anatomy in motion Archives | Page 3 of 3 | Monika Volkmar Bodywork and Movement Education

Removing the System’s “Handbrake”

A tale of navigating pain, with me, Monika. Our special guest for today is L.

L is one of my personal training clients. She is a badass 59 year old lady who has been slowly unwinding her body from a state of chronic pain over the past two years.

Last week she came into our session with a neck pain flare up. It hurt to tilt and rotate her head to the left. L usually likes to train hard, bust out push-ups (she can do 6 now!), and get a sweat going, but on that day she just wanted to be able to move her neck, so that became our focus.

Image result for your inner physician and you Concurrently to this story about L, I was reading John Upledger’s The Inner Physician and You in preparation for taking the Upledger Institute’s craniosacral therapy level one course (stoked!). Reading this book was fortuitously timed, as I began to observe some of its main themes surface in my bodywork practice. In particular while working with L last week.

The aforementioned themes, fresh in my mind from reading Upledger’s book, that seemed to over-arc this session were:

The individual is his/her own healer
We all have an “inner physician” and “censor”
Until the “root cause” is identified, the same symptoms may keep returning

Nothing new, I know. But sometimes these truths don’t sink in until we’ve had enough experience of them. The timing of L’s neck pain was a gift to me in order to better explore these themes in real life.

How do you even shoulder-check?

L’s neck pain had been present for a long time at a low level as general stiffness, but last week when she came in it was bad enough that I wondered how she had even been able to shoulder check as she was driving over to see me.

As a side note, the thought occurred to me the other day: How many car accidents are caused by people with left side neck pain who can’t shoulder check?

I asked this same question to a client of mine a few years ago, “How did you even drive here if you can’t move your head to the left?” His answer, “I don’t need to, I drive fast…”. Please don’t be this guy. Take care of your body and be less of a danger on the streets.

Anyway, back to L. Her history.

When I first met L she had two bad knees (one had been operated on), thought she was going to need a cane to walk, couldn’t sit cross-legged because of her painful knees, and couldn’t lift her arms over her head due to shoulder pain. You could say she’d gotten her body into a bit of a messy spot.

Today, L can squat, lunge, sit cross-legged comfortably, lift her arms up and hang from a bar, and best yet, can do 6 full push-ups. She’s come a long way.

The main issue that initially brought L in to doing sessions with me was her right knee. She’d had surgery on it when she was 19 and, like any normal 19 year-old, she didn’t put a lot of thought into the recovery process.

A few weeks ago I asked her how she’d rate the care she received for her knee, and she said, “I was 19… So. Yeah. That.” Like most of us at that age (or at any age, let’s be honest), she had probably rested until the pain went down enough to start walking on it again without a lot of value placed on doing any sort of rehab exercises to regain full motion at the joint.

If the symptoms disappear and you can get around well enough, no more problem, right?

And then if you develop neck pain 40 years later, it’s probably not related, right?

I will admit now that I too am guilty of this way of thinking in my previous work with L.

I ignored a problem

Very shortly after L and I began working together, her knee pain stopped. It was that dang Anatomy in Motion stuff– It really simplifies how to work with knees (and the whole body, really).

After her pain disappeared I reassessed her knee and saw there was still a movement issue: Her knee was stuck in an externally rotated position (tibia pointing out farther than femur), and her knee seemed to not have any transverse plane movement when she bent or straightened it (which we should be able to see and feel in a healthy knee).

But because her symptoms were gone, and any time we tried to feed what I felt to be “appropriate” movement into her knee, it felt painful. So, like any trainer who doesn’t want to lose a client because we keep doing stuff that hurts, I decided to ignore it. And we did that for a year without her complaining about her knee again. I thought this was good, and that the problem had taken care of itself.

Until last week.

Time doesn’t heal, healing heals with time.

Can we experience healing without pain?

Here we see surface an intriguing point of learning from Upledger’s Your Inner Physician and You. Upledger described several phases of an acute healing process. He describes, in his hands-on work, a “therapeutic pulse”, a “release of heat”, a temporary increase in the pain, and then relief from it. He says that this increase in pain is a part of the process, and it always subsides if the work is brought to completion correctly.

This has me wondering, what if, in the moment of doing the appropriate healing work, the increase in symptoms is necessary? When I stopped moving L’s knee because she reported pain, was that something to move into or away from? Healing or dangerous?

If it is true that a temporary increase in pain is part of the healing process, yet many of us avoid moving into a problem because it temporarily hurts, it is no wonder that we get ourselves into increasingly messy spots. We choose comfort over truth and deny ourselves freedom and ease.

But of course, it is hard to know whether this is true. Upledger was describing craniosacral work which is a gentle manual therapy. Does the same apply for movement?

Of course I mean moving gently, patiently, mindfully an area of the body that is experiencing an issue produce the same healing effect as holding it and waiting, with the same patience, for the area to release itself? If I start to move an area and feel pain, should I stop right away? Or is this a cue that I am initiating a healing process and would be doing myself a disservice by not bringing it to completion, fully exploring it.

I suppose this is something Upledger might say the individual intuitively knows the answer to in the moment, if we take the time to inquire.

Whatever the answer may be, I think the experience of pain is always a nice opportunity to open a discussion about the change/comfort matrix.

Change and comfort matrix

I think that all movement (and life) experiences fall into one of these four quadrants (in which “unsafe”, in the body, generally equates with pain or doomy apprehension, and “safe” is the absence of pain and a sense of comfort).

Safe + different= Where you want to be exploring (no pain, but maybe unsteady, awkward, challenging, shaky due to it being a new experience)

Safe + same= Staying in the comfort zone (no pain, no challenge, no change)

Unsafe + different= A new may of moving that triggers a threat response (painful, unsteady, awkward, challenging, fear provoking, activates sympathetic nervous system, and no lasting change)

Unsafe + same= Staying in the (not so comfortable) comfort zone (painful but no more painful than what we’re used to so it feels “normal”, moving habitually, no change)

Perhaps we just need to stay with a new input (movement, manual therapy, idea) for long enough to make the transition from unsafe/different to safe/different, because any new input to our nervous system may initially be perceived as dangerous, whether it really is or not.

Just some thoughts on navigating pain that I’ve had lately…

Pattern recognition

So anyway, here I was with L, feeling like I had no idea what we were going to do, plan for today’s training session out the window.

We had tried a number of movements that usually help get her neck and spine moving as part of her warm-up, but everything hurt too much to do, so we aborted mission.

From Upledger’s book, another theme presented itself: Treat the body on each day as if you are assessing for the first time. Try not to be biased by how the individual was last week, what other people have “diagnosed”, or even what the individual says about it. These stories may not apply to today.

And in that moment when zoomed out I was able to recognize a pattern.

In Anatomy in Motion (AiM) we assess the whole body in terms of phases of gait- What each joint does and when it does it as we walk. Each phase has it’s own signature shape, or pattern which we can begin to recognize in ourselves and others.

In the AiM Finding Center 6 day immersion course we are trained to understand what should be happening within each pattern at each joint in the body at any given moment in time as we walk.

L’s head not being able to tilt or rotate to the left was part of the same pattern in which, at the same time, her right knee should be flexing (we call this pattern “suspension phase”, more commonly known as foot flat). Since I knew, historically, her right knee had movement limitations, I wondered if the position of her neck was the result of an exchange within that pattern over many years of adaptation around a problem.

