E53 | Keep It Real Talk #5: Hip Impingement & Knee Valgus
On today's episode, Greg, Doug and Trevor #KeepItReal while talking hip impingement & knee valgus.
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Episode Transcription: Welcome to the Resilient Performance Podcast. This is keep it real talk number five. And we figured it out. Trevor, last time we had no idea what it was. I think it was four. So this is five. Uh, we had a couple of questions come in. Recently from our course or from, you know, just other, other people, sending you questions from listening to our podcast. Um, one was about just wanting to talk about hip and pins so we can go over that. And I think it's very relevant to a question we got from somebody who's, um, on our course, uh, recently bought our course and had a, had a question about, um, the biomechanics of. A rotation when you're going into squatting change a direction, really, anything athletic, um, any of the gym movements we can talk about and why we're looking for hip internal rotation, adduction with some of these things, um, and then why we might want for our nation at the foot. And I'm assuming they're talking about in the question as well, and then relating that to a knee valgus, right? Cause that's always something that. That's a common thing that we hear on our end course is, you know, being worried about ACL terrors or knee valgus when we're trying to improve femoral rotation, specifically internal rotation or abduction, because that's sort of just lumped into like knee valgus, which, you know, isn't really what we're, what we're going for. And it's actually, we would say if you're lacking rotation and abduction, you would have probably more knee valgus when, you know, when you need to access certain movement patterns. Um, uh, of a field report or whatever it is, but, uh, how do you guys want to start this off? Anybody wanna just take a, take the mechanics? Uh, you talk about how that femoral head's moving real quick and just keep it general. We don't have to go too crazy with it, cause it is more of an audio format, but, for hip impingement, a good place to start is kind of to like to define it obviously, but yeah, it's a real thing. Right. But I don't, I think like a lot of other things in medicine, it doesn't matter until it matters. So what I kinda mean by that as alright, like how we're defining hip impingement defined medically is, you know, you've got a bony approximation between the femur and the acetabulum, and then, you know, whether it's genetic or depending on the stresses imposed on that joint, you get increased bony overgrowth either on the acetabulum on the femur or both. And that's, that would be whether you're going to cam lesion, pincer lesion mixed, and then you know, that bony approximation and laying down more bone on either of those, um, you know, on those sites. Can create symptoms in the hip, usually a pinching sensation. And then I guess, you know, like I actually don't even have the, I like how it's the different degrees of impingement or classified, but I would imagine that the, or the more bone that's laid down, um, you know, that would be considered a more severe impingement and a radiologist is going to have their own definition based on like what they're looking at on an XRA. I mean, we're as physical therapist focused, focused more on the functional aspect, but I mean, as we know now, because of the increased utilization of imaging and the increased sophistication, that hidden impingements are more common now with that labral tears. Now, are they more common because they're truly more pervasive or is it because we're, we're looking for it more, um, Probably a combination of both, but I think it's more than likely if we got to pick one or the other it's because we're looking at it more and you know, like anything else, the more you look for things, the more problems you can find. So I say it doesn't matter until it matters because we get a lot of people that have been diagnosed with FAI or hip impingement based on, on an X Ray or an MRI. Um, and a lot of times it's, it's a great like fatalistic diagnosis. It's like, well, you have these bony changes. Therefore, like, you know, what's a general, you shouldn't squat below 90 degrees, or there's all kinds of things that you shouldn't do based on that x-ray and like anything else in medicine, the imaging should correlate with the clinical symptoms and the subjective findings. So a lot of times like people, they have a pinching sensation with deep hip flection or internal rotation, they have a bony change on an X Ray, and then it's like, well, based on these two things, You shouldn't do X, Y, or Z, but it's very fatalistic because if you have FAI on an xray and like, let's say a big thing is like that, um, that rock back test, you do a rock back test and it's like, now this should be your squat depth. It's like, okay, well, why don't, why don't we even have a job before saying, you know, you do a rock back test and now you should, you know, externally rotate your feet, make your, your, you know, your knees wider when you squat in assumes that like you can't change. Right. And that's why I said it doesn't matter until it matters because with the right interventions, you can get some body with Arthur, you know, with bony changes on an X Ray or an MRI to squat deeper, regardless of what that rock back test is, another thing is like, okay, you put somebody on their back, you have them internally rotate at 90 degrees of inflection. They get, you know, zero or five degrees. And it's