The crooked squat and chronic knee, arch and groin pain

I decided to pick the low hanging fruit. So we loaded the side of symptoms in this case, and it's not always that way. And he improved. He was able to squat with no pain. He can run stairs with no pain. He could run with no pain. And those are all things that he couldn't do before. 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 guys, this is Dr. Sebastian Gonzales today, again on the Restoring Human Movement podcast. Thanks for being part of the movement. Thanks for spending part of your day today with me, because I know this is an hour you can be spending watching Lost, or one of my new favorite shows is actually The Good Place. Has anyone seen The Good Place? The Good Place is the shit. Like, if you love Forgetting Sarah Marshall, you're going to love The Good Place. So watch The Good Place, season three. It's already on. Anyways, so this is going to be a solo podcast today, and I'm going to go over some of the interesting cases that have been coming over the last couple weeks. And I do get a lot of interesting cases. I'm not going to lie. They're fun. They're fun to me. They're fun to problem solve. But these three in particular were ones where I thought I should do a podcast, or at least an article, and I thought podcast me quicker.

And just kind of discuss why we took the route that we did. And all of these people, these three people, are very different in presentation. But the commonality, and the reason why I'm putting them all in the same podcast is that they had the low-hanging fruit, which is poor squatting mechanics, that when we recorrected that, and lo and behold, they felt better. They felt better without really even touching them, you know? And it was great. It was fun. And I thought, I think every time I get a case like this, we really hope an intern is in with me, because I think for me as an intern, or a young doc, I would have got this wrong, and I'm sure I got a lot of them wrong. But surprisingly, we were able to get them to feel better without even doing any manual therapy with them. And all we're doing is correcting a squatting pattern. So, that's what we're going to go through today, is just, I'm going to go over some of these presentations, and kind of these people's stories without actually revealing their identity. Mainly to scratch my own itch, honestly, because I know that the people like this are going to come in. And I thought that when the first one came in, and the story of not having anyone to really find this correction with her, and having been through orthopedic surgeons, and not playing her sport, and also the obscureness of what I was suggesting, but it ended up working, it was kind of sad. Like, I thought it was sad that there's, where was she supposed to find this? You know, where was she supposed to find any literature online on it? Because I don't, I haven't seen much. You know, like, we see them in clinical cases, people who correct movement, but I don't think many people write about them, especially these ones that are a little bit outside of the common, quote unquote, diagnosis. So, that's what I'm going to go through today. I'm going to go one of knee pain, that was actually resolved with just improving squatting mechanics. And another one is groin pain. These are both soccer players, repeated groin groin injuries. And the last one was actually medial arch pain. That one was a fun one, because he was right on the edge of getting some, getting a brace, which was kind of, I haven't seen one other than like this one stroke patient that I worked with, who was a cyclist. So, he had one, but I've never seen anyone else with one anyways. But maybe I'm working on the wrong population set. But I'm really glad that he has, at this point, although we're still ongoing with this care, we has not really had to do that.

So, if you're interested in these things that I'm saying, stay tuned to this podcast, because you're going to get a lot from it. I know if you're a young clinician, or a young doc, or someone in school, you're probably going to learn a lot. I always love case presentations, personally. So, if anyone wants to do podcasts with case presentations, let's do it. But now, before we get to that, let's get to the story that lets you hear a little bit more into an insight of who your host is. So, I don't know if any of you guys have a cassette player anymore, but I recently just got rid of my cassette player.

I had one of those old school ones, one that had three to five disc changers on top. And if you're lucky, it had a turntable on top. But it certainly had two tape decks in the radio, and it had these booming speakers, actually. I was really reluctant to get rid of it, because there was just one spot in my house that was in this old, I had this old blue rocking chair, that's right in front of the two speakers that were just up on the wall, those big gigantic speakers, but again, had a massive bass. So, you put that chair in one certain spot, and it felt like you were a surround sound, like you had one of those sound bars, Bose speakers, but these things only cost like $300 to get back in the day.

So, I think I had it since I was probably 16, 17. So, I only had really one tape I really wanted left, and it is of a band that actually one of my cousins was in called Sideshow Bob, and you can't find Sideshow Bob anywhere. So, you look up Sideshow Bob on YouTube and music, and like, you just can't find anywhere, because they didn't really do anything. So, anyways, I had this one tape left, this last, the last rendition, the last copy of Sideshow Bob, three songs that I liked on there, it was on this cassette tape. So, I'd thrown that thing away, and I found this tape. And so, my roommate, he still got one of these things, and I'm like, dude, I found my Sideshow Bob tape. Let's just play this thing.

Let's just rock. Let's do this. So, we put it in there. This damn thing starts eating the thing. It starts eating the tape. So, I pull it out. I almost rip his, like, thing off, and he was freaking. He's like, dude, don't rip. Don't mess up my stereo. I'm like, dude, he's eating my Sideshow Bob tape. So, I pull the thing out, and I haven't done this in years, but I remember that because the string was hanging out, the ribbon was hanging out. So, I found a pencil and rolled that thing up, and it was really nostalgic to do that. So, anyways, I put it back in, eats it again. We do this, like, three times. So, I'm pretty sure I lost probably about the first 30 seconds of the first Sideshow Bob sewing. But, when I finally find a tape player, I'm going to rock the hell out of that thing. So, yes, make sure that you put, you keep a dummy cassette, maybe, before you actually put in your valuable mixtape that someone made you back in the day. Mixtapes are hard back then, you know. You had to wait. You had to wait for the DJ to stop talking. They always talk at the beginning of the song. I won't talk at the beginning of the stories. So, let's get right into the stories here, okay? Okay. So, the first place was a soccer player. So, a collegiate soccer player, and it was a girl.