If the pattern can’t be completed by one joint (the knee), we see this phenomenon called “exchange” in which another structure will try to accommodate for that.

Exchange: If we can’t fulfill a lack (missing knee motion in this case), we will look somewhere else to fulfill it (perhaps at the neck?). This happens at all levels in our lives. When something is missing, we find other ways to fill space, whether they are the healthiest for us or not, whether we are conscious of it or not.

Had her neck become a solution for her knee that became a problem of its own?

To test this knee/neck relationship, I had L simply stand with her right knee bent while testing her painful neck ranges- They immediately improved in range and felt less painful. Not perfect, but better.

You should have seen the look of L’s face when I said, “I think your neck issue is because of your right knee”. Like I’m a crazy person.

For those who have already taken AiM or are interested in the biomechanics of this, these are the mechanics I observed when I reassessed L’s right knee:

Tibia anteriorally tilted (top of tibia tilted forward under the femur)
Knee externally rotated (tibia rotated laterally of femur)
No further movement into external rotation as the knee flexed (we should see the knee externally rotate as it bends)

If you haven’t taken AiM or don’t give a shit about biomechanics (unlikely, if you are reading this…), what this means is her knee was stuck in a more “bent” position in both sagittal and transverse plane, and couldn’t access any more bend, it already being there, bent.

The strategy, in my mind, seemed to be that we ought to show the knee how to extend and internally rotate, or more specifically, get the tibia to posteriorally tilt and internally rotate under the femur. Doing this would help it find a more centered resting spot allowing it somewhere to go when she bends her knee, rather than hit a block, and in theory, this would relinquish her neck of its excessive role in the full body pattern.

Using two movements from the AiM toolkit we explored ways of getting her knee to experience the above movements it was missing, and then integrated that up through into her neck as best we could.

L was mindful that the sensation in her knee felt different, and vaguely unsafe. At that point, we had a nice discussion of the comfort/change matrix. Fortunately, L trusted in the thought process I had explained to her, and after a few more moments of gently feeding movement through her knee, she reported that she was in the safe/different quadrant (is trust the anathema for feeling unsafe?).

When we finished, she stated that something definitely felt different about her neck, though she wasn’t sure what. She tested out her painful neck ranges, and they had improved. Not perfect, but on the right track.

Someone’s elses’ limiting beliefs

After this exploration, L told me an interesting story.

Apparently, when she had gone back for a consultation from a sports medicine doctor about her knee years after the operation, she had been told that she would never have full function of her knee again. She wondered aloud, “Have I been unconsciously limiting my potential because of something a doctor told me years ago? Something that wasn’t true?”. She didn’t question this statement at the time, that her knee was doomed never to work again, because he was the doctor. She seemed genuinely fascinated to understand how lifting this limiting belief could liberate her body from pain.

Let go of the handbrake

At this point I brought up the idea of the “handbrake” to the system- That we can try to teach the body to move “better”, but if there is something getting in the way (usually something from an injury history), then nothing will change because the brake hasn’t been removed.

Part of our job, as explorative movement facilitators (I am going to put that job title on my business card), is to find what’s getting in the way of people moving well, and then trusting that the individual’s own, intelligent system will be able to do the healing itself.

Another theme that surfaced from Upledger’s book: We are not healers, we are holding space for the body to heal itself.

I cannot be so arrogant to presume that I know what is best for someone’s body, life, mind, whatever.

All I can hope to do, and perhaps what is the highest form of healing, is to have the intention simply to be with somebody through their process. To listen before asking. To be present with them. Explain my thought process so that they have the option to trust it.

This is not a relationship between the healer and the broken, but a relationship between equals.

Priming the system

I also explained to L that other movements and stretches she can do directly for her neck are still good. The are ways of priming her nervous system for healthy ways of moving once the handbrake is removed.

By priming her nervous system with general movements, we are making future options for neck movement more familiar, more recognizable for her body to perform, once she has dealt with the thing that got in the way of it all to begin with.

And that brings me to…

The things that get in the way

I am reminded of a talk I listened to recently by Brene Brown, titled The Power of Vulnerability (listened to it twice in a row, strongly recommend), that mirrors this discussion.

To introduce her talk, Brown tells a story about a speaking gig at which she was expected to present on fluffy things like, how to be happy, how to be successful, etc. But as a shame and vulnerability researcher, her area of focus was “the things that get in the way”. The things people don’t want to talk about because they are hard and raw and most of us don’t want to go there.

It’s well and good to tell people how to be happy and successful, but how many people can actually take action on “happy and successful” until they’ve dealt with their own handbrakes? Shame, fear, and vulnerability. The unsexy stuff.

In the movement, personal training, and rehab worlds, we have plenty of people showing us how to move well (happy and successful), but not enough people talking about the things that get in the way (the handbrakes to the system).

There are literally thousands of resources that can teach you how to squat, deadlift, handstand, improve your “bad” posture, do yoga, “fix” your flat feet, etc. but hardly anything that can show you how to navigate the roadblocks. I think this is because 1. it is such an individual thing that it is hard to make a guide on, and 2. Becaues most people don’t think about “what gets in the way”, they just want to jump right into “happy and successful”, and “happy and successful” sells a hell of a lot better.

One of my teachers, Gary Ward, founder of Anatomy in Motion, has created an online resource that I think is the closest yet to removing the handbrake without actually working with a practitioner in rea life. His movement exploration is called “Wake Your Body Up”. <—Check it out.

The inner physican

Upledger describes in one section of his book that we have inside us an “inner physician”, and a “censor”. The censor has good intentions (safety!) but is the one who is skeptical about everything, who calls bullshit and can put a block in the road of healing. The inner physician opens a dialogue for healing, for finding the root cause of an issue and exploring, and asks us to trust the process.

L is in touch with her inner physician. She left inteigued to explore the work we did, intrigued by the thought process behind it. To her, it made perfect sense. As Upledger wrote, our bodies have an intelligence of their own, and if we open that dialogue with our own inner physician, we will find that we intuitively know what the problem is. Just have to pay attention…

Conclusions?

L’s homework was to practice moving her knee (safe/different) a few times a day using the movements we explored- remove the handbrake (stuck knee) and give the body a chance to heal itself.

I am grateful to have had this experience with L, and look forward to continuing this process with her.

I am left thinking, we always get what we need from life. Did L experience a neck flare up because she needed to address her knee? We’ll see what happens.

The Mindset for Healing

“Overall, these exercises are much harder work than the physio I was doing before, in that I have to really concentrate on small things. Can’t just put myself through them. Have to be present. It’s good. It’s why I sought you out rather than doing more straight up physio as I kinda knew this was what was missing, what needed to come next.”

This is an from an email sent to me by a lady that I am working with after, our second session.

We’ll call her Jean (not real name).

Jean is the epitome of the perfect student of exploratory movement, and I think the quote above sums up nicely just what that means.

When the body is in pain, generally there are three main systems we are working with:

Muscles, joints, structure, biomechanics (MSK stuff)
Mindset and emotions (perception of experiences, chronic negative emotional states etc.)
Organ and systems health (digestive, immune, etc)

Of course, these three become an inseparable web called a “life”.

Image result for biopsychosocial

As a body-worker, some things I can help with, and some things I can’t. For the individuals themselves, one thing they can start to work with that doesn’t cost a thing is the mindset bit.

