Piriformis, IT Band and Hip Flexor Syndromes: Looking Past the Label

I mean, I think there's a need for local treatment there, but I think for pain modification, though. Yeah, right. Well, I think in that piriformis example specifically, I'll be honest with you. I'll try and go to an exercise first. I will, too. For that reason specifically, you know, whether that's kind of whether you're trying to actually, you're putting the piriformis on stretch, but you're technically hitting the glute. Glute Max or Glute Mead, whatever, which one, all of them, and kind of devoting a little bit more nervous system attention to that area. And that, I mean, that alone will probably decrease pain anyway, right?

That's why a general exercise is so good. 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 with the Restoring Human Movement podcast. Thanks for being part of the movement. This one is actually going to be a fun one today. We have a guest host on, Dr. Cody D-Mack. Hello, everybody. So, we brought this up because we were talking on Skype a while back, and I said, it's really hard to do single podcasts.

And he's like, well, I think I can make them better. And I said, you're full of shit. Yeah. Well, just me in general is going to make it better. Right, because you bring out the best of me. Yeah, sure. So, just to frame this for everybody, probably the best, probably the clinicians, DCs, PTs, ATCs, strength coaches, exercise science majors are probably going to get a lot out of this. What my major topic was today and that we thought we'd discuss is the syndromes, kind of taking a step back from the microscope of the syndrome syndrome and trying to correlate the things together and see if we can – I'm sure Cody's going to have a big – a lot of things to say about this.

So, I thought it would be a good one to have him on on. You have a lot to say on this one? Oh, well, do you want me to get started already? No, no, no. Not yet. Okay. But – Yeah, we'll see. We'll see. Well, actually, it was funny. So, I brought up – well, I'll wait. I'll wait. So, just make sure that if everyone does like this podcast, give us a nice thumbs up. Or actually, that's not thumbs up. That's a review. Go on iTunes. Go on Google Play, all that kind of jazz. And give a nice thumbs up with a emoji or however you do it. And give feedback whether you like this duet or not. Because if not, I'm going to ditch him so fast like a rotten egg on a summer day.

Drop it. Drop it like it's hot. Right. So, I don't know if you know the format, Cody. I got to tell a personal story. And I thought you'd appreciate this one. Did I tell you the curse of the Stella? No. Oh, you're going to like this then because you're a beer man. So, I got this friend who brings over – he always brings over some alcohol to a party. And he's an Asian guy. He gets red after like one drink. So, he doesn't really drink. He just brings alcohol. So, he'll bring like kettle one or bring like Stella. And I'm like, dude, why did you bring Stella? Right? And he's like, I thought people liked Stella.

And I'm like, no, no one likes Stella. But he brought a 24-pack of Stella. So, after this party, no one had drank in the Stella. So, I packaged it all back up into a 24-pack and brought it over to a friend's house who has a lot of parties. So, he had a party and everyone thought, holy shit, he's got a lot of Stella. And they kept buying him Stella. So, everybody kept bringing him Stella. Right. So, it was the curse of the Stella. So, you have to – to give away the curse of the Stella, you have to package it in the 24-pack of Stella and give it to another man who loves IPAs. Yeah. I actually don't discriminate.

I'll enjoy Stella. Really? Yeah. See, the – I can take a good lager or a good Pilsner. But the foam has – the commercial has so much foam on it, they physically have to scrape it off with a knife. Yeah. Not if you just – I don't know. I don't know if that happens. I think it's just for show. They're marketing a very foamy beer. Showmanship. It doesn't turn me on because there's only like three-fourths of that glass left after all that foam. Don't let the marketing bring you down. Well, they have a glass – they have a gold rim around the glass. I don't know how that makes me feel either. I have one.

Do you really? So, they give you one actually. So, back in – went to chiropractic school at Logan. And so, they had the – well, they still do – the Budweiser factory there. So, we did a tour. And at the end of the tour, you actually – you get like one free beer. And we got a – I went one time. I got a Stella glass with a gold rim around it. Did you – what did you drink out of the Stella glass though? Stella. Did the glass make it better? It did. It made it more crisp. It was like – it was very regal. So, I felt like a king. Hey, did you put – you know those little wine marker things for glasses?

Did you put that under yours to make sure no one took your Stella glass when you were done? No. I called it – I called it ale though instead of beer. I felt like it was back in Game of Thrones. Wait, does – they called it – they called it ale? They call it ale. No. Did they – do they have more than one beer by the way? More than one – who's that? Stella. No, it's just the one. Stella. Stella's made by – I think by Budweiser though. So. Oh, I didn't know that. No. Yeah. Well – It was back in the day. I don't know. Well, if – If they still own it. If I own Stella, I would definitely sell it off.

I'll tell you that much. Yeah. You bring it to somebody's house? Yeah. Just dump it. The recurse of the Stella? Yeah. I just gave you all my shares of Stella. You don't own the company. Uh-oh. So, what's up? Not much, man. Just get home from work. So, ready to roll. Okay. What do you – what do you do now? So, the listeners kind of know. Yeah. So, formally, if you listeners don't know, I used to – my wife and I owned a private practice. My wife? Orange County. My wife. Back in Orange County for a little over five years. And recently, just moved to Dallas, Texas, and I started teaching at Parker University, the chiropractic school out here.

And so, my position at Parker is an assistant professor of wellness clinics. Basically, I'm a clinician in the clinics. So, I have students underneath me as they're going through and meeting their requirements for graduation and licensure. So, they have to answer to you for something? Yeah. They've got to go through me for, like, for treatment and whatnot. So, when they do that, do you grade them on a snotty attitude at all? No. It's not part of the rubric. Oh, damn it. Presentation bedside manner? Yeah. Well, I mean, obviously, if they would have an obvious poor attitude, then you kind of pull them aside and you could probably talk to them and see what's up, you know.

Okay. So, yeah. So, I guess I don't know if I really framed it either. So, I wanted to have you on because we have a good dialogue going on. I think you have a lot of good things to share. Oh, thanks. And every time we talk, you say that you can make the show better. I don't say that. Well, you don't listen to the solos. But I did say I did not listen to the solos, and I think, you know, I do think it, like you said, I mean, I can see where it'd be tough to just kind of talk for, you know, a half hour to an hour about stuff, you know, especially if you don't have anybody bouncing things back to you or, you know, asking you questions and whatnot.

So, I can see where that could be tough. Yeah, it's kind of like, like, you know, if you're doing, like, squats alone versus bouncing a ball against the wall, like, I think I could bounce the ball against the wall longer because you're reacting to the ball. Yeah. Plus, depending on the load for the squats, it's more of that pulse too, right? Well, I don't think, I think I could still, even if it was assisted squats, I could still less than... Smith or Shane? Yeah. Yeah, 0.5 body weight. I think I can do more ball bounces than squats. Either that or you could get on the leg press and just kind of flip around instead of laying down, pressing up, you kind of, like, press, you're, like, kind of squatting the leg press up.

Oh, oh, you're, wait, squatting the leg press down, aren't you? Up, if you flip around. We'll have to get a picture of you doing that, I don't know what you like to do. I'm good. I could, actually, that would be a funny fake max performance, Cairo. Well, there you go. You haven't done one of those in a while. I have not. I don't need to get back on that horse. Mm-hmm. So, the reason why I want to bring up the lower crossing today, actually, sorry, the syndrome thing today, is because I drew something. I don't know if you even saw that. I can show you a picture. I'll text you a picture. Either way, it describes Yana's lower cross model, roughly, with some DNS principles, and as well as going down into kind of tonic phasic groups, and to make it really coincide with what patients will ask, they're like, well, I have this piriformis syndrome, I have this hip flexor syndrome, I have this impingement syndrome, all this kind of stuff.

