the side there. And so, there was this fish just poking his little head out, right? There's this little brook trout. And so, I actually just stuck the, I stuck the little, the lure down there, just dangling it around. I just wanted to see if he would move, and he didn't move. Because I already caught enough fish, and I was like, well, I wonder if I could slip this thing in his mouth.

So, I slipped it in his mouth and pulled up, and I caught a fish just by putting a hook right in his mouth. I did return them after that, again. But that was probably one of the best fishing there has been. And I don't know if it's still like that again, because it's probably been about 15 years, 10 years since I've been there. But it was good, and I think that was the best part of the trip. The top of the mountain is really not that spectacular, other than the jets flying over real close. But it was, that was my experience at Mount Whitney. That was the first time we went anyway. So, there's just a little bit about me.

Let's get on to the content. So, I had a person show up in my office. This was a lady. She had started to run into her, in her 40s. She was about, she wasn't 50 at all. She was probably about like mid-40s or so. And so, she'd been running for a couple years. And she had reported that she was having mainly some right-sided outer hip pain, kind of into the, just a tiny bit into like the front part of the hip, mainly on the back side and on the side and sometimes in the back. And so, I'll kind of paint a picture of what she was experiencing some. She, in the history-taking process, I was asking her a lot of times about, I ask a lot of times with, what has happened in the past?

What have you experienced in the past? Because a lot of times, these little things that people think are kind of insignificant, sometimes are very helpful in painting a picture of why your body is reacting the way it is. Because in this case, there wasn't trauma that occurred. There was no slip, no fall, no hit. No one took a baseball bat to her. And so, there's really that, I guess, cumulative injury type of thing that we say, quote-unquote, or overuse type of thing, quote-unquote. Usually, it has a driving thing, all right? Typically, when we examine somebody, number one way to figure out, we call red flags.

If you have not, if you're a clinician or your doctor does not ask you about red flags, about if you've had differences of bowel or bladder function or numbness and tingling in certain spots or if you've had fevers and so on. And so, there's lots of red flag questions, and typically, you want to ask all these red flag questions because number one thing is we have to guide you to what is the most appropriate type of care for you. And there's a possibility, I think it's under 3% chance is the rough estimation, is that you're going to have something that is not, that wouldn't be addressed in our office, and it's more of something, more of the sinister pathology we say.

But that's the first question that we need to answer. Second question is, what is driving the symptoms, or sorry, what is the symptom-generating structure? And in this case, that usually takes history and examination, which we will go through in a second. The third question is, what is driving this condition to continually occur or keep re-injuring? And so, let's just say this person with piriformis syndrome here, they don't have any pain if they don't run, but if they run, they do have pain. And so, it's kind of that intermittent presentation. And so, if it's worse with sitting and not standing or walking, but it is with running, but only at a certain pace, what is the differences there?

And so, sometimes when you figure out what's driving the condition, that's where I like to dig into the past history. And so, this lady, she had reported about a 3 out of 10 type of symptom, or a type of 3 out of 10, 10 being the worst pain she's ever felt type of thing. She felt it pretty much all the time, like it wasn't really going away 100%, but it did kind of fluctuate. And it tended to increase a little bit more as she was a little bit more active as well. And so, it seemed like nothing really made it feel better, seemingly. Nothing made it 100% feel better, but there was things that decreased the symptoms.

But it seemed like running and laying on it were things that tended to make it worse. There was also, too, I believe that sitting was something that actually increased her symptoms as well. Running obviously bothered it. Turning in bed bothered it. Turning and getting out of a car bothered it. Driving, sitting. These are all things that tended to bother it. And she said it just seemed like it just wasn't really going away. Maybe it was getting a little bit worse. She described it kind of as like a burning and a sharpness, kind of into the outer hip area mainly. And so, she had really done some investigation on her own to see if she was having piriformis syndrome.

And so, although she really didn't have any numbness, tingling down into the backside of the thigh or into the calf or into the foot, which sometimes they say goes along with the piriformis syndrome if the sciatic nerve is being entrapped by the two heads of the piriformis. By the way, that's not always a common thing. And so, I know that people think it is. It's rare. It's really rare. And to be honest with everybody, I don't see very many cases of real piriformis syndrome. I see misdiagnosed ones that people come in the office. And a lot of times, we really have to investigate, is there a segmental issue of the spine or is there a nerve tension or compression issue?