Jean’s mindset is on point with where one would want it to be to make changes and heal other systems, and I want to use this blog post to explain a little more about what I mean by that- having a mindset to change and heal.

Because “healing mindset” isn’t this woo woo, think positive, manifest good health and meditate on being better you’ll be ok… It’s about engaging with the work.

When the standard approach fails…

Jean found me through my dance blog that I’ve since taken a break from writing on (danceproject.ca), but she is not a dancer. She is a pianist and also participates in horse riding and dog sledding.

Jean is in her 50s and has been experiencing pain for many years but had stopped seeing her physiotherapist because it wasn’t doing anything. When I first met her she expressed that she was frustrated with the care she was receiving from physio because they were only looking at the parts of her body that hurt: Her right knee and hip primarily. But they weren’t looking at the rest of her body, and Jean had a strong intuition that this was the reason things were going nowhere. She felt very distinctly that there was something going on with her upper body that was related to her knee and hip issues, but no one was looking there.

Smart lady to listen and act on her intuition.

Looking at the location of symptoms as “the problem” and stopping there is the standard approach. The approach that says, “treat the symptom”.

Luckily (I think…) for me, I never learned the standard approach because a) I went to school for dance, not for whatever it is I do now*, and b) all my most influential teachers are out of the box thinkers, who don’t ascribe to the standard approach and aren’t afraid to go against the norm, old-school movement paradigm. Maybe I’m missing out? I’m ok with that.

Jean was pleased that our initial assessment looked at her whole body, from her toes to her skull. Isn’t it nice to be treated like an entire person? Don’t you hate it when people only see you for one aspect of who you are?

*What do I even do? I dunno. I work with bodies and movement. I get people to move their joints in specific ways. I sometimes massage them, Thai style. I sometimes have people deadlifting heavy things if they want to. But the end game is always for them to have a different experience of their bodies, push their comfort zones, and access the movements their bodies are currently missing. What’s my job title? You tell me…

Ready for an AiM-style geek out?

For the Anatomy in Motion (AiM) students like me 🙂

Here is how Jean showed up (some interesting distortions):

Pelvis: Right hike, left rotation (stuck in right suspension)

Spine: Right lateral flexion, right rotation (stuck in right suspension)

Right knee: Can’t externally rotate (can’t access right suspension)

Right foot: Can’t pronate (can’t access right suspension)

The story her body was telling me was that nothing from the hip down knew how to pronate, and her pelvis, spine, and ribcage were trying to make this happen for her. Or, maybe her pelvis, spine, and ribcage were trying to stop her foot and knee from needing to pronate because it felt unsafe?

Regardless of the story I choose to attach to her structure, what I was witnessing was an exchange (something I wrote about HERE).

We can consider that in the phase of gait in which the foot pronates, that the entire skeleton is organizing itself to allow pronation. It’s not just a foot pronation, it’s a whole body pronation. In AiM this whole body pronation phase is called suspension.

As mentioned above, while Jean ‘s pelvis and spine are pronating, she is missing some very important pronation mechanics below: Foot pressure not getting onto the anterior medial calcaneous, foot bones not spreading and opening on the plantar and medial surfaces, and femur not rotating internally over the tibia.

If things aren’t happening below, something up top may need to do this for her. In her case, I believe this is why I was seeing the type two spine mechanics (same direction lateral flexion and rotation), right pelvis hike, and left pelvis rotation. If you can’t pronate below, something must make up for it above, or next door. A useful strategy to help her make up for a hip, knee, ankle, and foot that don’t pronate, but not an efficient way for the body to move that will stand the course of time.

Want to try this for yourself? Stand with your feet side by side and:

Put your weight primarily on the outside of your right foot
Hike the right side of your pelvis
Twist your pelvis to the left
Twist your ribcage to the right
Laterally flex your spine to the right

Not an effortless posture to hold! Feels pretty terrible for the right hip doesn’t it? No wonder Jean was having some issues, eh? But somehow this was the most efficient way her system knew to hold herself based on that tangly web of “life”.

So, we have really one of two options for how to sync her joints back up. We can:

Teach her foot and knee to pronate to match the rest of her body.
Get her spine and pelvis to experience the other end of the spectrum (left lateral flexion and rotation) to free up the opportunity for her right foot and knee to safely experience pronation.

Or, more realistically, probably do both (and we did both).

Anyway, that’s just a little bit of background on what she was dealing with to provide some context.

The mindset for healing

What I really think is beautiful to share about Jean ‘s journey so far is her mindset and attitude embracing the process that I suggested we follow.

If we come back to the quote at the top of this post, from the email she sent me, I’d like to break down what is so lovely to take from it, particularly if you are someone who has been in pain for a while, like her.

“These exercises are much harder work than the physio I was doing before”

In AiM, we try not to call the movements we do “exercises”.

This is partially because of the connotation the word exercise has for many of us.

“Exercise” brings up images of a gym, performing a set number of repetitions of a movement with the end goal of getting stronger, or more flexible, or sweating, or punishing ourselves for eating cake, or burning a particular amount of calories, or making ourselves vomit from effort, or escaping from reality, or for mental health, or cardiovascular health, or whatever our notion of what exercise is for may be.

And so the word “exercise” comes with undertones of needing to get something out of it, which is not what we’re trying to teach with the AiM philosophy. The goal, instead, is the process itself: Exploration and learning; investigative movement. To show the body a new way of doing things. Give it an experience.

How often do we go into an experience expecting to get something out of it, and missing the meat of the experience itself? Like going to a concert, and watching most of it through your phone to get that perfect video memory of it (done that…).

Image result for people on their phones at a concert — Wouldn’t you rather watch the show directly with your eyes?

The movements are simply to immerse the body in an experience it doesn’t usually get to have. To access joint motions that are currently being avoided. To move into new airspace and dark zones where learning can happen. To open up new options for movement that had been denied. To reorganize the skeleton and resultant muscle tensions.

Per Gary Ward’s big rule of movement #2, joints act, muscles react (from What the Foot). We want to give the muscles something different to do by moving the structures they attach to, not by trying to strengthen and stretch the muscles in an attempt to control the skeleton.

To quote something Gary said on an immersion course:

“The presence of muscles that contract first before lengthening will always be present in a system that doesn’t flow.”

No automatic alt text available. — You shoujld follow Gary on instagram @garyward_aim. He posts useful stuff like this and photos of his kids climbing that will make you jealous.

Some people report they feel “stronger”, or they are getting more “flexible”, or they have more energy, as a result of practicing the AiM movements, but these are only secondary to showing the body a more efficient way of moving.

How many of us have truly investigated our relationship with exercise? I did this in 2015 as an experiment and I would encourage anyone to do the same. I stopped anything that felt like exercise. I wrote two blog posts about it and the ensuing existential crisis here PART 1, and here PART 2.

Many of us are forced to investigate our relationship with exercise only when exercise has no longer become possible- after injury in particular, as was my particular case.

At this point we have a choice. To go back to the way of doing things before injury, or to try to understand that how things were being done “before” is what led to being in this state now.

“I have to be present. I can’t just put myself through [the motions]”

Not to go mindlessly, counting down the reps of the homework exercises until they’re done, but to be fully immersed in the experience.

In fact, I rarely give a specific number of reps to do. Why? Because the goal is not to get to 10 reps. The goal is to be immersed in the experience of the movement. Its not what happens when you get to rep 10, its what is learned in the space of reps 1-9.