So, she ended up having knee pain, and it was knee pain right around the patellar tendon. And the reason why I thought her case was really interesting was because of the amount of, actually, background she's already kind of gone through. And we don't always really get this, or I don't always get this, where someone comes in with imaging, which is positive or negative. But they have the information, nonetheless. And she'd already been through a lot of docs already. She'd had the thing for, I think it's been, I think it's been months, actually. I think it's been a couple months. So, then she wasn't able to play. And the frustrating part was that she'd already gone through, actually, some physical therapy, which included things like single leg balance. She used some bands. She did some small squats, she called them, or I call them SKBs, or small knee bends squatting, which is really painful for her. Running was really painful. She'd done BOSU balls, squatting, foam rolling, and what I would classify as open chain leg or hip movements, such as clamshells and so on. And there really wasn't any change with PT. And although they'd taken her off of running, she tried to go back to running, and she'd end up feeling the same amount of pain, or at least like half the amount of pain within the first 50 yards or so. So, and sometimes even in the first step. So, walking downstairs was painful, but her MRI was negative, and no one really knew what to do with her. And she, I think she'd kind of come to terms that she wasn't really wanting to play much past college. So, actually, my first question with her was, I was thinking that, well, maybe, like, I don't even know where we're going to go with this person, or I'm going to go with this person. Like, for all I know, I can't figure out either. But I kind of want to know a mental mindset with it, that if she's willing to not play, is she not playing because of the injury? Is she not playing because of, she just doesn't need to play anymore? And I remember stopping playing baseball, and it was kind of like, like, yeah, there was an incident that made me feel like I can stop playing. But at the same time, it's like, I'm making the choice not to play. It wasn't like you're pushed out. So, I always like my athletes to make that recognition first rather than regret it later. But, you know, actually, before we actually go too much into this, let me classify kind of where I wanted to go with all these cases here.

And I wrote down a little laundry list of the things that I wanted to do within these cases. So, first is, actually, the commonality was that all of them had about 50% to 75% reduction of symptoms within one session. Now, that's not to say the session or the symptoms reduced and stayed away. It just means they were gone for the activities that they chose to pick with it. This girl tended to tend to pick squatting and walking up and down stairs. So, I like them to pick their own stuff, honestly. And is it going to stick? I really hope it does stick. But at the same time, it's, it's, we're only taking that thread away for a little bit of time. The other thing was that I really wanted to make sure that in these, in these complex cases, I want to make sure I listen well.

And I thought I listened well in these because I figured out the things that they were already doing that already, that they already tried and I didn't want to do it again. And I didn't want to beat the same therapy to death. And when someone comes in with a knee condition, such as her, I didn't want to think, well, I'm going to tissue work the heck out of this thing, or I'm going to brace it, or I'm going to do banded hip exercises with it if she's already done it. If she's already done it and she can demonstrate good form with it, then I'm, I'm not going to bother. And I've heard this actually repeatedly over and over again from multiple people. It's not always about the exercises or multiple clinicians, clinicians rather. It's not about the exercise, it's about how they do the exercises. And I know that I put now, I put out courses and exercises and videos, but I always try to make sure that very, that people do understand that it's the small nuances of how you do it.

Because you can do, what's the saying? Squatting's, squatting's great except for the way you do it. Squatting only hurts how you do it to yourself. So how you do the exercise is really important. So I attempt to look at these small nuances in the beginning. Now when I'm examining, I like to rule out spinal considerations as well as roll out local instability. I'll talk about that in her case in a second. Also, I'd like to look at the other side. How is the other side functioning, the non-symptomatic side? So don't get locked in to what your, what your condition may be. Also, I like to pick the low hanging fruit. And I did in this case, it was a squat. Let them pick a movement that is a non-stretching based movement to retest. Try the recommended exercise dose and then retest that like that. So with her case, it seemed like everybody was kind of running down the possibility that diagnosis was patellar tendonitis or jumper's knee. But she wasn't really responding like that. And I thought also too that maybe she might have some type of referred pain from the inferior, infrapatellar nerve or contribution from the saphenous nerve or maybe the high lumbar spine nerve roots. Who knows? So I tested for that. I didn't find a ton. I thought I would. And sometimes, sometimes when I do, I think, hmm, this is going to be a really long conversation because this shouldn't, this shouldn't make any sense to them. But I didn't really find a lot in her case, honestly. There was a little bit of dermal traction that worked and kind of lifting the skin around the knee area on the inner part.

But really what helped out in her case was actually manually compressing her ileums together or kind of pressing her pelvic rim together. So I did this eventually throughout her examination because she showed me that squatting again was painful. Running was painful. Walking downstairs was painful. But I like to pick things that I don't have to chase them around for ideally if we can. That's not always the case. But in this case, it tended to work out. I looked at the knee and it was relatively stable. I didn't see anything that was alarming. I didn't see any symptoms or any positive testing to show me that patellar tendonitis was of high possibility or jumper's knee or quad tendonitis or meniscal tears or ACLs or just blatant instability. I didn't really see any of this.