Yeah. I thought it'd be really nice to show biomechanically how these things are possible and how a minor tweak sometimes can make people feel better. Mm-hmm. So, I started putting this thing out on, I put it on Facebook, and a couple people said, where's, has this actually been validated yet? And I remember reading through McGill's book, it hadn't been validated at the time, but he didn't disagree with it. Right. And I just spoke to Andy Galpin on a podcast, and I said, what do you think about the fact that something hasn't been proven? And he said, that's used in clinical practice all the time, and it should be used, because it's multifactorial, basically.

Mm-hmm. So, anyways, I thought we'd go down the syndrome syndrome today. Cool. Yeah. Sounds good. Okay. What do you think, what's your first syndrome that comes to mind to you that you, in clinical practice, you got tired of talking to people about? Piriformis. Why is that? It's because it's almost always never the piriformis. Can you dig deeper into that? Yeah. So, it's kind of like a blanket type, you know, it's just like plantar fasciitis, right? So, I think there are ways to determine whether or not it's actually the piriformis, you know, involved in any type of radicular symptoms. A lot of people think that just because they have kind of like deep glute pain that it's the piriformis, and they haven't ruled out the hip and or even the disc and the low back.

So, you know, Michael Shacklock has a, you know, portion of his slump test, you could actually tease in or out piriformis involvement in the slump test, too, with the internal external rotation of the femur as you're taking the knee into extension and putting tension on the nervous system, right? So, and the static nerve, rather. But, I mean, it's just a blanket diagnosis. So, when people would come in with piriformis syndrome, and all they're doing is they're shoving a lacrosse ball into their piriformis, hoping it will go away. The irony is that piriformis syndrome is usually active when the piriformis is long, and so they're trying to stretch to the lung.

They're trying to stretch a muscle that's already too long. And so, if the nerve pierces the piriformis, then that's actually causing the problem. They're like stretching it, hoping that it would just put in more tension on the nerve, you know, if there is that, right? Yeah, well, so the, yeah, is there a way then, do you see, when there's actually a, what percentage do you say is actually a piriformis, like, would you classify as a piriformis syndrome? I haven't diagnosed one. I haven't really either. I'd say, actually, I'd say in the past I have, and I would say they responded to tissue work, but not over long term for me.

Yeah, I've actually had one patient, but she was older, she was, she was kind of in a potentially stenotic group that you would classify, and your differential is what pops in your head when you look at her age and her activity and stuff. I literally, I just, I did soft tissue on this, more so a posterior capsule. I'm sure there's some piriformis in there, too, of the hip, and it felt good, but really the thing that, I think, got rid of the, her kind of radicular symptoms were just static openers, putting her in a static opener position for the low back, just kind of creating a little space in the IVF, and that really relieved her pain.

So, I'm not saying that you're not going to potentially address maybe soft tissue problems in the posterior portion of the hip, but a lot of times, that's not the driver. Right. So, I think that's a, that's a major point, because I think, I'm actually writing a, I was going to write a huge article based upon these syndrome correlations and biomechanical postural changes and see where we can tie them together. But, you said, so, you said it's really not the driver, and it's, but people really hang up on that, and I think a lot of clinicians still hang up on that, they're chasing that spot, you know?

Yep. So, is there, I mean, I think there's a need for local, local treatment there, but it's, I think for pain modification, though. Yeah. Right. Well, I think, in that piriformis example specifically, I'll actually, I'll be honest with you, I try and go to an exercise first. I will, too. For that reason specifically, you know, whether that's kind of, whether you're trying to actually, you're putting the piriformis on stretch, but you're technically hitting the glute, glute max, or glute med, whatever, which one, all of them, and kind of devoting a little bit more of the nervous system attention to that area, and that, I mean, that alone will probably decrease pain in any way, right?

That's why a general exercise is so good for everything. Well, that's why, I think, so you brought up the shock lock stuff, too. I usually go to an exercise first, just to see if an exercise or some type of differentiating factor to, I don't want to prove to the patient that they're wrong, but I want to provide some type of doubt, that we're not going to keep doing the same stuff that wasn't working for them. Yeah. Well, I think, too, it's, that becomes part of the, the, the attempt to try and empower the patient to be, to play an active role in their healthcare anyways. You know, I mean, cause if you can do one exercise, uh, and obviously this is after you've done your very, very thorough history and exam and movement evaluation, if you think this one exercise is going to be a place to start, that's why you do the exercise and you retest to see if you've made a change.

And if you haven't made a change, then you, you know, try something else, you know? Well, she, she, you know, um, I forget I was talking about this actually, but the, I remember when I came out of school, like we got, we got like say a piriformis syndrome and we would beat the snot out of it and the person would feel better and they said, oh, that's the spot, you know? But, um, I think, I think over the last couple of years, I've, I've really been happy with being able to make people feel better without actually touching them and the, the interns that I have come in there, they're like, I, they don't, they don't seem to think that that's possible and I don't want to see like it's voodoo because I don't think there's any voodoo, but can you explain biomechanically how you, you feel like an exercise or something like that would correct this problem, make them feel better?

Yeah. I don't know if it's necessarily correcting the problem per se. I think it's more so of, um, changing what the brain's perceiving as normal. I mean, you're kind of doing a lot of factors here, incorporating psychosocial factors and just movement in general, uh, playing with that stuff. Cause if you can do an exercise that doesn't necessarily reproduce their pain, but, um, maybe fires up or facilitates a muscle or something like that. And that, that takes away their sensation, you know, you're just, you're, you're changing what their brain's perceiving as kind of what the normal state is.

Hmm. I was going to take it. I was going to take a different round. I was going to go, uh, support like build, uh, building a, uh, a supportive system. So it decreases the amount of load on the structure that is the pain generator. Maybe. No, no. I think the big thing is maybe, right. And so mechanically that would be biomechanic wise. That would be the, the theory that we're trying to hit, you know, so, you know, an example of piriformis syndrome, we've, we've, we're suspecting there's some type of lumbar involvement that's referring to the area. We've ruled out a hip, actual hip. Uh, of course, piriformis is tender to the palpation.

Um, I don't know a person who doesn't have a piriformis that's tender to palpation. You know, we put, we take those individuals and start doing some sumo or monster walks with a band around the, uh, fifth metatarsal, the basic, and to facilitate some extra rotation from the, from the hip and have them do like, you know, lateral band walks, facilitate glutes. And, you know, they're keeping relatively good posture and position. Uh, I'm not having them brace super hard, you know, or I might not even have them brace. I'm just might even just trying to get the glutes fired up. So mechanically, you know, you were taking that approach.

We're trying to, we're letting the brain know, Hey, we can use the glutes now. We don't have to rely on, you know, piriformis to, to be our, you know, our stabilizer of the hip. So, so I think to clarify on that, cause I think I, I, I led that route a little odd. Uh, I personally think that majority of piriformis stuff is, uh, neurologically based, which makes the nerve fire up piriformis. I know I said piriformis might be loaded, but I, I, I think I misspoke on that. Um, so you're talking, you're talking about getting the glutes to work and tell the brain there's no threat. Um, I might, the glutes are probably, the glutes are probably working if they're standing.