There will be a distinct sense of “knowing” when you’re done with a “set”. You’ll feel something has shifted. You’ll feel things working that haven’t worked in a long time. Your brain and body will simultaneously say “enough!”. But to know when you’ve reached this point means you must pay attention to what you are feeling. It could happen in 3 reps, or it could happen in 12, but you have to tune in to this feeling.

In Jean ‘s case, the foundation of our process was to tidy up the coordination of the joints that were out of sync: Change the ratios and timing of pronation through her entire system, from her foot up through her spine.

It took a lot of focus and energy on her part. She had to tune into parts of her body that she had no prior awareness of and the movements they were capable of performing.

Just being able to feel where the weight in her feet honestly was through all the noise in her system proved to be a challenge.

“Where am I, and where am I not”.

Had Jean simply counted to 10 and gone through the reps without awareness, she would be moving too quickly and automatically to learn a new pattern or to feel whether she was moving the parts that we were actually aiming to move.

In the book Don’t Sleep There Are Snakes, Daniel Everett tells a story of how the remote Amazonian tribe he is living with, the Pirahã, do not use numbers or math. He tried to teach them simple addition, but they didn’t have any prior experience with the concept of numbers or adding and would not learn. What if for some people, areas of their bodies feel like math did to the Pirahã? They could learn math if they wanted to, they have the same brains as every other human, after all. But they have survived so long without it, found a way of living without math, why start now?

“I have to concentrate on small things”

We weren’t going for big sexy movements, but small, precise ones. She needed to tune into how things felt rather than just perform the motion.

For example:

Can you get your weight onto the anterior medial part of your heel?
Can you drop your right pelvis lower than your left?
Can you feel your spine bend to the left when you reach your right arm up?

As a closed system, changing one thing about the body must cause an adaptation from everything else. One degree can throw the entire system off.

If the pelvis isn’t level by one degree, everything else will be off by at least that much, probably more. If you draw two lines originating from the same point, one degree apart, how far apart will the two lines be after 2 inches? One foot? 100 feet? One degree matters, especially if there is pain present.

So for Jean to accomplish just several degrees of movement from a joint she doesn’t normally even have awareness of, or feel a change in where she is weight-bearing on her feet, while subtle, feels like an entirely different place to put the body. Off balance. It’s only a matter of degrees, but the brain starts to freak out because it doesn’t know where it is, and this is where the learning happens.

It takes so much more energy to focus on and feel the subtle differences I am describing than it does to squeeze your butt 10 times while thinking about what’s for lunch, and so for Jean, our work is hard not necessarily for the physical effort required, but for the ability to tune in, cope with change, and integrate it.

Not a “fire this muscle” approach, but a “move your structures into new spaces” one.

“I knew that this was what was missing”

“What’s missing”. In AiM philosophy, it always comes back to finding what’s missing, and claiming it back.

In Jean’s case, what’s missing was all of the above: Having her whole structure addressed, being asked to tune into her body, feel the parts she wasn’t aware of, move in ways she normally does not, access joint movements she has not felt for years, and do this subtle work in a completely present way.

I think Jean’s experience rings true for many people, certainly for myself in the past: Get hurt and go about getting treated in a way that has no expectation for us to engage with the work and be a part of our own healing process. Lie on the table and get worked on, without an expectation to do any work.

People are rarely presented an experience that allows them to heal themselves, and many people will rarely look for one because they don’t know what they don’t know.

In fact, in our first session Jean said:

“I’ve experienced body work of different sorts. But body work is something being done to me. It helps to get things to let go, to wake up things that are shut down. It does not teach my body what to do when I get up off the table. I feel like as soon as I move I’m going right back to whatever caused the problem in the first place. I need someone to teach me how I myself can get my body to swap out dysfunctional for better, consistently, and long term.”

I knew right then that we were going to get along great.

Conclusions?

If things are not changing in your body, ask:

Are you treating it as a whole system, or as separate parts?

Are you being present with it, or just going through the motions?

Are you checking in with it daily, or ignoring it’s signals?

Are you moving with awareness?

Are you moving out of your comfort zone, accessing ranges that you don’t usually move into, or sticking to what you know and normally do?

Are you determined, trusting, and committed to the process, or feel doomed to be stuck forever?

The real healing happens in the space of engaging fully in the process. Like Jean’s begun to do.

Realizing that the process is the goal.

“It’s the sides of the mountain that sustain life, not the top” ~Robert Pirsig.

Jean always mentions how because she is “old”, she is having a hard time at making changes. But I don’t think this is true. I think she is doing incredibly well at making changes because of the attitude she has towards her journey. Its not a race after all, and it will take the time it’s going to take.

Time doesn’t heal, but what you do with the time you have to heal, will.

Don’t Blame the Muscles…

I recently started a small group six week program that meets Sunday mornings. I unofficially call it “Church of Core”.

Its a program designed under the premise that, being that there is so much misinformation on the internet, in the media, and from people at the grocery store on what we should be doing to “train the core”, there should be a class to help people understand the truth of how the body moves so they can make their own informed choices on what to do at the gym.

And honestly, do whatever you want at the gym. It’s all good. Do what makes you happy. Just make sure your body possesses and understands the mechanics to cope with those choices.

I wanted to share a little case study from a participant in the program who was having some issues.

Twist and shout (ow)

Nancy (not real name) is a dancer in the program. We had just finished day two, in which we’d explored sagittal plane spine movement and stability, and she asked me if we were going to look at rotational movement next, because she was having some issues that and she had a big dance workshop weekend coming up. I said, yeah, come early to church next week and we’ll take a looksie.

Nancy’s primary complaint was that left ribcage rotation caused a straining painful feeling through her left side from her pelvis up to her ribcage. This is obviously an issue for a dancer because rotating is kind of a big deal in a lot of dance movements. She got the same symptoms with right pelvis rotation- Pain and tension through left obliques. So it’s not just a left spine rotation issue, its a transverse cog issue.

In AiM, “cogs” refers to the role in gait of structures moving in opposition against each other, like turning cogs. In gait, the pelvis and ribcage have a cog-like motion in that they should always oppose each other’s movement in all three planes of motion: In normal walking, when the the pelvis rotates right, the ribcage should rotate left.

In the case of Nancy’s symptoms, it was not just a ribcage rotating left issue, but an issue with any part of the gait cycle in which her left leg is forward (pelvis right) and her upper body is swinging to the left (ribcage left).

It’s nice when things make sense like this because they sure as hell don’t always do.

Her chiropractor identified that her issue was her left external obliques. Let’s look at why her obliques might be complaining about this rotational pattern.

Obliquing, long and short

If we’re going to blame a muscle, it stands to reason that we should know if its sore because of concentric shortness/compression, or it is locked long, under eccentric load.

Left ribcage + right pelvis rotation will lengthen the left external obliques, as the left EOs rotate the spine to the contralateral side

So, we could infer that the muscle is not happy with being loaded eccentrically to decelerate left spine rotation.

In the case of many muscles strains, the tissues have become locked long and because they are already loaded and lengthened they will have trouble decelerating joint movement because they’re already stuck doing that all the dang time.

In Nancy’s case we want to know WHY left spine rotation has become an issue to manage. Why are the obliques being lengthened all the time? Perhaps there is something NOT happening in this rotational pattern that the left obliques are picking up the slack for?