And so, a lot of times, we'll go through a spinal-based test as well as a hip one and check on down the line and see what's driving this condition to occur. When asked what time of day was more bothersome for her, she said usually about the first 15 to 20 minutes of the day are a little bit iffy. She wakes up and it feels a little grumpy, not necessarily when she is opening her eyes in bed, but especially when she exits bed. She tends to go through a stretching routine after that. But continually throughout the day, she has a couple things that pop up here and there that she takes Advil for. But the cool thing was, at least with her, she wasn't afraid of moving because a lot of times, people are a little bit afraid of moving because they think it's going to make it worse.

She had been playing tennis. She'd still been running a little bit, testing out the water, but for the most part, it didn't seem like it was really getting better. Funny thing, too, is with her, she did have some other issues going on. And she had some neck and shoulder blade type of mid-back, upper-back, periscapular, between-the-shoulder blade type of ache on one side. And so she wasn't really concerned about this extremely. I did examine both regions to make sure they weren't necessarily connected. And I know that some people believe that they're like, well, I have this thing and I have that thing.

And do you think they're the same thing? And I said, maybe. Like, you're allowed to have two diagnoses, though, too. And so I tend to screen them out both and just let them know if there's a different side-to-side or if there's a difference between each thing. And in this case, I feel like they were a little bit different. The diagnosis that I really fit her up with is, after examination, is the upper part, I would say, that was more of a C5 radicular type of symptom, mainly driven by a cervical disc. But there was a neurological type of presentation, I guess, because it was traveling. And so I guess I would tell her there was a disc issue.

I don't know how, what type, what staging or whatever, because I didn't have an MRI to look at anything. That was secondarily impinging on a nerve. In this case, maybe the C5, but who knows. And so that was the thing I gave her there, but also, too, in the lower half, I also gave her a radiculopathy type of diagnosis. And I'll tell you the reasons why as we go through the examination. By the way, as we go through this, the reason why everyone wanted the case presentation, I think, is because they wanted to figure out how to use all the little parts of rehab, loading, first aid, and diagnosis, and the tools.

So I'm going to get into all that kind of stuff as we go through here. But keep in mind, I do my best to remember these cases for everybody because I think they're interesting. I get excited. She was really fun to work with. But a lot of times, they'll throw a lot of information at you. And I think being able to sleep at night, you've got to be able to forget some of these things. So I'm reading up on it a little bit as we go. But looking back in her past history, she had a history of a right ankle that was continually irritated throughout college when she was playing sports. She was on crutches for a while, but there was never really a fracture.

And other than that, there was really nothing big. Now, back about 15 years ago, she did start—sorry, about 10 years ago, she did start running half marathons. And so at that time, she had right-sided, quote-unquote, IT band pain. And so this was kind of onto the outer part of the thigh, as she described. Again, her issues currently were right-sided hip issues that tend to go away with medication and positional changes. The right-sided IT band stuff was there. She also had the right-sided ankle back in the past when she was in college. And so in this case, probably about 15 to 20 years ago. And she did see a PT for this IT band regional thing that they had diagnosed.

It kind of as it was being driven by pronation of the foot. Or the ankle region. And so she said that pretty much went away. And so now it was mainly residing around the hip. So usually with this, I'll go through and I'll do all the standard testing that you guys learn in school. The orthopedic, the neurological, all the pathological reflexes. By the way, if you don't do every reflex every time, I think going through the Diplomate Program, the DACVSP, this sports physician one, I think one of the biggest takeaways was that you do every reflex every time. Upper, lower, pathological, all of it. Because you never know what you're going to find.

And so I screened all that stuff out too. Plus she had some upper base complaints as well. And there was really nothing big there. And even in the orthopedics test, there was really, there was not a lot that was really that impressive. And it's not uncommon to find people like this. We definitely found stuff in the cervical region. There was, it was aggravated with compression. It was decreased with distraction. But there was, again, there was a lot more going on there. And I don't want to focus necessarily too much on the cervical base complaints because I think it's, it wasn't her primary complaint.

But there is a finding later that we, that was interesting that confirmed, I believe, beyond reasonable doubt that there was a good path to take. But the lower area, like Faber's test was positive on, I believe it was the right side. Kemp's test was positive on the right side. So the side of symptoms. But there was no real strength loss. There was really, really no avoidance of lumbar flexion, lumbar extension, rotation, none of that stuff. And so I screened everything out looking for SI joint. I was looking for a hip FAI, hip labral tears. I was looking for discogenic types of symptoms. Also neurological stuff.