So, yeah, well, that's the whole, I guess there's a whole number of the conversation, I guess there was actually when I, so when I, I put this, when I put this thing out on Facebook today, someone sent me, uh, someone wrote, uh, sent me something that, that Lehman wrote about a couple articles that were not supportive of lower cross and basically talking about how, I think it was that glutes were not actually weak. They were actually strong on people that had short hip flexors, short hip flexors. And, uh, so I know that everyone's kind of going on that, that route of the weak and strong and facilitated and not.

And I don't even know if that's, I think it's, I feel like a lot of it is just like neuro-based, like what I've found. I think so too, yeah. I don't even know if there are any of them are weak. They're just on, they're just on, they're guarded. Right. I mean, I, I, exactly. Well, I don't think you're really going to have true weakness unless you have like neurological deficit, right? Yeah. Big deficit. Yeah. You literally, you were literally like a hard, a big, uh, uh, for aminal encroachment or, uh, something that's literally cutting the blood supply off the nerve where it's not working. So with the, what type of presentation, uh, I guess postural presentation, would you say a piriformist person usually is, um, are they usually flexion intolerant, lumbar spine?

Are they rounded forward? Are they, are they open? Do they have, do they fall into the category of lower cross at all? Or the ones, are you talking about the ones who, uh, who have legitimate piriform? Am I saying really? Oh yeah. Shit. Uh, sorry. Um, uh, posterior hip pain that they perceive as piriformis. I mean, I think you could, you could have both, right. Um, in terms of like a lower cross or even just a kind of somebody who you, somebody would classify as not lower cross, um, or excessive anterior tilt with a pelvic tilt with a, uh, kind of like a anterior superior rib position. Um, you know, I don't know.

And I don't know the, the, I've only read like maybe one or two research papers, research papers about this. But I mean, um, I think, I think DNS would, would say that that kind of open sister posture, lower cross syndrome theoretically will take the posterior portion of the, the, the bodies of the vertebrae and kind of soften it, soften the disc and the posterior portion. And if you look at McGill's work, he would say repetitive, repetitive flexion with a hand or flex rotation, um, over time could create a disc bulge. And he, um, um, but taking that too, I mean, if you take those two together, maybe it can create some, some potential, um, you know, uh, potential threats of the posterior, uh, portion of the disc, uh, to produce pain.

And that may refer to that area of the piriformis, so to speak. So that's an option. I mean, I mean, you got to consider everything, right? So, so then, uh, just to kind of wrap up here, piriformis syndrome, I guess a little bit is, um, I guess to tell you what the, probably the thing that I would try first is, is to, to see if a torso, I usually get them, I usually get them to sit or stand or lay or wherever the hell they're like, I don't care which position that they're in. As soon as they say this thing started to hurt, then I'll, I'll cue usually torso stiffness or I'll, or I'll take their spine or go to the side of them and give them a little support and move them forward, backward, side, side to see what happens, right?

Or I'll just, or I'll just hug them around the pelvis and see if, if me compressing the pelvic ring together assist just so, yeah, so we don't have any, so I kind of know that we're not hunting down just a muscle tear. Yeah, totally. That's a great, yeah, I use the same, same, similar for the different shape between that, you know, um, you know, if I really think it's something that this, a disc going on a low back, that's kind of causing their pain, you know, I'm going to try and find the things that, that trigger their pain and see if we can make a change right then and there, you know, and now we may have to modify their activity for the time being in order to let that area kind of calm down.

Um, but, uh, the ideal scenario for everybody, I think is try to get them, um, uh, decrease their fear in moving and, uh, but sometimes that does take a little bit of coaching of, of, uh, activity modification and, and kind of, uh, distributing the load amongst the, uh, the rest of the body or the joints above and below specifically in this scenario, probably the hips, you know, you know, maybe they're, but the piriformis, man, but you can't move the hip, the piriformis. Well, you got to use the lacrosse ball for something. Yeah. Well, you kick it. Shove it in your peck. Um, that trigger, that trigger point, that's a compensation.

Well, that compressive therapy has got to work for something, right? Yeah. You know, the, uh, so as we go down into actually just, just to catch myself, I'm realizing I'm, I'm going into interview mode and we're co-hosts. So if you got, yeah, I'm, I'm, so I need to, I need to make sure to, to, to tip that since it's the same, um, what, let's go to an IT band next. Cause I think it's probably going to be very similar. Yeah. Um, I know my perspective on IT band is that if it's, if it's actually around the, the, uh, focal point around the knee, around the lateral femoral condyle, there's a possibility we're looking at it actually.

Um, but if it's up and around the thigh and the TFL and all that kind of jazz, I, and it's, uh, correlated with a grumpy back, I would differentiate the back first as a nerve based one. Absolutely. Yeah. I think, well, I think the IT band gets a, you know, gets a lot of bad press, you know, you know, the IT band is just there kind of hanging out, you know, the IT bands formed by the tensor fascia lata, uh, all the, all it does is tenses a lata fascia. You know, so the, yeah. You're choosing, you're choosing anatomy class or pun class over there. Yes. Um, uh, puns are necessary when teaching the students, but, uh, you know, if the TFL is kind of being overactive, the IT band has no, no chip choice, but to be tight, so to speak.

But I mean, I think there's some research and I'm going to really mess the number up, but it takes thousands and thousands of pounds to, to deform the IT band. Uh, you know, so foam rolling, it gets kind of marginal if you're thinking that you're lengthening it. Mm-hmm. Why do you, why do you think people feel better after they're rolling it? I mean, you're just, you're, you're literally stimulating the skin and, and just the muscle fibers, right? Mm-hmm. So, so kinesthetically, it's creating a little bit more, potentially a little, a little bit more awareness around that. There, there was a lady that came in the other day that actually I was like.

I'm not going to get into, I'm not going to get into the piscineal corpussis or anything like that. No, you don't have to go crazy. We got a lot of syndromes to cover and I'm looking at the time. Um, I had a lady actually come in yesterday that, and actually this happens a lot. So I sit at the desk at the very end and I'm talking about like. Ladies coming in your office. Ladies coming in, ladies coming out. Um, but they're sitting there and like, so she had a shoulder thing and she kept like going like this to it when we were talking. I'm like, what are you doing? She's like, oh, sorry. And then we talk a little bit more and she's like.

So you're rubbing again, huh? Yeah. She keeps rubbing it. And I'm like, that's a normal response. Don't like, don't worry. Like, don't freak that I, I don't want you to do it, but we've already gone over four things that make you feel better almost immediately. And it wasn't, rubbing wasn't one of them. So please. Was she just checking, was she just checking to see if it was still there? The, the shoulder itself? Yeah. It wasn't. The pain hurt his comfort. Uh, maybe. Yeah. Have you had those people where they get numb and they can't feel the numbness unless they touch? Yes. Yeah. Mostly lower extremity though.

Yeah. That's where mine were. A lot of, a lot of post, uh, surgical, post knee surgical things. A lot of those kind of like the shin and stuff. So to find that it was improving or not, did you go like this? Did you keep touching them and then doing stuff? Uh, no. Oh, I did. It, it, it was, it was working. I needed to find out better versus the same. So, well, if it cut the nerves, then it's probably not going to come back. So, um, well, these ones weren't, these, these ones weren't post surgical. Ah, that, that's different. Yeah. One did, one did come back. Actually, it came back within like a couple minutes.