like, Oh, this is really bad. But like that, that, that can be changed. And that's why I say it doesn't matter until it matters because. I'm telling you try stuff. You don't actually know that FAI and the x-ray is meaningful. Well, like if you can elicit changes, if you can get somebody squat deeper, or if you, if you can improve their internal rotation, if you can improve their, you know, their squat depth, whatever, and not, not increase their symptoms. Then it's just a label. It's not a true diagnosis. So to me, FAI only matters. If the only thing that's going to help somebody is to shave off that bone shape, change their anatomy. If you can get somebody to squat, deeper, improve their IRR, improve their symptoms, improve their quality of life without surgery. Then it's an FAI. Really? Isn't the diagnosis. It's something else. It's motor control. It's soft tissue influences it's technique. And so we got a lot of people right. Where we don't even do a rock back test, because I think that it's meaningless based on your, based on your blog though, and really should bother. Right. Right. And we do, we should put this in the notes because I'm going to write it better than I can say it. But like, if you, if you have somebody squat with an anterior, a little like a goblet squat, a researcher, and they can go to full depth without any pain. Then did they truly like was the bony anatomy? Was that really the, the driver, like the true pain generator or the true thing that needs to be addressed clinically? So there's so many things that can influence things like squat depth and internal rotation, not just your, your anatomy on an xray, because that anatomy, anatomy, I mean, it's racing a snapshot in time. Just like that rock back test. It's a little bit more of a dynamic snapshot. But it doesn't account for all the things that can influence the relationship in that joint. So, um, I think that, yeah, you know, we hear a lot of things about like, here's how to determine the best squat that you have Scottish ship. I think like the amount of people now that have been told they can't squat because of Scottish. Yeah. Now it's like, I get that. We have to respect anatomy, but I think now it's been, it's been kind of used as an excuse to. Not know what you're doing clinically. It's like, Oh, they've got a scholarship. They've got FAI. Like they shouldn't squat when like, you know what, presumably what should make physical therapy, a valuable profession is that like, we can have people do what they do, what they enjoy and get them to squat, or do certain things in spite of that anatomy. Or obviously we're not trying to jam somebody into a deep squat if they have symptoms. Um, and there are certainly, there are certain, you know, if. That's that's why, like, if you have interventions that are, that tend to be helpful when you do those interventions, you may, and you make no change. Now, you know that maybe it is more likely the anatomy that's driving it. I mean, there are certain, if you assess enough hips, you know, after a certain time, like, wow, this feels like such a bony end field, no matter what you do, it doesn't change. Then maybe like the anatomy is the influence, but. Um, with this FAI stuff, I think, I think it's over diagnosed now. I think we need to be like respectful of it, but if we're this, this fatalist, well, you've got FAI on a radiograph or, you know, you have, you've got pool or internal rotation on the table. We still have try stuff. And if we're not trying stuff, then it's like, why don't we even. Like kind of have a profession in mind. It's like, why would, why would a, why would a hip surgeon or someone sends someone to physical every first? Anyway, if that's actually the true reason why they're having issues, it's like, well, we're not going to cut them open and fix it. We can do other things to improve that, which is like, I'm thinking about my, my, uh, case study that I wrote, like years ago. We should put that link in there too. Just about like, this is some things that we did that it proves this guy squat, that, and it was pretty dramatic. It's not how it always is, but it was just an interesting case because it was so such a dramatic change for someone who was told like, yeah, you should never squat deep ever again. And he like wanted to do some sort of like military. Special forces thing or a, it might've been like a law enforcement special, special group or whatever, um, selection process. And it's like, you need to be able to do certain things. Oh, we were able to make some cool changes, but yeah, I think with the hip impingement impingement to a certain degree, isn't normal when joints get to their end range position, and they're going to, something's going to stop it from going further, whether it is soft tissue, whether it is a bony block, just because you experienced a bony block, like you Doug's, like you said, Doug, it's a snapshot in time, whether it's an X Ray or whether it's. A body weight squat during an assessment, it's one movement. So when we take one piece of information and then we try to generalize, that means all of these different things and it becomes fatalistic. That's when I think the problems occur, especially for clients. Cause then they do become afraid to do whatever it is. But when you can give somebody an intervention that frees up the range of motion, or they impinge later in the range of motion, then that's a good thing. Then I don't think that that bony block or that cam punishment. And there's our cam impingement is what is limiting the range of