And even with shear testing, just pressing the joint through ranges of motion that should bother it and resisted ranges of motion, it didn't really bother her. The funny thing though, she was still really concerned that there was a patellar tendon issue. So I actually took the liberty to shoot an ultrasound while I was here. And it was a real quick bilateral comparison. I looked at the other knee and just, I usually in the wall at my office, I have in the ultrasound room, I have some very positive images as well as the person's other side to show that there's what colors are on the positive one.

Also too, how much black is in the area and differences and so on. And generally I say, can you tell which ones are the abnormal images on this wall? And they usually pick out the two without having a problem just because they're so colorful and there's so much black around the seat. It just doesn't look right. You know, it's just blatantly abnormal. So looking at her both sides, it's like, can you tell the difference? And she said, no, not really. Right. But kind of going down that, that low hanging fruit thing, I, I saw that her by pressing her pelvic ring together helped. And we then did it through squatting movement because then I can follow her a little bit. And so this helped. So I honestly don't know exactly why this works. I mean, I can guess, I can guess based upon theories. And I had an intern recently asked me like, you know, how do I go through and examine the way I examine. And I do take diagnosis that are higher up on the possibility list and try to rule them in or out.

But also too, when we do find the possible diagnosis, and I'm saying possible because I, I still have some doubt. That's why you have a secondary diagnosis. With that diagnosis, I want to see then what is the body we're going to respond to to reduce the symptoms of that? What is it asking for? And in low back conditions, we see that the directional preference is very useful for reducing the symptoms. So in conditions like this person's knee, I wanted to see what was going to reduce her symptoms in the thing that she showed me. So in her case squatting. So if I push the pelvic ring together, it could be honestly could be doing one of two things, I think. A lot of times this helps in lumbar spine cases or people who have sciatica, radiculopathy or nerve based pain. And I think it's because we're pushing the SI joints together and then supplying support to the spine and then all the components that come out of the spine. In this case, maybe the nerves.

So I did that and it helped. Or there's a possibility that I'm assisting a better fixed point for the glutes to then feed the femoral head into the acetabulum and then improve stacking mechanics of the knee. Or as if you listen to 105, you heard that Cody Diamac was saying, we argued a little bit on this, or we disagreed a little bit on this. It was about, he's like, you're just taking the threat away. Which I do agree with because what we're doing with pressing through, we're not really making them stronger. And I don't think over the course of doing a couple corrective exercises, we're really making them stronger either. But certainly their symptoms reduce when you pick the right thing.

So, in her case, what I picked was a oblique sit, as well as what I call a skater, which is basically a single leg stance and we're starting to load that side, the symptomatic side, or sorry, I take it back, the side side, that she is not squatting onto or trying to offload with her squatting pattern. I think to get the hips to be more active, let's just say, to get them to do a little bit more work and to get the glutes, then to improve the stabilization of the SI joint, and then maybe the base of support for the spine, the nerves, whoever, whatever, I don't really know. But either way, it tended to work. So, when I had this conversation afterwards, they said, well, what is this? Some type of voodoo? Like, is this going to, how long is this going to last? Because they were used to typical, you know, like working on the knee, working up at the hip, which I'm glad they did get some work with the hip. But they weren't used to the symptoms reducing that quickly. And I told them it was just the bank account effect. And I've learned this from Brian Carroll. I think Stu McGill mentioned this too, is that the more they build that bank account with that trust in that hip that then equates to the squat and also equates to running and all of her symptomatic movements, like walking downstairs, then the more you can make the withdrawal. So, make a deposit, make lots of deposits and make a withdrawal. So, I wanted her to do it a lot. And eventually then build that into improving the squatting pattern and eventually adding a little bit of load to then, what they say, hit the save button. I think that's a great cook thing. But anyways, this just tended to work. And what I had her do after that, I said, go ahead and squat. How's it feel? She said, oh, it doesn't hurt. I said, go ahead and run the stairs. She's like, oh, it doesn't hurt. And there was something though that was still painful to her. And I said, go ahead and jog. So, jogging was painful. She jogged around the office, kind of a slow lollygag. And I said, okay, so based upon what I know of what she's responding to, she's responding to some very direct and I would say intentional foot loading onto the ground and also bracing work. A little bit of improvement of intra-abdominal pressure also worked in her case. So, I said, okay, let's just do, you ever done high knees at soccer practice? She said, yeah. I said, cool. Can you do that? And I want you to drill a nail through the floor and then pump your arms extremely furiously like you're trying to churn butter. And she was able to do this, no pain. She then ran again or she jogged again and it was painful. She pounded the nail again. It became non-painful. So, what did that mean in regards to speaking to them for me? Because they asked, well, when can we start running again? When can we start playing soccer again? And I said, look, I think just for a graded exposure, she hasn't been playing for a while. And I think, why not do some intentionful footwork drills, you know? Why don't we continue to work on the improvements of the squat, whatever that may eventually lead to, in office here, unless she has someone then to do it with at school, like a strength coach or someone who would then apply the same system. I had to do a little bit of manual loading with her to improve it. But I don't see any reason why she can't actually do some footwork drills, some ball work drills. Maybe she might not be sprinting. Or maybe sprinting is okay because the plyometrics are okay. But maybe she's not going to do long, slow distance run. Maybe not endurance-based things. So, I found her case very interesting because they wanted to go in and just, they didn't know what to do. Honestly, they didn't know what to do. Sorry, I'm thinking about it. There was actually a fourth case that, that one's still in the works. So, I don't know how that one's going to go. But that one, they wanted to do exploratory surgery just to see because the MRI didn't show anything, right? And, you know, also, too, a conversation that I have with a lot of them, if they are questioning the MRI findings, then I typically have the conversation about the grading system of tissue injuries. And you'll find that, I think, on podcast 46. That's why I made this thing. I actually have a whole article on it as well. And it was based upon the 2012 consensus statement for muscular injuries and why MRIs and CTs and, or sorry, MRIs and ultrasounds will be negative on some people, you know? And this takes that into consideration. So, if she was a grade one injury and there's a large classification in there, there wouldn't be a positive MRI or ultrasound finding and there wasn't. So, then why are we looking still at the structure? We could be looking at neurological-based things. We can, we can just look at fatigue-based injuries and then just offload that structure and improve the mechanics and then it'll start to dissipate. And actually, if you guys haven't heard me say this before, actually, delayed onset muscle soreness. The soreness you get from lifting weights is actually within that category too. And it's kind of that realm where it's like we can get this thing to improve very quickly if we do the right things or if you take the necessary steps. And in the case of DOMS, it's like no one does anything. Just let it kind of chill itself out and then it goes away, right? So, even if you have a negative image, don't continue down the route and keeping on that you're looking for something to be positive on there because it's not always going to be positive. You might just drive yourself crazy. Maybe it's something simple as picking this low-hanging fruit.