One of the things that she did light up on is, was seated slumps test. And so I think this is a really compelling test to everybody. If you don't, if you don't do it already, you probably should. And so although it was really hard to find what was going on with her, you can do some more provocative tests and see if you can differentiate some of the symptoms. In this case, the right hip pain with nerve tension test. Usually what we'll find is in a nerve tension test, as you start to, in the lower extremity, the slumps one, as you start to extend the knee and dorsiflex the foot, or if you extend the knee and have the toes towards the ceiling, especially if the head is down, you'll find that their symptoms may increase on the side of complaint if you do that side.

However, if you get them to look up, you might find it go away. And I can't tell you how many people I've had, especially runners, where they have IT band pain or a hamstring that's tight or hip that's tight or piriformis syndrome or back stuff that tends to go away when they look up. And when you do this, it's mind-blowing to them. And I think it's a really pivotal point in the examination in regards to trust because at this point, a lot of these people have tried a lot of foam-wheeling massage, tissue work, Graston, active release, all this kind of stuff, which, again, has its merit when it has its merit.

But if it's a neurological thing, all we've got to do is a lot of times decompress or slacken the nerve, and it just feels better. So in this case, looking up, I don't recall it actually feeling better or not, but I remember the other side, and so this is the contralateral effect. If you put them into a single leg, so it's a bilateral slumps, basically. Leg goes out after you do the one leg. This was taught in the clinical neurodynamics by Michael Shacklock, by the way. You try one side, the side of symptoms. Yeah, that's my problem. And you passively bring the other one up, dorsiflex, and just pull that side as well, and they say, oh, that's interesting.

It went away. And so you keep trying this stuff. And so it's a good indicator. It's a strong indicator, especially if you do a clean test, that this is not necessarily a muscle-based problem where the issue is in the muscle, where they have scar tissue or adhesions or any of that stuff. So it's more that the muscle is either a symptom of the nerve tension or nerve pressure or it's a protective response. And so in this case, usually when I have this type of information and I've stress-tested the hip, I don't find anything really major. And all the data points, by the way, if you guys don't collect all your data points, the data points that you find for like, in this case, for hip FAI, I didn't find scour tests.

I did find Faberis tests, but I didn't find a bunch of other stuff, circumduction was okay. I wasn't going to progress down further to find anything on labrum because there wasn't any painful clicking and popping. There was no definitive arthritic grinding. There was none of that stuff. And so all those data points for that as being the thing is very low. And so we even looked at the lumbar spine disc, which I would think it was going to be that, but it wasn't. And those are really low because you can bend forward really no problem. And I think as you guys go through the examination of things, you'll start to see that as you collect all these data points, you'll figure out beyond reasonable doubt what is the path to take with this person.

And in this case, if I'm looking at somebody who has a nerve slackening, we're going to slacken the nerve as a remedy or open the space that is passing through as a remedy. Usually the slumps test is one thing that I'm going to find positive on. I might also find an SLR that increases their symptoms and differentiated with either the ankle or the head or the other side. And so when you differentiate and you are figuring out whether this is a muscle thing or a nerve thing, maybe in this case, you need to test at least a couple joints away. Meaning, let's just say this was the, say someone had a hamstring problem in this case.

Or, because I don't want to say piriformis because this is a little bit harder to, it's a little bit harder to talk about. So let's just say someone had a tight hamstring there. And so I put them into a straight leg test and they're like, yeah, that's really tight right there. And so you're moving the hip or you're moving the knee. And if you move those, technically the hamstring connects beyond those. And so it can have that effect. It could be, just be a muscle problem there. But if you move the ankle or the head, all of a sudden they're like, yeah, that's better or worse. I think it'd be on reasonable doubt.

The hamstring doesn't go there unless you're, unless you're very different anatomically. And so differentiating needs to occur pretty far away at the distal ends of the whip. And I've even muscle tested people before too. And I muscle tested this lady with, with stress testing the muscle of the hip. Yeah, it was, it was a little bit irritated. But also too, when air, when the area can become symptomatic because it's protecting against nerve tension, maybe in this case, it's going to hurt too. And so it's not very specific in my opinion. It's noteworthy, but I don't think the force that she had through challenging those muscles was really, it was strong enough to make me think she didn't blow some tendon off or she didn't have a grade two tear.

By the way, she never had any bruising. So I think those are noteworthy things in her case. Now, a really quick break from our sponsor. Pro Chiro Online CE is a brand new platform for online chiropractic content education. A lot of times through different states, many states, online hours are allowed. So if you've already been a chiropractor for a while, you probably realize, hey, I didn't get credit for that course and that course, but I need some hours. My birthday is coming. All right. And so this is a really common problem. And if you're just like me, you've gone online and you've gone through these courses where you literally don't learn a single thing and it's boring.