I was surprised. It wasn't the primary complaint. So, so what, so Seb, I got a question for you. Oh, good. Kind of leading to IT band. We already kind of got into TFL a little bit with the IT band. What about your, uh, super common presentation of, uh, hip flexor? Oh, the hip flexor? Yeah. Uh, this is probably better on a video demonstration. Now hip flexor. The hip flexor syndrome. Yeah. Well, I mean, so first off, I think people feel that, go ahead. Specific, specifically tight hip flexors. A tight hip flexor. My, my thought is that number one is they feel that anything on the front side in the anterior groin, they feel like it's a hip flexor, although it could be impingement is, is one thing.

And so I got to rule that thing out anyways. And that would be with like scours test, circumduction, um, for bears tests. Those are all real nice to try. I'm sure there's a couple more, but I'm not going to name them off because I don't want to dig that deep. But, uh, in regards to like, I always do a demo with this and I say that if we, if the hip flexor's job in this case, if you are trying to say it irritates them to bend their, to flex their hip. Yeah. I say that that only can, that can only bend, that can only bend your hip and flex your hip up if it has a stable point to move from. So I usually find random shit around the office.

Like I'll be sitting in a chair and I push, you know, that rolly desk you gave me. So I'll push it and I'll be more stable than it. So it moves. And then I'll, then I'll take myself against the desk that is more stable than me in the chair. And then I'll move in relationship to the desk. So I tell them it's based upon the fixed points. So usually when I see people with the tight hip flexors, I find that the, the torso is not stiff enough to manage the contraction potential. That's just me though. Yeah. Uh, I'm sure there could be a neurological based, uh, what is it? L two through four. I think that goes in there.

Right. But those are all torso stiffness corrections for me anyway. So if I know I'm going on the right path and it's the same, but I usually don't dig on them first. What do you think? Same. Yeah. I would, I don't really attack those soft tissue wise at all. Uh, but you, you get the, a lot of people come in with the tight hip flexors and, um, and I say, okay, well, what are you doing to help with that? And they're like, they're literally bringing their knee up into their, trying to bring it up into the armpit to stretch the hip flexor. What are they doing? They're literally like flexing their hip and pulling their, to stretch your hip flexor.

Yeah. I'm like, what do you, that doesn't make sense. They're probably trying to blow through that impingement point. But they're like, when they do that, they're like, yeah, it's tight right here. And so they feel the tightness or stiffness in the anterior portion of the hip when they go into hip flexion. And it's the same with the, when they lunge or if they squat, you know, so obviously it's not a muscle tightness. They are getting that, that take a potentially, um, type of impingement, like maybe a functional impingement where it's more soft tissue and it's not bony. Like a pincer or a cam impingement, you know?

So, um, but the sensation, if people are having sensations of, uh, of things being tight, if they're standing there like, yeah, I just kind of feel tight in my hip flexor. Generally, there's obviously some, uh, something's going on in terms of, um, something's overworking. Right. Or it's trying to do the job for somebody else or something else. Yeah. I know you've always been a big one of, does it feel tight or is it tight? Yeah. That's a, that's a question I ask everybody because it's, they're different, right? So something can be truly tight. Usually people don't feel true tightness. They don't feel like my, my left gastroc and soleus are legitimately shorter than my right from previous disc herniations.

I don't feel the tightness until I put it under tension. You know, same with my, the lateral hamstring group and my, uh, bicep from Morrison, uh, the group, um, on my left side, all that's atrophied from previous disc herniations. And I literally don't feel any tightness unless I put it through a legitimate stretch. Now, you know, a stressful day. Uh, yeah, my neck feels tight. You know, it feels tight. It feels stiff. But sometimes when I just, when I feel that tightness, I literally just relax my stomach. Sometimes the tightness goes away and I haven't done anything to change the position of my neck.

Yeah. Well, even too, I think with, I know this goes into like a, like the upper portion, but with, I mean, just, just cervical distraction a lot of times in those people where a little chin packing will decrease it. And in that case, let's say cervical distraction, in theory, the muscles would be lengthened. Right. So it should make it worse. Correct. So, I mean, I think definitely differentiating factors to figure out what we're actually addressing with these people, whether they think their stuff is tight or not. Yeah. The, the, I think the big take home is the perception of tightness isn't always tightness.

You know, and if you try and stretch something that's perceived as tightness, then, um, you're, you're kind of, it's more, you're looking at potentially something more neurological, not necessarily like it's not a disease or anything like that, but just, uh, uh, maybe some hyper, hyper tone, uh, hypertonicity. Well, I think too, that, um, I mean, after going to that shot clock course, I think something after talking to patients about, like I said, like you, this is neurotic. It's a neurological based condition. I think they have a knee jerk reaction and thinking about like, this does not feel like sciatica.

I, I, I've seen someone with that. It's not that bad. It's like, well, and we talked about just the amount of pressure that it takes to occlude a vein is all it takes to swell a nerve and create ambient responses. So I, I don't think, I think they, I think the public also oftentimes thinks that it has to be excruciating electrical, all that kind of stuff. It doesn't know. Yeah. It doesn't. Well, that's, that's the, that's what the textbook says too, right? And so that's, uh, you know, uh, in school, that's what you learn. You learn that straight leg raise at a specific degree, um, only, but only within a certain degree range.

If you, uh, it's positive that if you get a, the reproduction or a searing pain all the way down the back of the leg, down the calf to the foot, that's what the textbook says. And if you are above this certain amount of degrees, then it's SI. Uh, and if you're below it, then it's hip. Um, or vice versa. I don't really know, no, no, no one, no one, no one you ever see gets past that, that range anyway. Well, I mean, it's, well, it's the, you know, the, you have to take into account the sensation of, you know, tight, like a sensation of a tight hamstring too. You need to, you know, shack like cause of differentiation.

You have to differentiate between whether this is muscle or whether it's neuro, you know, and that's what, you know, uh, you try and we look at any neural tension tests, whether it's a front or lower extremity, when there's any sensation or anything, you have to wiggle the nerve from one or the other to see if that discomfort or that sensation goes away. If it goes away, then you know, it's not, uh, that, uh, something locally where they're feeling it. Right. In this case of the straight leg raise, you know, if, you know, you take it down, um, or if you, uh, bring their, if you flex their hip and they get a tight hamstring and then either you have somebody lift their head into flexion and, or you lower it and then you dorsiflex the foot, you're changing the dynamics of the nerve, but we really, we're not really changing too much dynamically from the hamstring aspect of it.

But, uh, some people might say, well, what about, you know, uh, your, your fascial slings? Yeah. You could take that into consideration, but, um, a shack lock has the option to, for, you know, in slumps to pull the other leg or, uh, pull the other leg up, which will move the spinal cord or the arm, right? Will the other arm pull the spinal cord? So you can kind of use that as your differentiation too. Yeah. And definitely those differentiating things, like I, like I, I leave it to the imagination of the, of the person, whether, uh, I said there's, there's no muscle that's going this far. So if you think you're, you got a muscle syndrome thing, it's not, it's vessel, it's nerve, fascia, or I forget the other thing I say, but it's make-believe, you know, like it's like, it shouldn't, it shouldn't change it.