So, the next case, let me get into, I'll switch these things up actually because there was a soccer player again. So, this case was, he was a very different presentation again. He was arch pain. He was arch pain within the foot with walking. And the time I was managing him actually for some low back conditions. So, I had him walking for some of the rehab. And we also did some split squats as well. And he was just very resistant to doing certain things. And understandably so because he was having this arch pain, which he was seen, he's seen a couple podiatrists for. And they're just, they seem to not have a good answer for him. And he offloaded it for a while. He went into a boot. I think, I think, he'd taken some anti-inflammatory medications. I think, sorry, if he might be listening here. So, if I got a story partly wrong, sorry. By the way, thanks for, I think this story is going to be helpful to people. And since we talk all the time, I think, I'm hoping I clean this up for you a little bit too. So, to improve your understanding. Everybody, just this, again, this is a very common thing for me.

I need to make sure that I'm scratching my own itch because I'm going to share this with a lot of my own patients that have things like this. So, thanks for sharing your guys' stories. Now, so he had, he had medial arch pain kind of around the heel. And they were thinking that it was a tibial, a posterior tibial tendonitis. And I look at, I looked at his ultrasound as well. Actually, I performed one. Both sides look relatively normal for age. So, he's, I think he's about 50 or so, 50, 55 maybe. Just overall active individual, active individual, small business owner, he, he golfs. And these, these findings are not always, these findings are not always abnormal for the person. And we had a long conversation about this because he had a positive MRI that showed that there was issues within the posterior tibial tendon. And he has flatness of that foot. Yes, he does. And so, kind of putting all these data points together, they're thinking, well, you got a positive MRI of that. You have a flat foot and you have foot pain in the arch, in the area where the tendon's at. Yes, let's work with it as if it's a posterior tibial tendonitis or a posterior tibial tendon dysfunction. And so, I don't, I don't, I don't fault them for that because I've definitely done the same thing. And people with flat feet, I think there's definitely a biomechanical consideration that they're going to have to be aware of over time because those tissues will load abnormally. If you've listened to the, I think it was 91, the podcast that I did with Tom Michaud, we talk a little bit about this type of thing of how to improve the biomechanics of the foot. So, if you're listening, you have foot problems, definitely listen 91. You get a bunch of great information in there. So, anyways, so this guy brings in this, it's, it's, it's, it's not a boot. It's not an orthotic. It was like a, again, it was almost like a prosthesis. It was carbon fiber. It was going to keep his foot into or out of a stressed position for the tibial, posterior tibial tendon and also to keep him out of plantar flexion. So, his movements were going to be a little altered. So, I was a little, I was a little hesitant with him. By the way, he did try orthotics as well. My recommendations were a little hesitant for him to try it and when I finally heard the reasons why they were proceeding that route is, you know, because they really didn't have much else to try and this was kind of a latch ditch resort, I said, dude, let's, let's just not do that. Let's not do that for now. Mainly because I was thinking about all the collateral damage that would happen with his movement and walking mechanics and we've come so far with his, with his back stuff and he wasn't able to get off the ground when he first came in. And he had had that for a year and he was, he was having trouble, trouble getting in and out of a golf cart. There was a lot of, there was a lot of hindrance of life that I didn't want him to have to be subjected to again. So, I thought, hey, look, if you're going to be in this thing for six weeks, why don't we then first try to pick some low-hanging fruit with it? We'll put the back off the side for right now and let's just, let's just check out this thing. Let's see what it is. And with an examination, he actually, he, he responded well. We were able to take his pain away in his arch on and off with abdominal bracing, which when I inspected his foot, I didn't see, I mean, I did see the deformity of the arch, but at the same time, like, I don't tend to think when you, when you, when you cue abdominal bracing, like, I'm more looking at spinal-based conditions, uh, referred nerve, maybe, maybe hip, um, or, or, uh, hip, uh, mechanics to improve gait. Who knows? But it's, it's something a little bit higher and it's usually not as direct as just putting like a boot on the thing. So, I, uh, I kind of took that route and I, and I thought, well, what else can we find? And so, I looked through his movements too. And again, one of the good looking glasses is the squat. So, we did the squat. I also did a star excursion test on him just to see if there was any differences of side. I think session number 75, me and, uh, um, uh, Dr. Colby Kondo's talk about the star excursion test that I think actually the FMS started to think, I feel like they bought the, the rights over the, uh, test maybe, but they have that Y test now. I think it was, it was developed based upon that. Anyways, we did some of that. There were some positive findings and it looked like his left foot, which was the symptomatic