motion. Like we always talk about, it could be a positional issue. Their doorframe could be out of alignment, and then we're going to give them some sort of intervention to realign the doorframe. And if it still doesn't work, then maybe we need to oil the hinges or apply some other secondary intervention to get them to achieve their functional goals. Which again, like you said, it's. Getting them to squat in the move, getting them to be able to do what they want to do. Pain-free and without any sort of irritation is always our number one goal. And I think like always knowing that's a snapshot in time, regardless of whether it is. Like so many people all have a terrible squat and because they do a body weight squat, and they're not good at body weight product, but you give them an anterior load. And the squat what's really good. That doesn't mean that they're bad at squat. Maybe that strategy for them is not their best strategy to squat. And that's okay because everybody moves differently and everybody responds, you know, um, forces or external loads it's differently. So it's understanding how can we give them a better strategy to do what they want to be able to do. Yeah, that goes back to like, this is, we're talking about FAI as a, as like an example, but this goes for like anything, like I'm having conversations about this stuff with patients all the time where it's like, Oh, you don't have a bulging disc. Or like, I have, you know, I have like framing of my supraspinatus or whatever it is. It is like, it's like, yeah, like that's, you know, that's what shows up on the MRI or the extra or whatever, but like, there's, that's a snapshot and there are things we can do to make you move differently. Um, so that's exactly like make it not matter. And that's a conversation we'll have with people all the time is like we're in the business of making things not matter. So you can do the things that you want to do that do matter. Um, and that's sort of like the conversation I I'm often, often having with people, um, But, uh, yeah. Anything else you want to jump on? I think it does. I mean, it can matter, right? Like it doesn't, but it doesn't matter until it matters. And that's why, if we're just going to say like, okay, people who have FAI on a, on an X Ray, shouldn't do all these things, then why are they going to physical therapy anyway? Like, what's the, sorry. I mean, cause it's like, okay, for that fatalistic, then you're either going to have surgery to change that anatomy or you're going to say, okay, like, well, based on your anatomy, we're going to teach you a compensatory strategy. Um, you know, so maybe it is like, you know, externally rotating your feet. But I think to, just to assume that everybody with FAI needs to externally rotate their feet, widen their stance, all these things, without trying other things first, I think is doing the patient a disservice because I mean, I think when it comes down to a way to reframe the question is like, when was the last time you guys had somebody. Who was diagnosed with FAI and after everything you tried, you're like, you know what? I don't think anything is going to help, except you going to a surgeon and having that anatomy change. I probably had, I think two people in the last, like three years, I felt like there nothing I can really do to help you, if your goals are certain things, then like the only way to get a bed to get the result you want is to change your anatomy. That's pretty infrequent. Like the, the, the numerator is really, um, really low and it's really a big denominator. I would say. I would say that I have one person in my head that I remember him coming in and somebody who has their hands is that far. And using the hip specifically is that far, you know, Down the road to a hip replacement or some sort of, you know, inner, like extreme intervention. It's usually pretty obvious. Like it's not, Oh yeah. My hip hurts when I squat and it bothers me a little bit. It's like, it hurts all the time. It hurts when I sit, it hurts when I do anything, it doesn't even matter what it is. And even during our, during our orthopedic assessment, like they have zero range of motion. I can't get them. They usually don't. Aren't limited with just flexion, adduction, internal rotation. They're limited with like, Everything, whether it's abduction, Exxon rotation, extension, nothing feels good. And they have just a serious set of symptoms that are way more than what a typical, you know, I feel a pinch in my hip when I squat presentation is. Yeah. And the one example I'm thinking of was a, like a high school hockey player. And he had all, he already knew that he had a torn labrum and he had some bony changes. It was something that was like, he's trying to delay it and kind of push it, you know, as far back as he can, because he sort of knew that he wouldn't be playing too much hockey, you know, as the ages maybe. Um, and that was something where Trevor and I both worked with them a lot throughout the, like his entire, um, senior, maybe junior year, a little bit too, but for awhile, we worked with them through the, throughout the season to sort of keep them, keep them feeling good enough to keep playing and, um, I did pretty well, but he wound up having done the surgery and that was somewhere it's like, yeah, like eventually, like this isn't, this isn't just going to go away or get better. But, um, you know, with all of the things that we had done, we can keep you in one piece for now. Um, but yeah, it's not very often Doug and yeah. I mean, that's the only one I