Yeah. And I think, I think, you know, people might be listening and they're kind of wondering what does this have to do with any type of syndrome stuff, you know, but these are all, these are all factors that you need to consider when, when you're, um, you're potentially looking at a syndrome, right? Is this really, uh, um, a result of a positional thing or is this a perceived thing in the brain and, or is this a response in the area from perceived threat? Right. Uh, you know, I don't know if I sent this to you or if you saw it, but there was, uh, this is, I think it was 2012. It was the, um, I'll pull it to, so there it's called, so 2012, I'll put a link to it in the show notes for everybody who wants it.

Terminology and classification of muscle injuries in sports, the Munich consensus statement. Did you read this one yet? Uh, is that the hamstring one? Um, I don't remember being hamstring base, but they broke down, they broke it down into. I think I remember reading that, but a long time ago. Instead of type 1, 2, 3, it had subcategories like 1A, 1B, 2A, 2B, and so on. Okay. So the, here's the basics though. There was, so type 1, type 2 were basically what we couldn't consider functional. And the reason I'm bringing this up in regards to syndromes, if we bring this back to say the, the piriformis, because everyone thinks they'll, they'll think they'll have scar tissue in there or all that kind of jazz.

And actually, so this happens to a lot of people. They say type, like I did this MRI and musculoskeletal ultrasound, they're negative. It's like, well, what the hell do I have? Right. Like I was told I have scar tissue in there. I was told this piriformis is tight and fibrotic and all this stuff. And the, the type 1 is type 1 and 2, they're, they're, they're dom, like, so type 1, I'll read it, read them off. Type 1 is overexertion related muscle disorders, fatigue induced or doms. Like no one's going to, no one's going to find a positive MRI of doms, right? Right. Or delayed onset muscle soreness.

Not that, not that I know of anyway. I don't know that I know of either, but based upon this, they would say no, but no one freaks out about doms either. You know, and type 2 was neuromuscular based disorders. So spine related or muscle related. And one of their specific examples was sciatica with tightness of the hamstring. We're going to find negative MRI and ultrasound findings, but certainly type 3 and 4, which are sub, or which are partial tears or direct muscle trauma or, or total tears. We're going to find positive findings and that's the reason to, to get into tissue work a little bit more.

But the indirect ones, we can certainly find some type of, maybe there, maybe the, the nerve related one or the spine related one. That's, that's something that you would differentiate with contralateral leg movement or the shack lock work. Um, and maybe it would work under a, or maybe even McGill model or a DNS model where you build supportive systems. Yeah. So, or you can utilize, you know, something that works really well that would, I mean, I use day in, day out for what I, if I suspect some type of a disc thing is, you know, some, some McKinsey extension stuff, you know, you can put them in passive extension, either have them, uh, knock out of a few press ups or you could just have them sit in passive extension and then you can retest.

And if there's a change in symptoms right then and there, you didn't do anything to the hamstring. We didn't just stretch the hamstring and all of a sudden now you have more mobility at your slump or your straight leg raise with a less perceived tightness. Right. Mm-hmm. So when in doubt, press it out, right? That's it. Well, yeah. Um, it just looked like you were doing, like you were doing a pit bull imitation and you had a BL in your hand. Oh, the lime. Hey, yeah, yeah. Oh, they have like strawberry now. It's orange. It's so gross. But like orange. Oh God. What are they thinking? Like they were making a michelada?

No. Uh, okay. No, but so, I mean, kind of going, keeping on the, staying around the lower extremity, I mean, I think the, the, are you, are you thinking that some of these like piriformis uh, syndrome stuff or some of these uh, uh, hip flexor tightness things, do you think that's a result of what, you know, what Yanda called lower cross syndrome? Well, I think it's a possibility and, but the problem is like, I, so I drew this stuff because it's a, it's a conversation I have a lot and obviously there's always the, the, the depend situation, but it's, um, I, I find it, it's, it's really common, but it doesn't always have to be that way.

But I, I think that I find that when someone has one syndrome, they also have aspects of another syndrome or they'll say their hip flexor is tight or their piriformis is tight as well. And they've experienced knee issues and it's like, where's the common meeting point here? Like we can chase these things down in a damn microscope or we can look at a broad picture. Right. And so I want to find the broad picture on this, or at least I want the listeners to be able to think, uh, I, rather than give this person five corrective exercises or treatments for like the piriformis and one for the other hip flexor and then the knee and then they got this foot thing.

It's like, where's the common ground? Get three or four birds with one stone, hopefully with a good exercise. Um, but preferably, you know, uh, for treatment wise, our goal and I'm sure yours is the same as when they come into us, we're literally, we're trying to give them what they're going to use the warmup before they train. Pretty much. And if, you know, if we can get them to train as fast as possible, to training as fast as possible, we're, we're hitting our goals. Mm-hmm. And, and, and we can definitely, and I keep coming back to the tissue work cause I know there's going to be a lot of tissue work people out there.

Is it, I don't, I don't think there's any wrong with tissue work, but they, they, they can't really do it on their own. No, they can't. And I mean, and it's necessary, sometimes it is necessary though. Right. Um, but I think if we're, you know, we're leaving a lot on the table, if we're not educating the patients in terms of, uh, you know, uh, not just what's going on, but what, what, what the plan is, you know, if all we're doing, all we're doing is relying on our manual therapy, uh, whether that's soft tissue or adjusting, we're missing a big, big, big, big, big, big piece, big piece of that.

Yep. And if we do have a true, I think piriformis that is getting traumatized or a hip flexor that is getting traumatized, we have to stop the insult. And I think we're going to do that with some type of supportive system or, uh, uh, movement modification. Really? Yeah. Um, facet syndrome. I know you talked about me, talked to me about that the other day. What do you think about facet? Yeah. Facet syndrome. Um, yeah, yeah. Facet syndrome. I don't, I'll be honest with you. I personally haven't diagnosed facet syndrome. Um, most of the, the, what people would call nonspecific low back stuff, uh, usually diagnosed a facet syndrome.

I see a lot of times, uh, facet syndrome being diagnosed, uh, when in fact, it's, they actually have some type of underlying disc issue. Um, uh, and, and since the, the, there was no, um, there was no full blown radiation down the leg or your classic, what you would consider sciatica. Uh, they're not doing nerve tension tests like slump and or, uh, uh, uh, straight leg raise and braggarts. So can you, can you explain that? Cause usually disc, uh, or flexion tolerant facet syndrome is usually extension. And I believe according to Wikipedia anyways. Right. Um, so, but, uh, but you see that, I mean, that's, that's kind of a blanket, you know, people are seeing, uh, well, they're diagnosing, uh, facet syndrome with whenever there's just back pain with flexion, you know, and, uh, and even, even if you have a, uh, an angry disc, you can still have back pain when you go into extension, but it's going to feel different.

It's going to be more pinpoint or midline of the spine is where maybe a facet syndrome might, that might create that kind of, that classic, uh, what you've learned as a, almost like a, uh, kind of like a referral pattern when you go into extension. Well, I know that the, uh, I was actually in the course of writing that article this morning and I looked up Wikipedia's four criteria for, uh, facet syndrome. And one of them was, uh, I'm glad we're using a respected source. Well, this is what the public's reading, isn't it? Good, good point. Good point. What does Wikipedia say? Did you go through Dr. Google first?