foot or that side was not bearing load. So, I thought, hey, let's just see what happens. Let's, are you open with loading this foot? And based upon my past experience with him, he tended to be very hesitant of putting a lot of weight on the foot because every step was painful and the next day it was painful as well. It was just, it seemed like it never got better. And so, I can totally understand his hesitation of not wanting to put weight on this foot. So, we did it open chain first. I, I did some stuff to improve intra-abdominal pressure as well as loading aggressively actually into the hip. It was very, it's very uncomfortable. It takes only a couple minutes. So, he stood up and he squatted down and he walked around. He's like, hey, that feels pretty good. So, I said, cool. Are you capable of going further? So, the next thing I wanted to do was some single leg stance work and he was a little hesitant again. So, I, I don't, I don't get to have this, this type of conversation with too many people because a lot of times in the beginning, they, they just, they just kind of follow the guidance. But I don't, I don't always get to be as, as candid really. But I've definitely talked to colleagues about this is that when, when patients are making an, trying to make an educated decision about what they want to do with their health, they kind of need the right background information or knowledge to be able to make that education or educational decision or that correct decision or else they're really just coming to you for guidance. So, based upon that, there's been a few times in the past where I've said, look, you, I will give you as much information as I possibly can find or I've written on this to improve your knowledge to make you, make it so you're going to make a good decision. If you do that, I will have a very detailed, full in-depth conversation with you about your condition. I will lay everything out there. If you want to know biomechanics, I'll tell you. If you want to know the current research, the stuff that I've read, I'll tell you. But if you don't care about that and you just want to feel better, just tell me too. So, the second choice in that matter, that's choice two. Choice one is, I'll just trust you. And so, this guy took, I'm really glad he took one because one's a lot easier for me, but one's a lot easier for him too. He doesn't really have to know as much. But also too, when we get in those hairy situations, I want him to be considerate of the fact that I am looking, trying to look out for him and we're taking a high reward, low risk approach. So, when we got into that exercise, a single leg stance one, he says, I don't know about this. And I said, well, what options you pick? And he said, option one. I said, you okay with doing this? And he said, yeah, okay, good. Let's just try it. If you have any problems along the way, we'll stop and we'll troubleshoot it, right? So, he did that and improved it. And the next time I saw him, he said that he hasn't been able to golf that well on that foot in a very long time. So, we were well over 50% improved within just one time. After that, funny though, when he eventually came back and we started working through some stuff again, he also questioned again. I said, well, what option did you pick? He said, option one. Cool, let's just do it. You go with that? Good.

So, that was a really fun case for me and we're still working through stuff. So, he's a fun guy to work with. But it was an interesting one also too because I don't always see those. Sometimes you do. But when there's so much data and information and even imaging, which is directing the person or the patient, and even when they get follow-up evals from from podiatrists or orthopedic surgeons is there's so much information that is leading them down this, I believe, red herring route where they're not looking outside the box. So, we never really find it. So, I took a blind approach with it and because I'd already worked on him with some other stuff and I saw the way he was responding throughout his rehab with the other stuff. So, I took the liberty to take that approach. But anyways, so going back through his case, I think now when you have a condition like that, again, you have to pick that low-hanging fruit and then just pick the appropriate dosage. I didn't 100% get to pick a movement-based trigger with him, but especially with people who are golfers or baseball players or rotational strikers which have issues through that quick movement, a lot of times I like to have them actually bring their clubs in or their implement in. And if not, I do have a baseball bat there or a couple dowels that they can swing around. But I want to see the way they actually load into the hips when they're swinging as well. Because I think the base of support on that, rotational power is really about the base of support. Can you post up onto the leg to let rotation happen about it? So, in his case, his foot of concern was the front side leg. So, improving the amount of stabilization or control of that front side leg or the front side post actually will help him through his golfing as well, through lots of different things. And I've found people with knee conditions that have that same issue with the front side post, back conditions as well. So, definitely if you have a rotational striker, I suggest looking at the mechanics of the post because they're shifting away from one to the other very quickly and with a lot of gusto. So, we might as well just look at those. The double-legged squat or the air squat really slowly is a good way to take a very broad look at it and to see which one is the untrusted hip.