can really think of. And in the last year, Yeah. And if we're just saying that, like anybody that shows up that has like torn her rotation, we're just going to say they have a hip impingement and just throw our hands in the air. I think, I think it's like, it's kind of lazy. I mean, pathology is a real thing and has to be respected. And I think there's a flip side where there's, you know, there's people walking around, like, who do you have? Like, you know, disc herniations and nerve root compressions. And it's like, Oh, we're just going to like bio cycle, associate social you out of that. Like, no, you're not like that's real pathology. Um, but you know, I think that a lot of this stuff with the hip is new. But it's really not new. Right? Cause like the hip is pretty similar to the shoulder. And when somebody like is lacking IRR on the shoulder, we don't say like, okay, we gotta go have surgery for your shoulder. Impingements like, you try things to get it back. But because like this FAI stuff and the imaging, I think just is, you know, it's a little more novel than some other joints. I think it has to catch up the thought process has to catch up, but it really shouldn't be that much different than like what we do in the shoulder. And I don't think we're as fatalistic with the shoulder as we are with the hip. That's funny. Cause I would actually think like the opposite. I feel like the shoulder to me is more complex than the hip. I feel like there's just less stuff that can kind of move on its own in the shoulder. Like the staff. Yeah. Just kind of adds more complexity to it, but yeah, I mean it's. It's uh, it's interesting. It's interesting to hear you say that, but yeah, then like there's a, there's some research that's old by now. I'm sure that Trevor goes into in his section, in our foundations course where like, just by changing the collect position on a table, like people were improving by like, I don't know the exact number of sub 15 degrees of internal rotation. Yeah. When the normal normal might be four days. So if you can get 15 more, like that's enormous for somebody, especially if they have zero and you give them 15, that's like a life changing thing for some people potentially. That's where looking at anatomy from a image we think it's fixed or that's kind of what has been been, you know, um, talked to the medical community and to patients is that you are, this x-ray, that x-ray does not change. Versus when you look at the research or you look at just how people move, like. Bones and muscles and tissues and stuff are moving constantly. So I've been saying this whole time, if you just taking a single snapshot snapshot in time in generalizing, the rest of what's going to happen for them, it's you're doing the patient a disservice. Yeah. So I think we kind of beat that to death, hip impingement a little bit. That's awesome. Um, but going off of, is that something we're always trying to improve with hip impingement or typically it's internal rotation, flection and adduction. Like, those are the three things that. Tend to be, you know, pain generators for people who have any sort of actual labor terrors, FAI go, any changes, um, that we're trying to help people with. And that was the other topic of the question, right? Was how are we, what are the biomechanics? What are the things that we, uh, we focus on for like, we want to improve these moments because somebody is lacking in, right. And then comparing that to knee valgus. What do you guys want? Just kind of jump in and talk about. How we might define the valgus. Um, and we're talking in with Aflac, I'm assuming we're talking about like ACL tears in an athletic population because that's 95% of the time. What people care most about with the valgus, but take it wherever you want to go with it. For me, knee valgus is. A true frontal plane and rotational torque at the knee. It's not just kind of the way it looks. We're where people think if the knee is inside of the hip, that that is the Valdez when that's not necessarily always the case. Um, so if we go into those motions that this question was asked of hip internal rotation, which goes along with hip flexion with add option, knee flection and ankle, dorsiflexion of foot pronation, that's just a position of loading. And if you're missing range of motion, At one of those joints and usually it'll be hip flection or ankle dorsi flection. Then the knee is kind of stuck in the middle and has to compensate for some sort of a force. That's not being able to be handled or distributed by it or to the ankle or to the hip. So that's when we see that, you know, typical like knee abduction with tibial, external rotation and femoral internal rotation, which causes that like medial force and rotation that we. See people have all the time with an actual ACL tear. Um, so kind of globally, it's like, we want to make sure people have hip flexion, adduction internal rotation, which is why, what we were talking about before with yeah. Hip impingement. When the hip is in a position that limits hip internal, that's something that we want to make sure people. Can control and are always relying on sh or using a strategy that limits hip internal rotation, which is that over back extension, anterior, pelvic tilt, all that kind of stuff that we go into. Um, but I think like the knee being inside of the venue, being inside of it, which made it look like valgus is a normal thing. So we look at somebody who's in a single leg stance pattern to be able to stand on one leg. Your foot hurts has to be underneath your hip hazmat