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Now, her goal was to get back into running. And she really enjoyed running with her son and she had some marathons she was going to plan. But also, she was honestly very, very realistic with what she expected of herself. She really didn't do much strength training at all. She did a bunch of stretching. She did Pilates. She ran. Like, that is just kind of what she liked to do. But also, too, since she was into a certain age, I don't like to disable people because of age. But at the same time, it's like if you're expecting to, if I'm expecting to be a professional baseball player now, I'm 37 or 8.

I don't remember anymore. I'm not going to be that. But it doesn't mean I can't have fun and still have a good time doing it, a good time playing. And so she was right on board with that. So what we did in this point was I usually do some movement-based testing. And usually for lower extremity conditions, I'll have them first bend forward, bend backwards. I'll have them turn, turn, deep squat. And we'll do Y excursion tests, which is kind of like dipping your heel forward or to the side or kind of like a Y type of thing. And I'm looking to see just general differences. And there's this thought where basically you just observe and collect data.

And then you strategize and create a plan. Then you intervene. And so that's basically all I'm doing here. And although I feel like I know what's going on, I still don't know what's driving this condition. I feel like I know what is creating the symptom. That is question two. But question three, based upon the script protocols, is what is driving the condition? Why does this thing keep popping up? And so usually observation is a really good way to do that. You can look at how they walk. You can look at how they come into the door. Do they have pain with pulling the door open in the piriformis, but they also get really sloppy in the torso?

So maybe this is a rotational lack of rotational tolerance in the torso, which can trigger a nerve, which can trigger their muscle to become pissed off. So I observed that she wasn't really loading that well into the right hip. Or sorry, let's just say not right hip. Let's just say right limb because I don't know why. We can guess. I can extrapolate and say maybe it was the right ankle that she turned back in the day. Maybe it was the right IT band thing that was or was not IT band. Maybe that was an L5 radiculopathy. Who knows? I don't know because it was years ago. Or maybe it's the fact that she really does have a need to unload that right hip currently.

And I think you guys have probably heard me talk about this before, is that is the loading of the hip appropriate at this time? And so a good general way to figure it out is you can stress test the area. But for the most part, timeline I think is pretty fair. And also to figure out if they're intermittently having no symptoms at all. She can walk with no problem. She can run to a certain speed, no problem. But at some point, it becomes painful. So the timeline thing is usually like man steps on tack, man limps for about four or five days, maybe less, starts to put weight on the leg, and then starts to walk normally because he has to outrun a tiger.

Like this is the normal process. If the person then does not bear weight upon it, in this case, maybe she was doing this, you know, since she had her IT band issue or ankle one back in the day. Who knows? And then an adaptive change happens. Adaptive changes will happen. And so we have to reverse engineer that process. So in this case, I concluded that it was okay to load the right hip if I wanted to. However, because I wanted to first see what I needed to do to get a baseline, a safety net for her problem, I didn't go there just yet. And so this is typically where I talk to patients about the three boxes of what we're going to do.

As long as they're not married to the idea of something, usually they're okay with this analogy. So number one is I provide number one first aid, okay? First aid is stuff that you don't do all the time, all right? You do it for about five days, maybe a couple weeks based upon what your problem is and if you tore the scab open, and then you start to get away from it. So that's block one. Some of the suggestions are block one. Block two is your corrective exercise. And this is the stuff that you usually see silly little videos on on Instagram or on YouTube where people try like best exercises for hip flexor problems, right?

They're silly. Like they're things that people normally wouldn't do if they'd given the chance. And so I might give you block two. But what I really want is block three. Block three is foot on ground resistance training, ideally single side. We can do double side. And then after that, we just mainly return into quote-unquote play. So I want to establish a safety net, number one, because I need to figure out trust or hopefully she trusts me when we develop that relationship. I can do some corrective exercises if needed, but really I don't want to unless I have to. And I think people fall into the trap of just doing these funny little exercises for the rest of their life.

And they shouldn't do either the first A block and they shouldn't do corrective block for the rest of their life. They should start locking that in with your block three and block four. That is your resistance training and your play. And so I think we struggle, and I struggled for many years with actually recommending beyond block, actually probably halfway through block two and beyond. I was really probably not great at. I thought I was good at, but I wasn't. And so in her case here, she had, again, I'll describe her symptoms. She had right-sided gluteal region pain and burning kind of along the iliac crest for all the patients out there.