Now, this last one was, again, a soccer player was a high groin pull. They called it, they came in calling it that. And it was inside the groin up into the high thigh. It wasn't all the way to the pubic bone. But it was something actually, it was interesting because this kid is not very old. He's in high school and he's had stuff kind of ongoing for like on and off or a history of this for about a year or so. And it tends to be painful with running and also getting out of bed. Stretching was painful to it. Butterfly stretching was painful to it. And it didn't hurt throughout the day with walking and so on. But there was really no lower extremity weightlifting within his program.

But there was some upper body stuff. There was pull-ups and push-ups and so on. And it was interesting to see that actually that was triggering his groin. And I still don't really know the reasons why because we're still working a little bit with this case. But I think definitely noticing some of these people, especially of this age group, they have, if they've grown recently, they tend to think some of these issues are from a lack of flexibility or a lack of stretching throughout the growing process. Because they hate growth spurts, right? So I don't always think it's the case. And actually, too, I don't know if this is true or not. But I learned through Michael Shacklock's course, Clinical Neurodynamics, that as the person grows, that some of the tension of the neurological structures to catch up sometimes can be the reason why these people are overly tight. So I don't really know the answer of if we should really stretch them out or not. So I didn't. But again, picking this low-hanging fruit, I was kind of curious the reason or where his past injuries were. Because especially when we have past injuries and they're not like fresh trauma-based ones, we've had an opportunity to adapt to the situation. And I actually have something on my email box that's there. It's been there for the last couple months. And I try to delete every email before that. So the first thing I see when I wake up in the morning, or at least the first 10, and it says, what's the adaptation? So I believe that every condition, unless trauma-based, is an adaptation to something. So when I look at these people, I want to see, especially with these older injuries, if they've had them for more than probably two or three weeks, and the fact that it's not swollen and reactive, there's no bruising, there's not, there wasn't trauma, or there wasn't just an accident, then I kind of want to see how the body is adapted to actually take the adaptation of the injury or make the area that is painful, painful. Sorry, I guess I just kind of burped there. But so in his case, I mean, he tried physical therapy, tried tens and stretching and so on. And it seemed to help him out enough through these other instances where it was good enough at the time. But at this point, he couldn't really change direction during soccer. And one condition that comes up the possibility of it being is with change of direction, obviously groin issues. But also two, we got to be considerate of sports hernias, or abdominal injuries, or at least it possibly turned into that because there seems to be some some evidence of lack of hip functionality, creating tears in the transverse salis fascia. So he didn't have the right area for that. And I've definitely seen some sports injuries come through here. But I always like to get the hips working. So when they have an issue with the groin issue, I kind of want to see how the hips are working again. So usually I examine them first, passively, I go through the standard orthopedic and neurological testing. In his case, I really didn't see anything that was making me think that the hip was a big, big issue. I didn't really see any big issues with the spine either. So eventually, I go through normal normal normal testing of movement testing anyways, when I've ruled out stress testing of the localized joint or the muscle in question, I usually do resisted range of motion in there.

And I test out to see if there's any major issues with the cartilage, ligaments, muscles, and tendons within the area, you know. And these are big concerns for people, and I get it. And I've, I was thinking about it before, and actually going through, I have a netters on my desk for the condition around the knee that I mentioned earlier, which was the, I believe, the infrapatellar nerve, possibly, that responds well to skin lifting or dermal traction. So I have the belief that a lot of people will, they like to categorize themselves as having a muscle cartilage or joint-based injury, because it's something they can feel and gravitate to. Like, they definitely can't, I don't think they can feel nerves. And I know going through courses where we, where we're feeling four nerves, they're hard to feel. They're really hard to feel.

So I totally understand. And after listening to Andy Galpin on session number 106, we talked about what people like about syndromes. And he said that they, people just like to partition things. It's easier to understand. He was saying that Mondays, it's nice to know you do a certain thing on Monday, but in the universe, there's not a Monday. You know, there's just a day. So when people come in with these injuries, and I'm suggesting that there's a possible other thing creating the issue, such as in that first example, the infrapatellar nerve, possibly, I got to show them on paper. And I have to also, too, show them that the areas that they have a concern about are actually very low on the list of a possibility. And that's why in that case, I did an ultrasound. And that's why in the case of the posterior tibial tendon, I also did an ultrasound too. But if they're not really, if that's not something that they're struggling with, and a mental barrier for them to actually get the care that they're responding to, then I won't bother doing it. But when I go through examinations with people, whenever possible, I like to tell them the things that I'm going to be ruling out. In this case, there was not really any bruising that ever occurred in the adductor. And if you've ever seen someone have a hamstring tear, like a big one, I mean, their leg is black and blue, it even goes all the way down to their foot, the bottom of their foot, because just the blood gets taken down by gravity. And when there's not a significant bruise, I kind of wonder, is there even a tear, you know, is or is it a grade one rather than the more advanced grades? Now, this is actually a reason to why when people come in, and they've sustained like a pulled muscle, I really don't want to do tissue work on that on them immediately, because there's a chance that they might bruise. And I've definitely done this on a couple people in the past. And when if there's a bruise that forms, then who is it from? Was it from me? Or is it from the injury? And I don't bruise people a lot. But there's some people that bruise really easily. So I don't really want to muddy the water, because I want to figure out exactly how to improve how this person's feeling. Now, he actually was one that he, he felt pain with squatting, there was also he felt pain with stretching. And I suggested that to that we don't use a stretching based outcome measure to see how you're feeling and see if something's working for you in the examination. Because I mean, it seems to not really work for me. Anyways, there might be another reason why that I just don't know about. But for some reason, I just I don't like people picking that.