underneath the center of mass, which means our pelvis has to rotate. Our knee has to come in a little bit. And we're keeping the foot or sorry, the foot underneath the knee, which is typically inside of the hip. So that may look like valgus kind of statically, but it's not actual valgus. That's just a little bit of hip internal rotation at the pelvis as we're rotating in the closed chain, along with a little bit of knee flection and ankle dorsiflexion and foot coordination. Yeah, exactly. If you aren't using the range of motion and able to get it in other places, that's what we see now, us as a compensation. Right? So if you're going to go shift your weight over to one side in an athletic movement, let's say, and you let's say you're lacking a hip internal rotation, which you kind of need to get your, to get yourself over to that side. Uh, let's say you have five degrees of it and like you're required to have 15 or whatever who cares what the numbers really are. Um, it's almost like you're impinging, so to speak at the hip and you're taking up all of the range you might have there. So then you're going to have to find another way to get your knee underneath the view underneath your center of mass. And the next best thing might be to just gap the medial part of your knee to actually drive your knee inward, being what we're talking about it as like the knee valgus position or the knee valgus, you know, like. Like another death sentence, right? Like you can't have any new values, um, even going back to like squatting. Um, that was also part of the question too, was even just talking about like gym movements, right? Like, cause that's something where, you know, if you look at some of the squat, you're not necessarily seeing them. Uh, like their needs, not coming into the middle of their body. And that's something that we're trying to do. We're not having, having people squatting with their knees driving in towards each other. So maybe Doug, you want to just talk about that? Um, taking a more, you know, Jim centric exercise and why we're still chasing internal rotation and adduction reflection. Yeah. And first, let me just piggyback about, about cutting. So there's no movement that's like inherently bad or good. I mean, we often hear things like. Internal rotation of the hip is bad pronation of the foot. It is bad, but avoid extremes. Like if you had no pronation at the foot or no internal rotation at the hip, like you wouldn't be able to change direction, you wouldn't be able to reload and absorb force. Um, so like, if you look at the foot, like, A little bit of pronation is good because it acts as a shock absorber. It helps to create kind of, um, like an elastic component of the foot. So that now when you go to supinate, you've got this elastic component and this sort of transfer of elastic energy. The problem is if you pronate so much, but now you're like in this absorbed, just you overly absorbed to the point that you can't generate propulsive force. Now you're, you know, you, you create like an instability, same thing with the hip, right? Like if you. Have so much internal rotation that now you're lacking stability. And now where's your body going to find stuff ability. If you have too much internal rotation, you might try to find out by protein too much at the foot. You might try to find it by, you know, generating too much torsion of the need. And that's where you get in trouble with like at the knee with ACL. It was like, when you have you lose stability right now, you're instead of having this. Active motor control. Now you're at the last line of defense, which is your ligament, your joint. And when that fails, then, then your joint fails. And then you're, you know, you're in the operating room. So we need internal rotation at the hip. We need pronation at the foot. We just don't want to have so much of it. But now we have a lack of stability because if we absorb so much force that like now, how do we, how do we generate propulsion? If we have to get into these end range positions? At any joint, whether it's the foot or the knee to try to create stability and get out of these bad positions, then, then we're in trouble, but we need internal rotation. And if you don't have authentic internal rotation, that range of motion is not available to you. Like if you have none, then we're like, where do you get that? How do you absorb force? You have to get it from somewhere else, like Trevor said. So, and it's one of those things where, you know, I don't actually. If you asked me to technical definition of valgus, I probably get it wrong. Someone's going to look at a research paper and tell me that it's wrong, but you know, you know, good, you know, what a good position is when you see it. And if you look at like somebody cutting or changing direction, there's always internal rotation, but we're, it looks bad as when you look at that Nene looks like there's torsion at the knee. There's a ton of proport of a foundation of the foot where even in a snapshot, you're like this person is such an end range. I don't know how they're going to get out of that. Um, without doing something weird and that weird thing is usually putting a joint at risk. So that's kinda like, you know, the valgus propulsion loading to explode kind of a thing you need to have all these things and be able to control it with regard to, to squatting. Like, like you said, Greg, I don't think that we're visibly observing internal rotation in a squat, but I think the ability to internally rotate is ref reflective of the hip health it's