That's around like your hip bone if you put your hands on your hips. And she also had a little bit of irritation kind of into the front part where the fingers would go if you had your hand on your hip. Kind of like following the presentation of a belt buckle. But nothing really went too much beyond that. She did have some tightness into her back right there. And she could duplicate it a little bit by running it throughout the office. And so I said, great, cool. Let's use that. And by the way, she could feel it with deep squatting as well. That was something that was helpful in the exam. And usually I have people pick their outcome measure.

I don't want to redo a test or a stretch. The rule is you can't do a stretch because everyone can feel pain at some point on a stretch. Really hard to test. So all we did is I concluded at that point that we're going to first do a trial of care where I'm going to see if opening the IVFs or the little holes in the spine on the side of symptoms was going to reduce her problem. The reason why I did this is because, number one, nerve tension testing was positive. But also, two, nerves that usually can't tolerate tension are just kind of sensitive anyways. And it's not uncommon for them to be a little bit more compressed.

In this case, my first guess was going to be at the low back. And I don't think it was necessarily disc-based or else I would have taken a different option. So I did a contralateral opener, we call it. And this is, again, a neurodynamics thing. Michael Shacklock taught it. They're amazing. They work for a lot of things. And so all I did was I had her on the table and I kind of opened up her spine a little bit, not with a scalpel or anything. We just kind of bent her towards the other side, not aggressively, just away from neutral. And so we kind of hung in this position for about 30 seconds, took a 10-second break.

We did this like for five minutes, on and off. And so after that, I said, go ahead and get up. Let's just test and see how this goes. And typically I'll tell the person, look, I'm not offended if it doesn't work. Just tell me honestly if it works or not. Let's just see. It gives me information. I'm still collecting data to see if this trial of care is going to be helpful. And so she goes and runs about the office. She's like, wow, that feels pretty good. And then she just squats and she's like, wow, that feels really good. And so she wanted to challenge it a little bit more with running outside, which I'm okay with.

And so that was already conclusive enough for me to see that that was going to be a nice addition to her block one, which is first aid. Now, her block two, I really wanted to get into quickly. And so for this one, I'd probably just go off my observations with the right limb. She wasn't loading the lower extremity on the right side. But let's just see if we can challenge it a little bit more because I want to see if she's feeling good already. Like the incremental increase by what I'm going to do next might, it might not be enough to really give me the right data that I need. And so we went and ran outside.

And so I said, how far do you have to run before you might think this might bother you? And she said, down, down, down and back. I said, good, good. Go ahead. And so she ran down about 50 yards or so and came back. And she's like, nope, didn't bother me. I said, cool. Go again. And she's like, well, now my shoulder blade's kind of hurting. And so based upon the data that I collected on that, I said, go ahead and run again, but give me a double chin. And so she ran again, came back. She's like, that's weird. It went away. And so at that point, we know what's going to be helpful for her neck. Again, collection of data, tests and retests.

And so she ran a couple times. And finally, she got the hip to become a little bit more irritated. And so at that point, the volume wise is she ran down about six to seven times, I think it was. And so I was going to have her retest that again as she, after we implement what we're going to do. And so in this case, we attacked the right hip is usually a really easy one for me. And funny, I went to a workshop by Scott Morrison, DPT, and he kind of confirmed. I never, I thought about this, but I didn't realize everyone else did it too. If they use loading, he said, we're probably just gonna be really good at 10 to 15 exercises.

And we just change them based upon the person's problem. If we want to reduce the symptoms via a loading progression. And so in this case, I chose a low diagonal sit, which I learned at a workshop with Koichi Soto and Craig Liebenson. Cody DMACC also helped me out with refining this and did this with me. And so it was really helpful. We actually were going to include that on the ProChiro thing, ProChiro CE online, but we forgot. I apologize. So this is one that I use on a lot of lower extremity conditions. And so the reason why I use it is not because I like the corrective nature of it or I like the fancy name or any of that type of stuff.

But I needed to make sure that everything was controlled. And so sometimes when you get someone into the next progression, which might be a half kneeling version or maybe even a single leg hinge or I guess single leg quote unquote deadlift without weight. Sometimes they get a little squirrely. And so I kind of at this point, I just want them to feel what I want them to feel. And I want them to feel the right hip start to load up. And it's going to feel like muscular burn. It's not going to feel painful. All right. You know, and probably an important thing if you guys tend to use something like this is you ask them where they feel it.