And also to sometimes they pick things like, well, I can I can make it hurt if I contort myself like this. I'm like, well, you're never really gonna do that. So let's not do that. You've been probably testing it that way for a while to see how it feels and see if it's improving. But for now, let's just not do that. Let's not tear that scab off that thing. So he responded really well to manually bracing the pelvis as well, similar to the first one. So taking that same approach, I looked at if there's any low hanging fruit squatting, and he really slid off of it. And also two, he couldn't squat with keeping his heels down. And we might say, well, yeah, it's just this normal tight, you know, teenage kid who hits some growth spurts and can't squat. Yeah, sure, maybe. But I don't think he should be at least sliding away from a certain side. I totally understand not being able to squat to a certain depth. And I and I typically don't force people into squatting to a certain depth, especially if they're springy athletes, you know, if they're sprinters, I really don't force them to because there's a possibility that you trigger something, you know. So there I mean, they're like, they're like loaded springs. So I as I started to work with him, I saw that he was sliding again off of the side of concern. And actually, I kind of thought he was gonna actually slide onto that side, but I was wrong. So but whatever, taking taking it in the light that it was that I saw it, I decided to pick the low hanging fruit. So we loaded the side of symptoms in this case. And it's not always that way. And he improved, he was able to squat with no pain, he can run stairs with no pain, he could run with no pain. And those are all things that he couldn't do before. And one of the things he really noted, which was the change of direction, which I know with the sport of soccer, there's gonna be a lot of that. He couldn't change direction before. And now he could. So within just under 10 minutes of doing that, actually of doing the actual correction, he was able to improve. And the reason why I'm telling you the time window was because I know that there's a lot of healthcare providers who do not use corrective exercise. And I would say, and I know I've been there that you that the corrective exercise, sometimes you say, I don't have time amongst doing all these other things. And they only have a 30 minute or 15 minute appointment. Yeah, I get it. And there's a lot of people who spend a lot longer time with their patients, which they might be taking too long, who knows, you know, there's two sides of the coin with that. I think, though, that when you find the right direction that you want to take and test the theory that you want to test or prove or disprove, then I think it's only going to take less than 10 minutes to do it. Now, the person might not respond to what the theory that I was following was. And I've had this happen quite a few times. And I remember this one girl that came in that she responded really well to, let's see, what'd she have originally?

She had, she had hip pain. And she responded really well, really well to me pushing her together in the pelvis. And then she moved, moved about into a squat and she got better. And I think at the end of her session, it was an hour and a half, I literally, I was like a kid that had all of his toys out on the ground and didn't put them away at the end of the day, or like a dog that just pulled every toy out of the toy chest. I couldn't, I couldn't get anything to stick. But when you get them to stick, it can be extremely quick. So the reason, again, the reason I say this is because you're a healthcare provider and you're thinking, well, I don't have time to do this kind of stuff. You do it, you do if you are precise with what you're testing. Don't just give them a single leg bridge just to give them a single leg bridge. And I was talking to someone a couple of weeks ago about this, that for a very long time, I, well, probably one of the first exercises that I put on video was a cook hip lift or a single leg bridge, the great cook variety. But I, I recommend it to people, but I really didn't understand why. And I gave it to him kind of as an afterthought. It wasn't in the corrective manner that I'm talking about with this. So in this case, I might've given it to test that theory to see if we can get them to load onto that hip, to pick the low hanging fruit, then to see if it improves the way his groin feels. And it might've worked. But also too, as I mentioned earlier, that the way they do that single leg bridge might be important because certainly the, the tactics that I used on all of these cases, they still, the second time they came in, they still perform the exercise poorly. And I had to correct them. They, their intention was good. They got to the ground or they got into the position, uh, very similar. I'd say about 75% correct, or at least in one of the cases, it was almost a hundred percent correct, but then the tension and the ground contact was a little altered, which then when we improved it, their symptoms improved too. So the way you do it and the way you coach it and the cues that you use for that specific person are extremely important.

So you have to be very, uh, you have to, you have to observe how the person is, uh, moving. And if you, what the correction that you gave didn't address the low hanging fruit, in this case, the squat and the offloading of a certain limb, then you have to pick something else because everything's, everyone's going to respond really differently. Now to recap these things a little bit, um, I, I guess I want to pose the question of why, you know, why were these people offloading that side of their body through probably squatting as one sitting on the toilet, sitting on the chairs. And then when you consider single leg stance, walking and running, you can look, uh, I live by Huntington Beach Pier and you can sit and look on the pier and watch people walk and you can see which sides they probably they're having pain with, or at least that they're not comfortable putting their weight on. And there's a reason why these people are doing it. So taking that process of figuring out why we can reverse engineer it. And I think we can really improve a lot of the conditions that these people are having. And in session 105, I spoke with Dr. Cody D. Mack about the, the intersection points of syndromes. And I also wrote a very long article now that you can find on my site that is hopefully in very easy terms to understand about the intersections of syndromes.