Time to stop thinking about muscles

I’m not telling you what to do, but muscles are confusing and chaotic. Looking at joint motions makes things much less noisy.

To quote Gary Ward, “Would you rather look at 13 muscles that connect to the knee or look at the 4 movements it can do?”.

I’d rather work on 4 things than 13, personally.

What stood out in interviewing her body was that her right talus was positioned internally rotated, everted, and could not externally rotate and invert. The chances of her right foot being able to supinate were pretty slim. This turned out to be key for helping her access left ribcage rotation with much less discomfort.

In the Flow Motion Model™, whenever the talus goes right, the ribs and spine go left, and when the talus rotates left, the ribs and spine go right.

This is because the rearfoot and pelvis always move in the same direction in transverse plane in gait (in all planes, actually), and recall that the ribcage and spine always oppose the pelvis.

So we could infer that the ribcage and spine should always oppose the talus*.

Therefore, if the talus can’t go right, another structure might have to go right MORE in order to accomplish every phase of gait in which the right foot supinates (and that’s most of the gait cycle, FYI).

In Nancy’s case it seemed to be the spine/ribs trying to rotate excessively to make up for a lazy right talus. And what might get tired of decelerating this motion over and over? The left external obliques.

Supinate the shit out of it

So we got Nancy’s foot to experience supination with her foot tripod grounded on the floor. With a little nudging and wedging, her right talus obliged and started inverting and externally rotating. Sweet.

We then integrated it into a pattern that required her to do left spine rotation and right pelvis rotation (we chose right propulsion phase). What was cool was that as long as her right foot was supinating, she could access left spine rotation with almost no discomfort.

When she retested her rotations there was significantly less discomfort than before. Her right talus was also sitting less everted and internally rotated at rest.

The entire process took about 20 minutes. Then we hugged and went to church.

*Talus and ribcage always oppose… Except for that fraction of a second in which gait is homolateral!

Conclusions?

Few things, I guess:

Learning to work with the FMM and AiM philosophy makes connections like this possible.
Blaming muscles for issues doesn’t provide enough useful information. I was not thinking about what muscles were tight or overworking of facilitated or inhibited while I was working with Nancy (which would have driven me crazy back when I used to do a ton of Neurokinetic Therapy® testing). Saying “it’s my oblique that’s the problem” doesn’t tell you why. Muscles react to joint movement. The answer will show in the structures, their position, and the movements they can and cannot do.
Thinking about her oblique pain in terms of concentric muscle action might not have led to the same resolution, but thinking eccentrically made a lot of sense in this case.
The “talus drives the bus”, and its useful to know how movement of the foot affects movement up the chain.
Knowing how to palpate the talus is a useful skill (that I didn’t have until very recently, thanks to “Foot Dating” on an AiM course).
It really is true that one of the most powerful experiences for the body is just to help the feet to experience true pronation and supination.

Why Should You Stretch? (part 1)

I used to be very flexible. These days, it’s a slow grind to get my hands to the floor in a forward bend.

I’ve lost the ability I had as a dancer to bust out a middle split, cold, anytime or place, provided I’m wearing stretchy pants (and I’m ALWAYS wearing stretchy pants because I made excellent career choices).

May be an image of 1 person and smiling — *A spontaneous JCVD splits-off moment with my step-nephew-in-law, back in the day when I could splits anytime…*

I don’t consider myself to be flexible anymore, and you know what? I’ve never felt better.

Ironically, most people think they need to stretch more to get out of pain. Or that being flexible is a universal goal. But the stiffer I get, the less pain I have.

So what’s that about, huh??

Flexibility doesn’t make you a better person

I’ve spent months and years worth of hours of my life stretching to get more flexible, and all I got was injured, tight, and fragile (that should be on a T-shirt.)

But it wouldn’t be completely accurate to blame my problems on stretching. The fact is I made pretty bad life choices. Excessive, mindless stretching just happened to be a symptom of my complete lack of respect for and awareness of my body.

I pushed through pain, performed through injuries, and I lived in fear that if I ever stopped stretching my dance career would end. Which was again ironic, because I wanted to quit dance when I was 15 but just couldn’t seem to let go…

Anyway, flexible as I was, I was trapped in my body. Shackled by the constant tightness you know probably all too well if you are as obsessed with stretching as I was. A tightness that only seems to be relieved by stretching more. A tightness which, ironically, is your body’s way of asking you to stop stretching it.

I’ve learned that my body feels much better when I don’t stretch it when I’m less flexible. So I don’t stretch anymore because I like to think I’m not a complete idiot.

This is part one of a blog series about why stretching and flexibility are not the ultimate pain panacea. Part one is a bit of a rambly, ranty thing about the traditional paradigm: “If it hurts, if it’s tight, stretch it”.

Beyond mobility and stability: Harmony

In 2015, I decided to try elimitating the words “mobility” and “stability” from my vocabulary to see if I could define everything the body did in terms of actual anatomical motion. It was an awkward, challenging year (probably for my clients, too…).

How is that body part moving? In what direction? Is it moving too much? Too little? Too fast? Too slow? I wasn’t focused on muscles, I was looking only at joint motion, which was a big paradigm shift after taking the Anatomy in Motion 6 day immersion course in 2015.

The reason why I started this vocab change was because the words no longer seemed useful to describe an experience the body is having.

Stability implies no motion. Mobility implies movement. But in the body, nothing is ever not moving. Everything is always moving, just in different ratios, relationships, and timings with other body parts.

When something is actually NOT able to move- true stability- there is problem. For example if your knee actually can’t bend and is stuck straight. That’s a stable knee. But that’s a problem.

Knees have to be able bend for us to walk. But we want to get it to bend in a way that is meaningful for the rest of the body. With the right timing, and ratios of motion in relation to the other body parts, not just by doing a mindless leg curl, inconsiderate of what every other joint in the body should be doing when the knee bends.

So is stability a good goal? Not in the true sense of the word. Is mobility a good goal? It depends on how the thing is moving, in relation to the entire system.

To me, a better word is harmony. Or order.

I don’t want my body to be mobile just for the sake of mobility, because Kelly Starrett said you should want to be a supple leopard.

Becoming a Supple Leopard 2nd Edition: The Ultimate Guide to Resolving Pain, Preventing Injury, and Optimizing Athletic Performance: Starrett, Kelly, Cordoza, Glen: 9781628600834: Books - Amazon.ca

I want my body to move harmoniously, in an orderly way. This goes beyond mobility and stability. Beyond flexibility. This is a unique state for each one of us.

Am I over-thinking? I don’t think I’m thinking enough…

Flexibility is not a universal pain solution

One of my mentors, Chris Sritharan (Anatomy in Motion instructor) once said that there are 4 ways we can use a body part:

Overuse
Underuse
Misuse
Disuse

Do stretching address any of these? Not really… (but over-stretching a muscle that doesn’t need to be stretched falls into the “misuse” category).

I hear people say stuff like this constantly:

“I should stretch more.”

“I never stretch, that’s probably why my body feels so tight all the time.”

“I do always do hip stretches, by they just keep tightening back up.”

“My neck hurts *goes on Youtube to look for neck stretches*”

Sound familiar?

Back in my pre-thinking days (I consider age 22 to be when I officially started trying to use my frontal cortex for inquisitive thought), my left hamstring felt really “tight”, so I stretched it daily, really hard.