I don't like the idea of internal cues, but I can't tell you how many times I've said, okay, so we're going to do this, this, and this. Do you feel like, yeah, yeah, I feel it. I said, where do you feel? And they say, they point to a different spot. And I said, no, no, no, it's not. That's probably a symptom you're feeling. You feel it right in that pinpoint single spot. I want a big handful of muscle, right? I want that whole area to work. In this case, I'm looking for the downside hip. If you know what the diagonal sit is, great. If you don't, you might want to investigate that and you'll get a better idea.

So in this case, we loaded that thing up. And I'm talking about we loaded it, right? And so I tend to load people to the point where they feel like they literally cannot do anymore as long as it does not generate a symptom. And I'm pretty sure that this does not generate a symptom on her because I've already done my due diligence through examination. That's an important part. You can't just throw a bunch of shit at a wall and expect it to work. So as you start to refine these things, they're going to be very helpful when you communicate with the person, but also, too, if you've already tested to see if there's any risk in it.

Because I might not actually load this person. If she had a severe, ridiculous symptom, she had leg pain, shooting pain, I wouldn't load this person at all. I would just send them home right with that thing that I already gave her. But she can tolerate a little bit more and I had a little bit of time, so it was cool to do. And so she was more of like our high-function person. But as an outcome measure at home, what I really wanted was for her to be able to sleep throughout the entire night without having a problem twisting, turning, and getting out of bed feeling good. And so we were able to accomplish that, by the way.

I guess I might be jumping ahead. By the second time she came in, she was 75% better subjectively. No problem sleeping at night, no problems getting out of bed, no problems walking, no problems squatting. But she still had a little bit of pain when she got to too many miles because I didn't clear her to go do some miles. And so I think that's a great outcome. That was after about a week. But on that first day, we did one more thing because I wanted to make sure that she had gone into block three, as we call it. That's more of a strength conditioning put on ground. But this one I wanted to control a little bit more, so I put her into a single leg hinge.

I call it a frozen skater. You might have seen it on Instagram. If you haven't already, go to appperformancehb. There's a bunch of references in there because I use it for a lot of things. I just cue it a little differently. And so I'll cue into a single leg hinge, which is, again, frozen skater because I don't want her to move. We're going to do an isometric non-movement one. We're just going to make sure that she finds the area that I'm looking for. So typically when I cue this, I go first in a sagittal plane. All right, dip your toe into the water behind you or look off this cliff. And usually they'll displace a little bit more.

If they're not, usually it's because they have the back foot loaded on the ground. I say put 99% of the weight in this front leg or find power in the front leg. After that, we can cue them a little bit more with a sassy hip. So runaway models are typically sassy in their hips when they walk. Go ahead and push a little bit into the sassiness. Good. Cool. Do you feel that? Usually they'll start to grab a big old chunk of outer gluteal, posterior glute region. And they'll say, this is starting to burn. Perfect grit. It's all I want. I might cue them into a rotational type of movement as well with that or transverse plane.

But not everybody because a lot of times they lose the frontal and a lot of times they'll get enough benefit out of the frontal where I don't need to go into the other one. So I keep them. So I keep them non-moving in this case because I want them to feel what they're supposed to feel and still challenge the range and challenge the muscle group and then challenge the limb. I could get them into a movement-based one later or put a weight in her hand, but I just didn't get there. And a lot of times this is a lot of information for the person at one time. And so in this case, when I release this person until the next week, I gave her a first aid safety net.

That's block one. I gave her a corrective exercise, which is that low diagonal sit on the ground, which is block two. But I also gave her foot on ground. And so I told her that if she feels like she can get what she's trying to get or what we need to get out of that block three frozen skaters foot on ground one, then she doesn't need to do block two. When at all possible, get away from block two. Block two is okay, but it's not where you should be living at. So she came back in the next day again or the next week about 75% better subjectively. She was really excited. And so, by the way, she'd been dealing with this for a while.

I think it was months. It was months, almost a year or so. And so she was really excited to see it had gone away. She was able to sleep with no real problems. She still had a little bit of pain with starting running too far. And so in that case, we just had to build up a little bit of mileage because she wasn't really. I think it's ridiculous to think we're going to throw someone back in from zero or relatively zero miles to like four or five. You know, that's like, what was that, 400% almost of your volume per time. And so there is something that needs to be progressed upwards as well. So I think an important part with this is, and I actually, she was, she didn't live here, so I didn't have her too long.

She might come back, though. We did talk about that because I wanted to implement a little bit more of long-term strategy with her. And so, although at this point, I guess we can say you quote unquote fix the person, I don't think he really did. You know, and I've been in practice for about 10 years and I realized that people come back with the similar problems over the years. And it's no surprise to me now. And I tell them, look, you got block one, block two, block three, and block four is returning to the things that you love. Not necessarily exercise, unless you love running, that's cool. But return to something that you love to do because there's variations of movements in there.