If you just Google, or if you go on the site and the search function puts syndromes, you'll find it, um, as well as the podcast that we did. And I think that when someone has a lot of these things going on, in this case, you might say that one of these people had a congional patella, maybe, maybe they had also, I know she had low back tightness. In this case, this guy had foot pain, this, and this other kid had groin pain. If this was all one person here, are you going to work directly on each spot? Or are you going to globally look at movements? Uh, as Aaron Horschig said, I think in session 104, you know, we're talking about squatting.

Oh no, session 103, maybe. And squatting or bilateral movements, uh, or at least movements that they're doing daily are good looking glasses into what we can address. And what is the most blatant thing, the most white elephant in the room could be a very good intersection point. So I know that if patients are listening to this, they might think that I, I don't squat. Squatting is not in my repertoire. I don't go to the gym and add weights to a machine or to a barbell and do a squat. That's fine. We still need to look at it because squatting is a normal human movement. And if you listen to that one that I did with Aaron Horschig, we talked about how squatting is a movement first.

It's before it's an exercise. Just some people tend to turn into an exercise and there's nothing wrong with that. I squat. Um, I squat with barbells. I squat with kettlebells and, um, I squat throughout the day. I'm squatting right now to be in a chair to do this podcast for you. So just because it's an exercise doesn't mean it's not a movement too. We should be able to do a ton of movements with competency. So I hope that was helpful in understanding, um, the possibility of why those corrections worked in cases of foot issues that might be nerve based. Maybe we don't know. I didn't confirm it, uh, with knee issues that could be nerve based or it could be loading mechanics based. Again, there was no positive MRI findings or ultrasound findings. Who knows? In the case of a two that, um, again, and no positive findings on MRI. So we don't really know what these conditions were.

And I honestly, I don't really, I don't really care what they were as long as they are. We've ruled out all of our red flags and we're getting the person to improve. Again, my, my thought process is I do suggest that every doc out there, you have to create your differential diagnosis. You have to know the things that you need to rule out your red flags, your cancers, your infections, and so on, but also to know all the musculoskeletal conditions or the local based conditions that might be there, but don't get caught too much on, on just looking at that one spot and getting hooked into that diagnosis because diagnosis are just a, they're just a collection of, of, uh, or syndromes are basically collections of symptoms. You know, there's many, there's multifactorial reasons why someone can have the symptoms that they do. And if we find the thing, the body will respond to, to reduce them right in that point, right in that instant, I think now we've got a direction to take on the rehab, on their return to play and throughout the rest of their life. Now those recommendations might vary based upon each person or based, based upon each clinician. That's okay. But I think that the, the body is in, it's interesting to me. And I don't think that any of these suggestions that I've done in examination, such as holding the pelvis or improving torso pressure or improving their basis support or, or doing, uh, squatting corrections. I don't think they're, they're not intended to be parlor tricks. They're not intended to be quick fixes. They're just testing a theory. And if we know what theory is working, then we have the responsibility to create a chronic environment to reverse, to create the reverse adaptation. The body didn't get like this on accident. It adapted to become that. And over the course of time, if you spent a year within a crooked squat, I guess, maybe you want to spend another year of working on reverse engineering that thing. Okay. Pain is probably going to be, and pain and symptoms and sensitivity are going to be the first thing to go away. Uh, I've seen people with horrible movements in theory that should be in pain, you know, but they're not. So pain comes and goes, but the movements can be cleaned up, um, overall. And, um, I think that's all I'm going to say on this podcast really. So if you guys are, if you guys like this one, tell me, if you hate it, tell me. Um, I, I want to keep doing ones that are patient friendly.

And, uh, over the past few months, I've done a lot more that are clinician based because, um, I keep running into very interesting people who want to speak on a podcast and want to be interviewed and I want to keep learning from them. So it's like, it's like free education for me. So, uh, if you guys have certain topics that you want to hear about, then tell me and I will do my very best to bring on an expert or another doc that will maybe bounce ideas off of me or I'll bounce them off of them. And I'm hoping that these single podcasts are good enough. I know the audio is better on these ones, but I don't know how it is listening to one person. So, um, I'm hoping to tell enough stories for you guys. Anyways, if you're looking over the show notes on this, um, I have actually have had a recent transition in transcription. Uh, so I have different people doing transcribing for me. So if I'm a little late on my posting of the show notes, that's the reason why. Um, but I'm doing my very best to get them together, um, within a reasonable amount of time. And I make every attempt to be months ahead on these podcasts and, and as well as the, uh, transcription. So I'll do my best. And if you're looking for the show notes on that, just go to, what are we going to call this one? We'll probably call it a crooked squat. So if you look up crooked squat on my, uh, p2sportshare.com site, just type it in the search bar or just look up number one, one, one. Don't even put a number sign before it or a pound sign. Just put one, one, one, and you'll find the show notes to this podcast, which is 111. We're coming very close to, uh, 112, the players club podcast coming next.