A few months later I strained my left hamstring while I was stretching in jazz class warm-up one day. Injured while warming up… The irony. Well, I was only doing what I thought was right based on the information I had.

I thought stretching would set me free. Make me a better dancer. Make my tightness go away. Make me a better person, even (if only I could do deeper splits, everyone will admire me and I’ll be a big success! Nope…).

Can we stretch my shoulder?

A few years ago, a client came in saying that his shoulder felt “tight”, and, “can we do some stretching for it?”.

I had to take a breath and collect myself. A part of me wanted to say, “No we cannot stretch your GD shoulder because the problem isn’t your shoulder, it’s that ankle sprain you keep denying is a problem!!”.

But I didn’t… Because I like having clients that support my ability to pay my rent.

His shoulder didn’t actually need to be stretched per se, because the muscles were already in a lengthened state in the area he had discomfort- That spot actually needed to be shortened to take the tension out, not put more tension in by tugging on it more.

But, because I try to be diplomatic, we did a thing that I told him was a “stretch”, and afterwards, when the sore spot felt better, I explained to him how it wasn’t actually a stretch and why it worked (it was a whole body lunge-type-movement to get his foot to pronate, disguised as a shoulder stretch).

How the traditional stretching-makes-everything-better paradigm fails

A client I used to see many years ago would come in every week with low-grade back pain that she describes as tightness. In her words, “it’s fine because I just stretch it out with yoga.”

To which I wanted to ask if yoga “works”, then why do you show up every week with the same old back pain? But I didn’t… Because it was a time in my life that I was financially insecure and was terrified of losing a client by asking potentially provocative questions like this.

My point is that stretching a muscle doesn’t necessarily teach that muscle anything. To again quote Chris Sritharan (aka #sritho):

“We’re not trying to stretch a muscle, we’re trying to give it something to do.”

What do muscles do? Manage joint motion: Joints act, muscles react.

If flexibility and stretching were the solution to the body’s problems, then contortionists, dancers, and circus performers would never have issues. Ever. But they do. Lots of ’em. Explain that for me with stretching logic.

I think a big problem is that most of us look for a solution too quickly when we should take the time to ask better questions.

Asking questions like, “why is it tight?”, instead of “what stretches should I do?”.

In fact, this blog post was born from my feeling completely insufficient at the art and science of asking questions.

Questions help us see facts. “My neck feels tight”, isn’t a fact, it’s a subjective experience.

“Tightness means I should stretch”, isn’t a fact. It’s a belief.

Well, that’s enough of a ranty primer for part one. In part two (and probably three) we’ll go deeper….

What are the questions we need to ask to get the facts we need to go beyond stretching?

What ARE the facts we need?

What do I mean by harmony and order? (hint: gait mechanics)

If not stretching, what SHOULD we do?

How is stretching different than eccentric loading? (hint: center of mass management)

“But Monika, I hear you talking about feeling stretches all the time in your classes… I’m confused.” Me too! It’s a good way to be. It means there’s something to learn 🙂

Stay tuned!

Until then, may you have the courage to stop compulsively stretching your tight spots, and the curiosity to wonder, “why is it tight?” in the first place.

The Week of Externally Rotated Knees

Last week I saw three different people with externally rotated knees. In particular: Three externally rotated right knees that don’t internally rotate, causing the individual some grief (not just at the knee, but definitely at the knee).

Image result for knee external rotation — These “deformities” actually happen in gait… I guess we’re all deformed.

I remember Gary Ward saying something to the effect of, if you keep seeing the same thing over and over again in your practice within a short period of time, check to see if it’s not your OWN issues that you’re projecting onto your clients. Have been guilty of that in the past.

Just to make sure I’m not full of shite, I stand up, check out my right knee, and, lo and behold, it appears my right knee doesn’t fully internally rotate. Actually, both don’t. Well damn. However, my right knee internally rotates a lot more easily than my left, so, maybe my awareness, despite my imperfections, is helping to keep my perception honest. In any case, the important lesson: Whenever you see a bunch of the same thing, check to make sure it’s not just YOU.

I already wrote a little (kind of long) piece about a lady I worked with who had an internally rotated knee that wasn’t externally rotating. Her knee was actually stuck in some kind of purgatory in which it neither rotated in OR out. Maybe you’d like to read that, too (slightly different case than these three peeps).

I would like elaborate on a few observations I noted in working with these three individuals, aka, how not being able to internally rotate a knee can potentially wreak havoc on the body.

Some stuff they had in common, in particular:

Missing an effective propulsion phase of gait
Feet turning out in gait, aka, the “duck walk”
Rock solid, toned up, tibialis anterior
Low femoral external rotation
Limited right trunk rotation

Are you ready to get excruciatingly technical? Hell yeah!

LACKING PROPULSION

Propulsion- The phase in the gait cycle just before the foot picks up off the ground prior to swing in which the pelvis is travelling (propelling, if you will) forwards, the extending hip fully decompressing, and the foot is in a maximally supinated , rigid lever position. To create this rigid lever, the knee also needs to be locked in extension in order to anchor the foot to the ground so that the pelvis can travel forwards, allowing the hip to extend and load the hip flexors for the next moment: Swing.

Getting to propulsion effectively is important.

However, in all three of my funky-kneed individuals, propulsion was just not happening.

In propulsion, the knee will be in its end range of extension. For this to happen, the femur twists externally on top of the tibia, locking the condyles together into it’s “screwed home”, comfy position (home= comfy). This creates a position in which the tibial tuberosity is rotated medially of the femur, giving us an internally rotated knee.

Knee extension = knee internal rotation in an ideal situation in gait.

If the knee can’t get “home” to internal rotation and extension, as was the case for these three individuals, then the rigid lever to propel off of will be compromised, and resultant shite: The hip won’t extend, swing may be compromised, and all the muscles that load up in propulsion (psoas, iliacus, distal tibialis anterior, peroneals, distal hamstrings, distal FHL, adductors, to name some biggies), will not get their chance to lengthen.

Internally rotatable knees= Happy hips that can extend.

FEET TURNING OUT IN GAIT

That funny “duck” walk thing. I used to do that. And then I stopped ballet…

A little experiment you can try. Standing bilaterally, turn your feet out. Can you feel which way your talus is now pointing? If you are a normal human being, you should feel that feet out= sub-talar joint axis (STJ) pushes in. The opposite is true if you stand with your feet pointing inwards- STJ will point out.

Feet pointing out in gait is often a hint towards a foot that can’t pronate, and an attempt to give the STJ an opportunity to point inwards.

In pronation, the STJ axis will orient internally of the 2nd toe (usually wayyy more internally than that). But what if the foot can’t pronate? Or, what if pronation has become dangerous for some reason, and the body has needed to find a way to work around it?

Turning out the feet is one work-around: Feet out, STJ pushes in, medial arch gets to open, brain thinks it is “pronating”, but without actually pronating.

In gait, pronation and knee external rotation happen at the same time. This means that, in the case of the already externally rotated knee that doesn’t internally rotate, pronating the foot may feel dangerous because with the knee already externally rotated, there’s nowhere further to go if the foot pronates.

If the foot does pronate, the knee will reach end range external rotation (XR) too quickly and that may not feel so good. As a strategy, the body needs to find an alternative way to get a bit of “pronation” through the foot, and tan easy way to do this is to turn the foot out so that the talus can feel like it’s pointing in, and the medial arch can open. Not ideal. Definitely a work-around, but better than not being able to walk in the short term.