Volleyball requires changing directions, jumping up and down, semi-quarter squats, diving, so on. And so, there's variation of movements a lot of times I think is the skeleton key that we need to get into reducing this thing from coming back. But a lot of times people don't get into the loading process or resistance training. And as I mentioned in the last case study, by the way, if you have not heard the last case study, it was on hip flexor and sit bone problems, again, running population. I talked about adding in resistance training at least one time a week in the area of interest. It's nice to have all the other things too, but with an area of interest, with an actual intention, an actual plan to create an adaptive change in a certain region.

In this case, I believe the lady responded very well to glute or hip-dominant movements. The stuff that we did on day one is not going to create a long-term adaptive change. It's not going to create hypertrophic change. It's not going to create strength. It's not going to create endurance or power. It's not. The volume wasn't enough, and the chronic stimulus wasn't enough. So, you need to keep subjecting this person to something similar but a little bit different. And so, that's the magic of your strength conditioning. And at this point, you might choose to do some of that programming or you might have someone you can refer out to like a strength coach who's really good at doing it and who's on board with the plan, right?

I tend to push people towards, and I've done a podcast on this as well, the exit plan or the way to exit care at least in my mind from my office with the goal of someone who wants to be active and wants to just be able to be free to do whatever they want, hacky sack, throwing frisbees, playing with kids. If they want to do that stuff, they should get at least into some resistance training, all right? So, in that episode, I think it was like 123, 125, somewhere around there. I talk about the Dan John push-pull carry squat hinge model and ideally pushing that into single or double or single or single arm or double, I'm losing my mind now, single arm or single leg types of movements because, again, life is experienced without weight training.

It's experienced with single arm or single leg movement. When's the last time you picked up a golf ball with two feet or two arms? Like, typically, you don't hold like a sandwich like a squirrel. You don't do two hands. So, usually, the exposure to those movements or positions with singles, I think, is a very useful thing. Again, the adaptive change needs to happen, and it's going to take a long time, all right? It won't happen overnight. Now, it tends to go down the route of how much is too much, and I tend to think that, let's just say we're talking about deadlifting. I weigh 160 pounds roughly right now.

Do I need to deadlift 500 pounds? I don't know, right? I tell people, at least, and this might go, this might fall on deaf ears with maybe the strength conditioning professionals, but I know that for my observation, working with people, if you can hinge up or pick up at least your own body weight a couple times at any given time, so I should be able to walk up to a bar with 160 on it and pick it up a couple times at any given time, right? It shouldn't take me a warm-up to do it, and it shouldn't take me, like, months of training to do this. Like, I'm already kind of in that realm there. Do I need to deadlift 300 pounds to do that?

I don't. And I know there's ranges where people say you should be able to deadlift or double your body weight and blah, blah, blah, and I don't, I'm not on board with all that stuff, and I think it's just very goal-dependent, all right? I personally, in my office, I don't treat professional athletes, and I think a lot of you don't either, and I know when we go through these workshops and these symposiums and, like, people keep talking about, like, all these things that we do with our professional athletes, and I'm sitting there and I'm thinking, like, I'm like, yeah, this is important, but it's not that important for, like, these gen pop people, or these, no, I'm not talking about the people who are deconditioned severely.

I'm talking about the people who are just generally active. Like, I see active, like, 30 to 40-year-old people, right? And so, I don't need to go crazy with them with a bunch of extreme things that are all of a sudden mind-blowingly different in regards to research. Like, some might be implemented, but most of them aren't, in my opinion. And you might find that if you work with general population, the deconditioned general population, you just give them a couple, like, bodyweight movements. Like, you remember, like, back in the day on TV, on Channel 3, I think it was, someone would be doing squats and lunges in a chair with a bunch of people behind them, and this was kind of like your daytime TV stuff.

That's okay, but that's not enough for someone that comes to see me, typically. A couple of them here and there, but I think you need a program based upon what your person is asking for, and if they're asking to subject themselves to a marathon a couple times a year, because that's what they want to do, and they just want to feel good and look good and so on, then I don't need to deadlift some lady 300 pounds, all right? They might not have to deadlift at all. And I know we've all gone on the route of, let's stop doing as much passive care and let's go into loading. I think the pendulum swings both directions, right?