I, well, so to be fair, so, I mean, I could easily go through all of the, uh, like research based crap and everything, but realistically the, I think the problem is like when people come in and they're, they're reading that this is what they're getting exposed to. So, and I know everyone bitches and complains about like, oh, all the, the noise on social media and like these gurus and all they're talking about and blah, blah, blah, and all this stuff, it's like, unless you drown them out with better stuff, it's not going to change. So I'm trying to figure out what, what they're already seeing and change it.

So Dr. Google says, number one, trophic changes in the skin, uh, referred to as, uh, cellulgia. Actually, I hadn't heard that before. Um, patient will not be able to feel, or patient will feel pain at correlating spinal levels with facet palp, will not feel correlating pain levels at, uh, levels with facet palpation. Imaging unremarkable. Local injections into the correct facets will seem to decrease symptoms, but basically it seemed like it was a hunt. Since the person can't really identify them anyways. Yeah. So. Yeah. I think, I think, um, I think we have better tools to, to identify, um, uh, potential disc issue.

It just in terms of, of, of, of assessment and, and, and really history. I mean, gosh, so you've missed so much on the history because if you don't have a really good thorough, long history and some, you ask a question and somebody says, if they answer you, you ask open-ended question, hardly anybody pulls that string and starts unraveling the rest of that, you know, go down, goes down that path and you still, you're still, you're, but you're making directed open-ended questions or specific things, you know, and if, and if they answer no to that and you move on, you know, uh, but that takes your differential and cuts it down, uh, almost more than in half.

So, um, and then your exam is going to be much more efficient and I just think we, we were better at detecting, uh, a potential disc problem than we are with that syndrome. How, how long would you suggest your history taking process be? Uh, including review of systems? Um, let's, let's X out review of systems. Um, it kind of depends on, on if, uh, if it's pure, pretty clear cut, it ends up being, it could be anywhere from, you know, 15 to 20, 25 minutes. Mm-hmm. Okay. I'm much longer. Um, mainly cause, uh, uh, hearing concerns and all the other stuff. It's more of a relationship thing. Mostly hearing concerns.

Mm-hmm. What? I do have hearing issues, but, uh, what, what is the, what's the typical exam time that what, what, what's the criteria in, in the boards now? I think they have to go through their part four and have an exam in what, 12 minutes or something. Oh, you know, I actually don't know that. I guess it would be good for me to know that right now. I, I thought it, I thought it was under 15 minutes. Wow. That's a, that's impressive. Do a thorough, thorough, uh, exam. Um, you know, it's funny, uh, and when I first started practice, I, uh, uh, uh, I was like, I was like, man, an hour, cause I had an hour of new patient visits.

I'm like, oh, it's not enough. I just can't, I can't fit it in, you know? Uh, and then, uh, a couple of years in practice, I'm like, oh, I can knock this out in like 45, 50 minutes. And then after that, you start to learn a whole lot more and you're like, I need an hour and a half. It's a, it's, it's funny how I kind of swung from one pendulum to the back to the other. Uh, but I'm still kind of leaning towards like that hour and a half, you know, if you're really going to do it, I know this is including, um, what some people, you know, uh, review systems, history assessment, orthopedic assessment, neuro assessment, uh, functional movement or a movement assessment.

Um, uh, and, and like a kind of brief, a brief little report of findings, let them know what you found, uh, or you could do that as you're going with the assessment, you know? And then, uh, and typically in practice, you might make a, uh, an intervention right then and there, you know, give them one thing to do or, um, or, or, uh, mix of activity or some, um, you know, activity modifications or, or, um, basically teach them how to avoid their painful trigger. Yeah, yeah, I, I, I've gone to about an hour as well. Um, I'll, I'll fit a bunch of stuff in it and I usually, I usually screw up and, and don't actually, uh, do a bunch of documentation yet.

Like I, I get to do it later. I got to dictate it, which I guess in all honesty, then it takes me about two hours for a new patient processing and exam and, uh, pain modifiers and exercise and blah, blah, blah. Yeah, but I don't even, I try not to go through tissue work first time because I don't want them to feel like that was the only thing that fixed them because someone else has already done that with them. Right. No, I, and, and that's when people came in to see me in my practice, California, they've already seen, you know, three or four people, uh, sometimes more. Um, and sometimes I was the last stop, you know, or they've, they've already had a couple of surgical consults.

So they're just looking for something new or they heard that I'm, uh, I'm, I'm a, he's a chiropractor, but he's not really a chiropractor, but he is a chiropractor. He just does, he does different stuff. Just start your new practice called that chiropractic, but not really. Kind of, kind of, but not really, but I am. Yeah. I am definitely a chiropractor. So, but, um, but no, the, uh, it's the, um, they would, they would look for something different and I would give them something different, you know, and every now and then I would have the person come in expecting kind of what a traditional chiropractor would do.

Uh, and I, I, that, but that was, the precedence was, uh, set before we even got into the exam. You know, after I, I took the history, um, one of my questions that I asked new patients was, uh, you know, what are your expectations of me in terms of like my treatment? And, and, uh, how do you, what do you expect from me as a doctor? You know? And so we got it all out on the table right then and there, if they're in, just get adjusted. Then I told them, I said, look, that's not what we do here. Um, this is going to be different. We're going to do some exercises and that type of stuff. And it says, that's something you want to try.

Let's get it. Uh, if it's not something I fully understand and I can help you find somebody else if you want, you know, if you want, if that's what you want, you know, so. Did, uh, and I don't know if, uh, Ben talked to you about this topic yet or not. Just no, no, no. So we talked about this cause I, cause I actually, I used to go, I would get a lot of phone calls over like, Hey, I just want a quick adjustment. I'm like, Oh, this God, this is the worst. Like, I think I've talked to Ben about this, but go ahead. Yeah. So yeah, he's, he's like, he's like, I, I take them. He's like, I, I, and I'm like, well, why?

And he's like, they're paying me to market to market to them of the things I think that work for them. And, uh, yeah, he's, he's like, he's like, I'll, I'll spend a couple of times doing what they want, but he's like, look, what have I taught you how to do this? Uh, and you feel better all the time. You don't have to pay me for it. So that was, that was his edge in turn to meet them where they're at. So I, I, I get it. No, I get it. No, I do. But I don't, I don't, I don't think they, I don't think they would last an hour and a half talking to me and not, not adjusting. It's the principle. Yeah, I know.

Um, so back out on the syndromes here. Um, let's go further down the line because I know that we already talked about impingement in the hip. Uh, we talked about hip flexor, piriformis, IT band, and, uh, I think we should talk about patellofemoral pain syndrome. How do you think about, you want me to start on that? Um, you're sure. Yeah. What do you, what do you think about patellofemoral pain syndrome? Well, I think that. I am curious actually. Oh, really? So, because we've never talked about knee stuff. I don't think we, well, we talked. No, go ahead. Okay. I'm not sure what we have actually.

So my, my theory is kind of based upon, uh, what was the work that Powers did in 2007, maybe 2009. Uh, there was a dynamic MRI that it was a weight bearing dynamic MRI. And so versus, uh, recumbent or, uh, supine ones, non-weight bearing. And so what they found was that the patella didn't move laterally. The femur rotated under it. Yeah. Right. Yeah. So then that obviously comes from the hip. And, and this, this, I haven't, I haven't clarified yet, but I have a respected source that he believes this and he's a super nerd, like a Sheldon. And I said, what, how do we control femoral internal rotation?