If the knee was able to internally rotate, this would free some space for it to move into external rotation as the foot pronates, rather than immediately crash into end-range. The change in timing allows pronation and external rotation of the knee to couple together safely.

In the case of these individuals, reintroducing knee IR was a foreign, but nurturing experience.

ROCK SOLID TIBIALIS ANTERIOR

Tibialis anteriori? Anterior tibialises?

(also see T: Tons of tone…)

Tib ant is a cool muscle that I don’t completely understand. Its triplanar functions hurt my brain (and I still have to see some clients today who need it).

That said, I did spend about 20 minutes on my couch groaning in agony trying to make sense of tib ant, my room mate giving me strange looks (rightfully so).

Tib ant is a strange and fascinating muscle.

It lengthens and shortens at both ends simultaneously, despite being a multi-joint muscle (which generally do NOT do this unless you want it to feel really bad).
It shortens in two planes while lengthening in another, and visa versa (sagittal and transverse couple, while frontal opposes).

I enlisted a little help from some smart AiM friends to understand the closed chain mechanics of tib ant when the knee is interally vs externally rotated. Here is the verdict:

Knee extension + internal rotation + foot supination:

SAGITTAL: Long (except in strike phase of gait in which the ankle is actually dorsiflexed with an extended knee, and so the tib ant will be short here)
FRONTAL: Short
TRANSVERSE: Long

Knee flexion + externally rotation + foot pronation:

SAGITTAL: Short (note, this is passive shortening, as gravity does the job of dorsiflexing the ankle and pronating the foot.)
FRONTAL: Long
TRANSVERSE: Short

So, in the case of our friends with externally rotated knees and rock solid tib ant, what does this mean? Few theories for the increase in muscles density and hypertrophy:

Length tension: Being used excessively to decelerate a joint motion. For example:
- Tib ant decelerates the arch lowering in frontal plane to manage over-pronation (aka shin splints). Slowing down pronation will serve an already externally rotated knee by preventing it from rotating further, and tib ant may be working overtime for this.
- Ankle may be plantar flexing too quickly out of late swing in an attempt to decelerating sagittal plane ankle motion into dorsiflexion, and block over-pronation and thus, more knee external rotation.
Short, overworking tib ant: Concentric muscle tone. Some examples:
- Not being able to lengthen and load tib ant in sagittal and transverse plane in the previous phase of gait, propulsion, the tib ant will have to contract excessively on swing to dorsiflex the ankle to clear the ground (or turn the foot out).
- An externally rotated knee may be attached to a foot stuck in pronation and ankle stuck dorsiflexed, which will shorten tib ant in sagittal and transverse plane.
- If a high varus angle of the foot is present as an attempt to slow pronation and knee external rotation (as this increases the distance the 1st met must travel before it hits the ground), this will contract tib ant in frontal plane.

I’m sure this is not a complete list. I am, of yet, not sure which one of these is the most true for each of my three individuals, but what matters more than the story I choose is the “what will I do next”?

LOW FEMORAL-ACETABULAR EXTERNAL ROTATION

In order for this to make sense, we must distinguish between femoral rotation (FA: femur moving in acetabulum), acetabular-femoral rotation (AF: acetaculum moving on femur), and hip rotation (the orientation of the space between the two bones).

Until I understood this distinction, and a lot of it has to due with timing, hip mechanics fucked with my mind. I blame PRI. Just kidding… I blame my limited thinking, conditioned by previous PRI training.

Image result for left aic — LEFT: Right AF IR, left AF XR. RIGHT: Right AF XR, right AF IR. I had to temporarily forget about this to learn AiM.

Moving on!

Curiously, in all three individuals, the right hip- the same side as the externally rotated knee, was more limited into external rotation than their left. Why could this be? (and yes I am aware that this is a left AIC pattern…)

When the knee is externally rotated, the hip can be either internally rotated (IR) or externally rotated (XR), depending on which phase of gait we’re talking about.

There are two phases of gait in which the knee does XR: Suspension and early swing. Both are pronating, and knee bending phases. The distinction: In suspension (closed chain), the hip is in XR, while in early swing (open chain), the hip is moving into IR from maximum XR.

In either case, if you were to freeze time at the moment the knee is in XR, the hip would appear to be in XR as well. In one case because it is really truly in XR (suspension), in the other, because it is still in a state of XR but moving into IR (early swing).

PLOT TWIST: In suspension, though the hip and knee are in XR, the femur in the acetabulum itself in internally rotating.

How can an internally rotated femur be labelled as externally rotating hip?

Here’s how:

Suspension= FA IR + AF XR + (*some timing stuff*) = Hip XR.

Remember the femur and the hip are not the same thing. The femur is the bone, the hip joint is the space between the femoral head and the acetabulum.

*Aforementioned important timing stuff*: In suspension, the pelvis is rotating away from the suspending leg (AF XR) as, just prior to hitting the ground, the leg was in swing. The leg swinging rotates the pelvis away from the swing leg (creating AF XR), as the femur also rotates externally (FA XR). Then, as the first met hits the ground and foot starts pronation, the femur begins to rotate internally, initiated by the talus as the foot begins to pronate. However, the pelvis is still rotating away (into AF XR) faster and farther than the femur is rotating internally, which creates a global position of hip external rotation.

Clear as mud, right?

Early swing, by contrast, is simple:

Early swing= FA IR + AF IR = Hip IR

So, when the knee is in XR, the femur IS internally rotating regardless of what the hip is doing. When the knee is in XR, the femur is internally rotated farther that the tibia.

Knowing this, it makes sense to feel a limitation in femur XR on the side that has an externally rotated knee.

This also makes sense as a contributing factor to why propulsion wasn’t happening: In propulsion we need hip AND femur XR along with knee IR.

LIMITED RIGHT TRUNK ROTATION

Having an externally rotated right knee and limited right trunk rotation are not an absolute coupling, but it was curious to see it in all three individuals this week. It was pretty interesting example of the clever body making adaptations above to accommodate something below (or is it something below adjusting for a structure above…?)

In two of the three, the same situation was going on:

In gait, both had an observable left trunk rotation. Ribs were going left-center-left-center, and never making it to the right.

BUT, in a bilateral stance, the opposite showed up: Both had an inability to rotate to the LEFT. What the f***. I was not expecting that.

Why would someone rotate left so much while they walk, but not at all when isolating ribcage movement in bilateral stance?

My operating theory is, what if they were already rotated left, and in which case, there is nowhere else to go. You can try this in your own body. Stand with your shoulders rotated to the left. Now, try to rotate them more to the left. Doesn’t get you very far, does it?

So why would the body choose to put its thorax to the left, and how does this relate to a right externally rotated knee?

Remember, knee XR happens twice: Suspension, and early swing. In both those phases of gait, the spine and ribcage will be rotating, wait for it….

TO THE RIGHT (as per the Flow Motion Model™)

What if the body is avoiding right spine rotation because the knee is already in end range XR? More right trunk rotation would potentially require the knee to XR further, and that would probably not feel good on an already externally rotated knee.

We can look at it from another perspective. Maybe the left trunk rotation is what is trying to create right knee IR. In all (but one) phases of gait in which the right knee is in IR (transition, shift, and propulsion), the spine will rotate LEFT. (the exception is right heel strike, in which the trunk will be rotating to the right, even though the knee is in IR).