Too far, and passive care, when passive care is appropriate. Appropriate means staging of the person's problem or based upon their goals, all right? Or maybe they come in and they believe that that's all they're going to let you do. That's okay, all right? But when someone comes in and they just want to be a runner, a recreational runner, not even a professional, not even someone who has stellar times, do you need to crush them with a barbell? No, you don't. Like, just general recommendations of like a split squat will probably work. A single leg deadlift will probably work with probably just kettlebell base weight.

Not even something over 70 pounds will probably work. You can fatigue those muscles out a different way. You can get them to crawl. You can have them do side planks. You have them do carries. I think carries, by the way, if you're not doing carries, I tell every runner that comes in here, if you're not doing carries, you're missing the boat, all right? It's the easiest one in the book. Just carry something around. Farmers or suitcase carries. I don't care which. So, I hope this was helpful to everybody. And I think as I go through these, I'm going to attempt to have a little bit more case studies over the next couple months and just see how things fare with everybody because I know that when I've gone through workshops, it's really nice to be able to have something that describes kind of in full detail about how the tools went with this one certain person because I've been to workshops where they talk about like, here's 30 different exercises.

By the way, you should use them if someone has a deficiency of T-spine extension and rotation. I want to see which ones works with each case, maybe, you know? And I don't need 30 of them. I just need a couple. So, I'm very appreciative on workshops when everybody lays out the tools, but at the same time, tell us how you use these tools. I would really like to know. And it keeps my attention. And I learn very well by shadowing people. And I think some of the interns and docs who have shadowed me have learned a lot through cases. And just shadowing and seeing how things are applied. Yet, having that basic foundation of what to do or, sorry, what tools to have is important because if you guys are going through this podcast and you're like, I don't know what a contralateral opener or slumps test is, those are things that you need to go investigate.

We do have some on Pro Chiro Online, but they're all based upon, those ones are based upon Michael Shacklock's work. Again, by the way, I don't get anything by recommending his course. I think it's just a stellar thing. It's a really good thing to add to your Block 1, right? Block 1 is hard for people to, but we're taught really well in school a lot of Block 1. So, you might have a lot of Block 1 stuff. That's okay. Block 2, a lot of times in school, they teach you what a bird dog is or a dead bug and so on, but they don't tell you how to always cue it in a way that biases the movement to reduce the person's symptoms nearly immediately, all right?

After that, you got to get into your loading. Now, the loading that I learned when I was in high school with where we would do chest and tries and back and bys, and is that going to work for this person? Maybe, maybe not. You got to have some ability to kind of shift and weave and figure out what's going to work best for this person, but again, I think case studies help with this. So, just know that the way that I manage this person is probably not the only way, and I'm not saying I know everything. I'm just saying this worked for me, and so for all I know, too, since I haven't seen her since the second time, and that was months ago, for all I know, she's worse now.

I don't know, but it was a favorable direction at the time. Again, when you're recommending things to people, there is no single way, but you're testing the trial of care. It's a trial, like a clinical trial. We don't know. We just know that it might, and it looks like it should be favorable, so we're going to test that thing, and we're going to know over the course of the week or so. And in this case, 75% better within a week. I'm going to say that trial of care was pretty productive. I might have to change things as time goes on, but I need to see how she comes back. She might come back a little different, and she might come back needing something very different.

Who knows? That's why you get to retest everything at the time. So now, again, if you guys have not already done so, I really only have one request of you, is that if you've learned something from this podcast or you've learned something from the other podcasts I've done, please share it directly. I mean, text it or email it to another colleague, a DC student that you carpool with, or maybe another doctor that you see and have a beer with every once in a while, but you guys are kind of on different levels of what you do. Share it with them. I have not really promoted this podcast other than word of mouth, and it's grown.

It's grown really well, and I'm really happy that everybody's gotten information and learned from it. And I've learned through the student interviews that it's changing the profession, at least in its own small way. And what I'm hoping is that over the course of time that, like, say, I have a friend living in, you know, Tempe, Florida, or Tampa, Florida, that I can just suggest somebody and just know that somebody there is good and high quality. I'm not saying there's people who are bad, necessarily they're malicious, but I'm just saying that there's people that need to up their game and skill set because we all get busy, and a lot of times it's really hard to know what there is out there if you've not been subjected to it.

And so, kind of like with patients, it's like they don't know what's available to them because no one told them about it. So, I'm telling you about it. So, please share this directly with a colleague. I greatly appreciate it. It's even better than doing a review on iTunes or Spotify or any of that stuff. Those are helpful, by the way, if you want to do that. You totally can. But what I really want is you guys share it with your friends. So, as always, leave people better than how you found them. If you're dating, dating Eagle Scout. And I will talk to you guys soon.