And he says, the ilium is the boss. And I said, okay, what attaches to the ilium? And that led me up to the lower cross again. Well, let's, let's revisit that. What attaches to the ilium that attaches to the femur? What attaches to the ilium? You talking about the glutes? Yeah. The piriformis. The piriformis is the answer to everything. So what is, whenever the femur, the femur goes into internal rotation or valgus collapse? Deceleration via. Yeah. Oh, are you asking or telling me? I'm asking you. Oh, okay. E-center control of the lateral rotators. You are almost there. So the, so in valgus, right?

So the, um, technically you're, you're right, but being a little more specific, you know, valgus collapse of the knee. That study, was the foot in contact with the ground? That was standing. So I hope so. So the foot was in contact with the ground, which is an important thing, right? So when the foot's in contact with the ground, the valgus collapse, let's say the valgus collapse happens. So the femur's going into the flexion, internal rotation, and adduction. Literally the exact opposite of that is extension, external rotation, and abduction. What muscle does those actions? Are you talking about the max?

Glute max. So whenever the, so it's the e-centric control of glute max, right? I think they all work together though in that. It's just not hard to separate that. Plus now we got, now we got QL, the torso. Well, opposite QL. Yep. Yeah, so contralateral QL, you know, it's, it's not always one muscle, right? But if we're looking at, we're looking at a big driver of potential valgus, you know, you can't, you can't pass that one up. But again, does that come to, come back to, is that a core stability thing? You know, why, why aren't, why, or why isn't the glute max or the glutes or whatever's controlling the femur?

How come it's not doing its job? Yeah. Is the foot, is there an actual foot or ankle problem in order to, and where, um, we're not having, you know, when having the glute be as efficient as it can be. And I think we can kind of pick, uh, you know, pick this apart all we want to, but if, you know, uh, yeah, sometimes that we need to address the minutia, but most of the times we don't. And I think if we can find something that, find a, uh, a painless range, or we can find a, uh, a way there to, they can load a painful area, uh, with no pain or, or minimal pain or just some, just discomfort, you know, nothing above with, you know, we try and stick around a three or less.

Um, I think you're going to get more bang for your buck anyway. Mm-hmm. I agree. The, uh, do you have a good way of explaining patellofemoral pain as you're exploring the upper parts of them to a patient? Cause it might seem kind of like, Hey, pay attention to my knee, man. No, I, I literally tell, I, I literally say, okay, so this is what we, we think's going on here. So whenever you are doing X, Y, Z and your foot's in contact with the ground until I'm, we're, we're kind of, it's almost like we're losing control of the thigh here slightly. So what we're going to do is we're going to do some, some stuff to, to kind of help support that thigh and do some, uh, some stuff to help support what attaches to the thigh and really just kind of train, try and train some movement patterns and find some good exercises that you can train the whole thing, um, and, and get this better.

Okay. That's good. I usually take, um, I usually sit them down on the table, put their feet on the ground and I put my hand in their hands and, and I say, I'll give you a dollar if you can push me away without using your belly. And so I've never lost this bet except for one time I was close cause they were on the ground pushing up and I'm like, I'm like a lamb lay down again. They gotta be seated. So I, so I, I say that the hip, the knee and everything below, it also works the same. All the extremities work the same. You have to have a, we have to start at the center and that's it. And then we, then we go and play around and they tend to feel better.

So then they stop questioning it. Um, is there more symptoms that, you know, one that's a tangent that you might be familiar with now is pelvic separation. That's a pregnancy one, huh? Public separation. I have no idea. I'm not pregnant. Mary, Mary Ann would know that one. My wife, my wife. My wife. Yeah. So I, I don't know about that one. Oh yeah. I think that one happens with pregnancy and they, they get like the looseness of the pelvis or the pelvic ring. And then they, Oh, pelvic. Pelvic. Oh, what'd I say? Public. Oh yeah. It's a public separation. That's, that stopped in the sixties apparently, according to law.

I was like, what are you talking about? Talking about a tangent. A pelvic separation. No, so you're kind of talking about like, just like in a loose bolt. Oh, I don't know. I haven't done a lot of research on this one, but I feel like it's just the ring is, the ring is loose for whatever reason. Well, I mean, you are getting ready to push a, a mini human out. Yeah. But it remains, but it remains. They, the people, the people that I've talked to, you said they have that and they're talking about a year after. Yeah. I don't know. I don't know if I know enough to really comment on that. I mean, if you think about it from a mechanical standpoint point, maybe it's, uh, you know, depending on the size, the size of the, the mom and the size of the, the mini human coming out, uh, that may play a role in how much the actual pelvis did have to, to distract.

And then your, your activity or probably lack thereof activity, uh, depending on, um, you know, how traumatic the birth was after the birth, you know, I, I think all of those are probably a huge role in those and that. Okay. And your activity and your, maybe even your activity leaving up, leaving up to it. Yeah. I, I don't know much about that one, but I feel like it's, uh, I think, I think Marianne would probably have a better answer for you on that one. Honestly. Yeah. No, I think so too. We, we talked a little bit on the phone about it, but, uh, it was, uh, yeah, since we're talking to syndromes at that, did we, did we miss a syndrome here?

I want, it's kind of cross. What was it? It's lower cross in general. We, we talked, well, yeah, I guess lower cross in itself is a syndrome syndrome. Yeah. I don't, I hate to call it lower cross. I mean, I hate to call it a syndrome. Honestly, I feel like, but like just, I imagine the dials and that's the whole thumbnail of this show is the dials, so let's just dial them back, close it down. I don't know. Center point. What's going to be your entry point for that, for the close it down? For the entry point for, for any of these syndromes? Uh, what does it lower cross to close it down? For lower, lower cross, I'd, I'd probably start with, um, I've been starting with a dead bug, honestly, or some type of like supine, supine breathing dead bug thing.

Mm-hmm. Um, I don't know what you call this stuff, but, uh, if you were to load a dead bug and go hand on knee, contralateral, and then have them press in and supply their own load. What are they pressing in by? They're pressing the, the palm, the, this part, the, so the thenar eminence into the thigh of the contralateral leg. Contralateral, yeah. In, in a, in a dead bug position as having breathe into a floor. So, uh, that's, uh, that's not really where I've been starting, but I like that it, that's a nice starting point for people. Um, I mean, I can go into like some of the DNS stuff and face down and all that, but like some people don't tend to get it as much and I don't always have time to, to teach it yet.

So I think the supine dead bug is a nice one to start for me. Where would you start? Where'd you start? I'll be honest. I never did that bug. Really? I just, I did the true dead bug. I thought it was too hard to coach and that, not that many people were, were good at it. And whenever I thought they, they would be good at it, I think we could, we were, we were, I found that we should have been kind of moving on to other stuff anyway. Um, if I really, really do think that it's something that needs to be addressed in terms of the actual posture positioning, um, I'm not trying to have them statically change and hold positions, uh, you know, when they're just kind of doing their daily activities, but I'm trying to expose their, their body and their brain to a new position.

I coach ribs, reposition only really. Um, I don't really do a lot of, uh, pelvic positioning or pelvic tilting at all. I think if you, if you can control the ribs and everything else can, probably fall into place a little bit better. Um, and I try to pull them away from that as fast as possible. Uh, but I will, you know, they kind of, if, if they have a problem with kind of reposition or if you look at, you know, some DNS stuff that they have that, uh, poor ability to kind of, uh, fill in intrapedal pressure and the posterior lateral portion of the trunk. Um, I'll put, I put it actually, I put the core 360 belt on them and have them kind of breathe into that and brace into that.