necessary to squat. So. If somebody, you know, typically people who like have terrible internal rotation can't squat well, um, or if they can, you're wondering, you're wondering how they get it. And the ability to internally rotate and flex is reflective. Yeah. I love, you know, a hip capsule that where you can get, you know, posted your translation of the femur, which is going to prevent some of that impingement when you get into deep hip flection. So we don't expect to observe, you know, at least observe a ton of it. Internal rotation during a deep squat, but typically people who have internal rotation available or able to get into that position, at least at the hip. And then assuming that things, you know, they have the deflection at the ankle and the knee, they can get, they can get a deep squat, but we want somebody to have that internal rotation available because then they're more likely to squat without some kind of the compensatory strategy like impingement. Right? So it's like the movements that you need to get into a SWAT that are happening at the femoral head. Yeah, you want it to be able to slide post the early, you want it to be able to rotate and those things go together. So those are the things that we're, we're trying to improve maybe with some of our table movements or giving somebody a stretch or some sort of lower level exercise to kind of give them access to those positions where they can do it then on the table. But then they're not going to go and like, you know, go to enrage interpretation while they squat. It's just giving them space in the back of their hip to get into a Jeep flex position. Yep. And then, uh, that just makes me think about, you know, talking about FAI and you had Doug spoken about recently and the whole, like don't translate your knees forward past your toes when you squat thing and how common that is. And it's like, if somebody's told that and they're going squat, one compensatory strategy is just to arch your back and then you've got hip impingement. So it's like. Pick your poison. Do you want to load your knee or do you want to create some hip pathology? And we've had patients before where it's, you know, they come in and they've been told that with good intention, but it just take that coaching cue away. And all of a sudden their hip feels good and it's like, all right, so you just need to do things a little bit different. And that's a great point. That's why I think the rock back test is like kind of a waste of time, because first of all, you're not, you're not weightbearing. You're not on your feet and your knees can actually go forward when you're in a rock back test because. They're in contact with the ground. So it's like, it's almost like, okay, we're, we're squatting with a, a vertical tibia. And if you squat all the vertical tibia, it's more likely you're going to have to go into an anterior tilt to maintain your balance. And then we know from the research paper, you referenced that the Trevor has in his portion of the course that now you're, you're gonna, you're going to lose internal rotation and flection. And you're more likely in a mechanism. A lot of times for hip impingement is. The, the inability to get out of this anterior tilt and to control it and just getting somebody into a posterior tilt allows people to get more hip flection, more internal rotation. And how do you get a posterior tilt? You let your, you bring your knees forward. Um, so even without making any changes at the hip, if you have somebody squat and let their knees go forward, you might reduce some of the impingement so that it wasn't always the pathology that was preventing that deep squat. Like, how are you squatting? You just don't lecture them on. Don't lecture them on flying if they, uh, cause that question asked about the queuing for those different things too. Right? Greg, uh, let me pull it up real quick. I think it's, uh, I'm interested to hear more about the biomechanics surrounding the need for femoral interpretation during squatting jumping, cutting, differentiating, and queuing for those movements versus unwanted move out gets. I think so much of it from a human standpoint is not queuing and just putting them in positions where we're going to elicit the movement magic that we want, which is why we always choose from a squatting standpoint in anterior load versus a back spot for 99.9% of our people, um, is again, it takes away the need for us to coach and helps them get into a position where they're going to use a better strategy. That's right. Getting him to distribute stress over multiple joints. I think we would all agree anything that is going to be relatively high force or high, low. We want people to distributing the force and the stress of that over multiple joints, over telling people to not let the knees go forward. Then we're limiting how much they can use their ankles, how much they can use their needs. Well, how much can they use the calves and their quads? Um, and same thing with, you know, so many athletes are taught. When they're playing defense in sports, and they're going to an inning in an athletic position to keep their chest up where their strategy to keep their chest out. Well, there's two cues to either keep your chest up or get on your toes. So their heels are off the ground. So both of those strategies kind of limit what they have access to and it's going to make them use what we've been talking about this entire time of that, more of an anterior pelvic tilt back extension strategy, where they're not going to have access to good ranges of motion that they need for the different movements that they're going to be able to do. And then, uh, I was just going to sit, I'll let you go Doug. More about like what you don't say. Like, if you tell somebody when they squat to, you know, big arts, stick your chest out, you're going to make it here. You're that, that, like, if I was thinking like, right, what cue would I use to try to, um, encourage a hip impingement? It would probably be that it's probably the number one cube now, you know, and we're talking about like, At clinical population athletes who use a squat as a means to an end of the field. I'm not talking about, like, if you want to squat a thousand pounds, like kind of disregard what we're saying. Cause then it's about like, that's about performance. You're willing to take a little bit like compromise health to achieve that, to put more weight on the bar, but from like, if you're just squatting as a way to strengthen your legs for sports, I. I wouldn't use the cue chest out. Right. That was actually what I was going to start talking about. Go ahead, Trevor, go ahead. No, it doesn't say like there's so many cues like that, just like the don't let your knees cave in thing that we give as the teaching cue, not as acute or fix something that causes the problem. So instead of just giving somebody a weight and telling them to squat, or sit down, stand up or whatever, kind of just basic overall things be. Teach them how to, Oh, we're trying to teach them how to do it before they even try to learn how to do it themselves. So it's the same thing with that, like that the knees. And it's like, I don't want, I agree if I don't want some of these knees touching when they're squatting. But if they're squatting and their knees are just going forward, don't cue their knees. Let them just keep doing what they're doing. But instead people say, keep your knees out. So people who have their knees straight ahead, then start trying to drive her knees out as hard as they can. People who are squatting with a good back position, sort of arching their back as hard as they can, because that's just what they've been told. There was a of test out. Cause if I've see if I see somebody folding in their squat and my chest is parallel to the ground, I'm going to tell them to keep their chest up without a bed cue. But that's not the cute we give to everyone all the time. Right. And then that was what I was going to go into Douglas. Uh, like I don't work too, too often with powerlifters. It's, it's pretty infrequent with where I'm at. You probably see more powerlifters than, than Trevor and I, and that's probably, you know, maybe a conversation that they have to kind of have with you is like, okay, well, my, my sport requires me to keep a vertical tibia as much as I can and just try it, you know, hit that, hit that point and then get back up. And I'm doing this with such maximum loads, like. How do you talk to a power Lister about the stuff that we're talking about right now? Um, well, I mean, it's, it's easy to get buy in when they see, because usually it's because like something hurts, but, you know, I work with some powerlifters who were like really, really competitive in their weight class. I don't generally try to change their squat. And this is what you do is when you enjoy doing. But I give them things to do that. Whether or not squat, like I want them to have it a different strategy. I mean, we could, we could start with like, how do they test on the table? Because if they're missing key ranges of motion on the table, now they don't, they don't have the option to squat a different way to do a pluggable. Like self-organization like maybe, maybe they're squatting a certain way because they have like negative hip internal rotation. If I get them to five degrees or 10 degrees or even zero degrees. They might not even think about changing their squat, but they'll feel better just because they have more range of motion in their hemp available to them. So I want to make sure that they have the raw materials, the squat and the raw materials for a powerlifter are much different. My expectations are much lower than what they would be for like a field sport athlete. I just, I don't want you to have like, Negative internal rotation. I want, you know, I don't want you to, you don't need to have 40, but if you have like zero may, if I get you to 10, like we're doing a little bit better. So we'll start with like, do they have the raw materials? And then if, especially if they're competitive, I'm not going to try to change their squat. But I might say like, look as an accessory movement, maybe do like a two kettlebell front squat, or is your at squat because a lot of these athletes, these athletes, these lifters are doing like. Ex, you know, accessory movements where they're like squatting and doing it, like we're trying to get more volume and I'm like, look, excuse me. Maybe when you're trying to get more volume, use a different squat, just so that you're, you're stressing your hip in a different way. You're, you're not in as much of an anterior tilt. You're getting to a different depth to preserve your, your hip health. And then they might even say, okay, like, all you ever do is like sagittal plane, you know, like maximum effort squatting, like. Just like once or twice a week at a single leg movement, you know? So I'm giving them a little bit of variety. They're going to do accessory work. Anyway. I might try to get them accessory work in like in a single like exercise, or maybe that's not as sagely dominant. And hopefully