And then we could go do whatever. Uh, and so I don't have to keep queuing or anything like that. Wasting my, wasting my words. You know, you don't have extra fingers to just stab into their sides. No, no, no. I mean, I think, I think when the one, again, you know, even the person, Erin McGuire, who created the core 360, she doesn't want you to use that as a crutch. You know, she would rather you use that as kind of a tool to bring some awareness to the area and maybe check in with the sort of breathing stuff every now and then. And then when you take it off, you can still feel it on you. And so you can do the pattern with that.

And then, uh, ideally we could, you can load it. And the idea is we want to make those patterns stick and we want to make those, um, those, uh, you know, positions and postures, um, uh, kind of, uh, easily accessible. I guess it would be a better way to put it. There's, um, I don't think we talked about it yet, but there's, uh, the way I was using that, that dead bug and also some other stuff, there's, you ever, you ever done, you ever done so many bicep curls, you walk out of the gym and you feel like you can't move your elbows anymore? Have you seen my arms? Yeah, you, you did, uh, yeah, you did a bunch of, uh, thigh masters.

It looks like. Did you hear it pop? Yeah. Did you just, did you just suggest your elbow? Um, but yeah, so like just that phenomenon for me is, I'm not saying I'm trying to get someone to go into like a mini rhabdo or anything like that. And this is, this is for special circumstances. But if, if I feel like someone is constantly defaulting to, let's just say if they're, if they're, um, open in that lower cross syndrome thing, I feel like if the front side wall or even the oblique slings on front, if I can, it's the feeling that I get with it is like, you know, you take saran wrap and you, and you put on the table and you put a heat gun over it and it just wrinkles.

You get to that point where like a muscle feels like it's kind of like that. It's like they're completely gassed out. And then they, they seem to retain the same positional change, at least with a little bit of guarding and not guarding in a bad way. It's almost like if they're arching or the ribs are flaring, if I were to just pull their shirt down and walk around with them all day and it seems to stick some, even thumb, even people who have like, um, uh, hip impingement, it seems to help because it raises the rim. It seems to help out with people with like a mains syndrome. We didn't talk about mains.

Right. But so that's, that's what I'll usually do if they'll be tolerant to it. But then the deconditioned person, then I, I'm risking like killing them almost. Right. It's funny you bring up mains. I mean, that, yeah, I've actually seen that decent amount. You've seen mains? Hmm. Huh. I actually, I actually, I actually had a case where patient had, uh, uh, I don't definitely one hip surgery, maybe even two hip surgeries, uh, with no, uh, to fix the labrum, torn labrum and no resolution in pain. And then we did like rib depression, breathing, intravenous pressure, and the pain went away. Mm-hmm.

Needless to say, uh, they weren't very, very happy. Right. There, there, there was a girl I had here that she, uh, she had pain with, uh, it was, it was lat activation, I guess. So she was seated and she would drive her lat down into my hand and she mainly had pain with pull-ups. So I had, she had her do some pull-ups. It was, it was painful. I put her into more of a hollow position, uh, or at least assisted her into that a little bit. And she did pull-ups no problem. And yeah, she was, she's like, you tell me this is an ab thing. I'm like, well, maybe it's probably the torso thing, but I should correct.

When I said those four things earlier, I was reading off of mains, not facet syndrome. Ah, there you go. That'll be in the article, everybody. Yeah. Uh, so as we close up here, is there, uh, anything you want to add on this? Um, gosh, um, uh, we can go down some rabbit holes, but I don't, I don't think that we have enough time for that. Right. Well, well, I think I'll, I'll, I'll, I'll try to tie it together nice in a bow here. I think that if you have a syndrome person, then perhaps we look for differentiating factors first to confirm there is or is not a muscular injury. Uh, if it looks like that air is bearing fruit, go down that route and try to get the person to become empowered with it.

It doesn't mean you can't use tissue work or any of the other tools that you use, but at the same time, make sure that you're not leaving some supportive systems on the table. Yep. I agree. You know, and a lot of times, you know, you're, you know, if you're looking at, uh, um, you know, back spasms or something like that, instead of just, uh, diagnosing or trying to treat the back spasms, you kind of have to ask the, the why, why are, are there back spasms? Or if there's a trigger point somewhere, uh, ask why is there a trigger point? Don't just attack the trigger point in order for spasms to calm those down.

Those might be protective. Absolutely. We'll say the times trigger points are protective. Yep. Damn trigger points. Uh, are you going to help me close the show down? Close it down? I've never had a co-host to close it down. Oh, yeah. Well, I think, uh, yeah, I haven't either. So you're not going to say, um, what did, what did Ron Burgundy say? Say classy San Diego. You got to have a closing line. Yeah. Oh, yeah. Uh, so actually, do you have a contact you want people to reach out to you with? You're not in clinical practice anymore, but not, not practicing currently. Uh, but yeah, if you can feel free, um, to either email, email me at, uh, D R C O D Y D I M A K at gmail.com or hit me up on Instagram, uh, still at max perform Cairo.com.

So it's at M A X P E R F O R M C H I R O. You know, it's funny. I was trying to do some closing stuff, some mock closing stuff earlier, and I was referencing your name and I realized I didn't know if there's a C in there or not. No, no C, no C, no C, no C, just a D I M A K. Yeah. Got it. Okay. Everyone. So if you're looking for the show notes on this, go to P two sports care.com and there is a pretty comprehensive service function there. You can definitely go through and check shit out. This is going to be session number one Oh five. So you just type a one Oh five, no pound or hashtag sign, or you can probably look up Cody's name.

Uh, I think you're only, you're only on two of them. So one of them will pull up. So that's where the notes are. And any references that we've made, I know we talked about the article as well as a poster and all that kind of stuff. I'll put links in there so you guys can see them and any topics that you do want to hear about it for, if you have questions or think that we're full of shit or whatever, just email us as well. Just keep it classy. San Diego, uh, my, uh, my, my email is S E B at P two sports care.com and Cody got anything. No, I mean, especially if you think some of the stuff is BS.

Cause I mean, that's what you know, start some, some good dialogue and, and, and talk some stuff over and just, just to kind of let everybody know, we don't think that we know everything that's for sure. Um, and we don't, uh, we were always, we're both seven. I are continually learning. We're doing always doing a lot of research. We're trying to learn, trying to better ourselves. So, um, you know, if you think we're what we said, it's totally BS and don't let us know. Yeah. And also to just, um, I'll just make sure that I'll mitigate a bunch of emails on this right now is that, uh, if you feel like there is no science or research to validate these concepts, you're probably right.

And actually just after this, the following podcast is 106. I interviewed a researcher, uh, Dr. Andy Galpin at Cal State Fullerton, and we discussed that. So he said that actually a lot of stuff in clinical practice has no science to validate because it's the human is so, uh, so many variables that we can't control. So listen to that podcast and that's, we'll help guide you down the thought of there is no science to prove some of this because we both recognize that it's just what we've observed in clinical practice, put shit together. That's it. Absolutely. Cool. You want to hear my closing? I do.

Mine is leave people better than how you found them and date an Eagle Scout. You would, you would, um, my, my closing is football season is upon us. So, uh, who dat, who dat, who dat, all right, we'll close it off here. Talk to you guys next week. Yeah, you're right.