that gives them enough kind of bandwidth because specialization, I think is like, you know, that's where you get in trouble from a health standpoint, it's like, you're so adapted to do one thing. Well, it's what helps you perform at a high level, but. If you get to the point, we just can't do anything else. Now, your, your bandwidth from like a health standpoint is very low. So if we can expand that bandwidth, like I'm not, not a lot, a little bit, maybe allow them to compete without as many symptoms without having to change their squat, because that's generally the last thing I'd ever want to do with somebody who is competitive. I was wondering if something like that with, and not necessarily just power lifting in general, but just, you know, with, I guess probably is a good example of it, where. Are they is the strategy is a strategy in the position, meaning the feet with feet turnout, all that different kinds of stuff. Is that the strategy that they were taught by their coach, because that's what their coach has just kind of been taught how to do, or is that the strategy that actually works best for that person based upon their mobility and range and, you know, actual physical constraints and strengths. Um, so that's always just something I think about. That's just an interesting, um, Like almost rebuttal to that, is that, is that person actually using a strategy that is best for them, because again, like so many people don't have that much abduction, but they're taught to squat and this crazy, crazy, crazy wide stance that limits how much they actually have to go down. But maybe if they tend to feed up, not inside their hips, but just two inches on each foot that can make their, that could make their hip pain go away and against those keep, keep their big squat numbers. Yeah. And it's like, you know, why do people like arch their back and a bench press to reduce the travel? You know, the distance, the bar path, like with a wider squat, you don't really have to squat as low to, to hit your, hit your depth, the bars, and moving as much. But I think it's a great question I would look at, I think it's both, I think like, If you look at the world record holders in a squat, it's unlikely that they like their, they have this really terrible strategy. They're only doing it because their coach told them. Right. Right. So like, I think the best squatters in the world from like a, not from like a aesthetic standpoint, from like a weight standpoint, they are squatting wide. So there's something to it. Um, and so there's a reason why, like, if you want to set the world record in the squat, you're not going to have like a narrow stance and put into a front squat. Um, so I th I think, I think it is both. We have to dig deeper and figure out like, all right, like you said, maybe they're going wide, but if they're always hurt, if they brought their stance and an inch where they feel better without compromising the weight that they could, they could put up. And that's where the trial and error kind of comes in. Like, the last thing I want to do, like I said, is, is changed that stance that they're successful. But if you're always hurt that you're not successful because you can't compete. Yeah. I think that's a good point. I mean, you said that when you first started, this was. They're coming to us for pain initially, which kind of almost changes. The entire, and it's not like they're coming in and like, Hey, I feel great. I'm just trying to optimize my movement. And you know, my knee bothers me every now and then or something. So we're doing more maintenance stuff to keep them healthy. If they are injured and are not healthy and cannot compete, then maybe we do have to not necessarily completely, you know, Reteach their squad or anything like that, but maybe we are looking a little bit more at the strategy that they are choosing and see a thing. Seeing if there is some little small tweak that can make a big difference for them. That's not completely starting from scratch. Awesome. Anything else you guys want to throw in there for hip impingement or knee valgus? I think it's like, you just don't know until you try stuff. That's it's like, it's hard to say like, If you see this, you should do this because there's so many variables that can influence, like you might not have to change someone's squad stands, or you might try everything. And the only thing that makes them asymptomatic is to narrow the stance or turn their feet out more, whatever it's like, you know? So, um, performance is important, but like I said, if you can't compete, then it doesn't matter. Like how well you perform when you're healthy. If you're going to miss your. Your competition. So like, what do they say? Like availability is the best available ability. It's kind of true. Um, it's a fine line because, you know, and if you have too much bandwidth that you're not going to be good at your sport and powerlifting is a very specialized sport. Um, so yeah. Yeah. Awesome. Cool. I think that's good. That wraps up Keep it Real Number five. Perfect. Um, That's all we got. Hopefully we see you guys again soon. Thanks everybody. Thank you. Thank you for listening to the resilient performance podcast. As a thank you for listening, we'd like to offer a 10% discount on our online products, which you can [email protected]. We'd like you to use the promo code podcast, P O D C A S T to get the 10% off right now, we have the resilient movement foundations course, an online format for you to purchase there. 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