So, right trunk rotation couples more with right knee XR, and left trunk rotation couples more with right knee IR.

So which is it? Using left trunk rotation to attempt to IR the knee? Or avoiding right trunk rotation to protect the right knee from excess XR? The answer will be “both” until we know for sure.

In any case, working on reintroducing right trunk rotation and right knee IR will be a nourishing experience. Hopefully… (so far so good).

CONCLUSIONS?

Yeah, I guess I have a few.

I’d better take care of my own right knee just in case I’m projecting my own problems onto people. Will put that on the to do list for today.
Is this right knee external rotation a PRI pattern? Part of the lef AIC pattern?
These three individual cases also had other different things going on. This is not the full picture and not meant to be taken as an absolute. I just like to write out my observations on the shit I see to make sense of it.
Part of the solution for all three of these individuals was to work on “transition” (AiM movement) to experience knee IR. All reported that it felt “weird”, “good”, and “I never do that”. No shit you don’t!
Knees are pretty cool. For a joint with only two planes of movement, amazing how overlooked its mechanics are. It only took me 4 times through AiM to start to get a grasp on the knee. Maybe after my 6th I’ll understand shoulders.
This blog post is entirely a thought experiment. None of this may be true. Take it all with a grain of salt.

Singer Case Study: Breathing, IAP, Spinal Mobility, and Larynx Stuff

I recently began working with a very talented professional singer/vocal coach we’ll call Louise (not real name). Her primary goals were to improve her health, movement quality, and strength, aka, my favourite kind of person. She also enjoys geeking out about breathing and her super interesting feet, which makes her my very favourite person right now (not that I play favourites….).

We’d had a good chat about breathing before our first session (my fascination with it, her need to have good control of hers for her profession), and so I was particularly curious to see what her breathing habits were like, among other things.

A few interesting things have come up in our work together so far that I’d like to share as I attempt to make sense of the relationships between breathing, spine, and larynx mechanics in my head.

Belly breathing vs. “ideal” diaphragmatic breathing pattern

I would imagine that singers pride themselves on having good diaphragmatic control, but, much like Tiger Woods’ swing, there is much that can be improved upon mechanically even if you perform at a high level and kick ass already.

Louise is very good at using her diaphragm as a breathing muscle, but, and this is a big BUT, she uses it at the expense of maintaining any tone through her abdominals, which shows as a belly-pushing-out breathing pattern rather than an “ideal” diaphragmatic breathing pattern that could create greater intra-abdominal pressure (IAP).

Belly breathing IS diaphragmatic breathing- The abdominal excursions with inhalation are due to the diaphragm descending (contracting), but, the belly moving forwards, and only the belly, is indicative of the contents of the abdomen moving forwards without abdominal or pelvic floor eccentric co-contraction. This forwards movement is not going to be the best way to create “support” through the midsection, both for singing and strength training.

An ideal diaphragmatic breathing pattern involves, upon inhalation, both the belly and chest moving anteriorally, a posterior lateral expansion of the lower ribcage, and the pelvic floor descending as the organs are pushed down by the diaphragm. Not only the belly moving forwards.

A nice way of visualizing it is a 360 degree expansion of the thoracic (ribcage) and abdominal cavity, much like an umbrella opening, or a balloon blowing up. The balloon doesn’t just expand on one side, unless it’s a fucked up balloon.

If the belly/organs are pushing forwards, it is likely because there is no room for the abdomen to expand to the back (posterior-lateral expansion), and the pelvic floor down (descending), and so the only place for the organs to move is forwards (not ideal).

The excursions of an ideal diaphragmatic breath will appear to be smaller than those of a belly breath. Part of this is due to the abdominal fill being redistributed in a 360 degree fashion, and air flow also expanding the upper ribcage and subclavicular space, which creates a more evenly distributed fill, rather than the prominent belly breath. This “smaller” fill (volume of air) with the more ideal diaphragmatic breathing pattern will initially feel as if you are not getting enough air. This may be simply because the fill shape feels different and freaks out the nervous system, but could also be because belly-breathers often breathe in excess of metabolic demands (see G: Gasping for Air), whereas an ideal diaphragmatic breath will get more oxygen with less total air volume (let’s not go down that rabbit hole today…).

The posterio-lateral expansion that allows for the 360 filling can only happen if the abdominals (transverse abdominis- TVA, and internal obliques- IAOs, primarily) stabilize the ribcage: Eccentrically loading to slow it from lifting up and flaring excessively and the belly from pushing forwards.

Needing to counterbalance the organs being displaced forwards, belly breathers tend to get pulled into lumbar extension pretty easily (I would know, because I’m a recovering compressed-spine belly-breather), which makes it even more difficult to maintain any abdominal tone with inspiration due to the lengthened state of the abs, and compressed state of the spine.

To summarize, a belly breathing pattern does use the diaphragm, but not as effectively as it could, as the abdominals are not doing anything to generate internal pressure and muscular support. The big movement of the belly means that:

Minimal expansion of the thoracic cavity will not decrease the intra-pleural pressure as much, meaning that the lungs will not fill as deeply and efficiently with each breath, reinforcing the need to take bigger belly breaths to feel like the lungs are filling “enough”.
It will be more difficult to create pressure within the abdominal cavity (IAP) due to decreased TVA, IAO, and pelvic floor support, the foundation for spinal stabilization with movement and, importantly for Louise, support while singing.

I believe it will be useful for her to train herself out of the belly-breathing pattern and into a one that uses more abdominal co-contraction.

Training to hold onto an “air reserve”

In other words, training to create a functional hyperinflation just in case the need for more air should arise while singing. I can understand how holding onto a “reserve” would be useful if you have a long phrase or note to hold, or you accidentally neglect to breathe at the most effective time and need to push your air a bit further.

But there is a consequence to this, as training to hold on to extra air over months or years can have the effect of creating a more chronic hyper-inflated state- Excess air in the lungs, diaphragm and ribcage stuck in an inhalatory state, with an inability to completely exhale.

Why is this an issue?

Over time, hyperinflation alters the position of the ribcage, and puts the diaphragm in an even further disadvantageous position to breathe from: A state of perma-semi-contraction (that’s a word…).

Louise noted that she has a difficult time exhaling completely in our breath work, and would quickly feel the urge to breathe in deeply. She struggled to get her ribs to move down and in to an ideal zone of apposition (ZOA), or exhalatory, depressed (anteriorally tilted) rib position and breathe without flaring up her ribs with each inhalation (which would lose all IAP, aka “support”).

Image result for zone of apposition

Because the diaphragm lengthens and ascends with exhalation, when more air than necessary remains in the lungs over long periods of time, it can become difficult to get diaphragm to get to a fully lengthened resting state. Because muscles must lengthen before they can contract, this makes an ideal diaphragmatic inhalation near impossible, spinal stabilization difficult, and compromises IAP generation.

Holding a “reserve”, or, a functional hyperinflation, does make sense as an adaptation to her “sport” of choice. However, if left unchecked, it will keep her from using her breath as efficiently as she could be, as being stuck in a perpetual semi-inhalatory state impacts on her quality of both inhalation, exhalation, and internal pressure regulation. Perhaps this is a deeply ingrained part of the singing training tradition; much like passively overstretching is part of ballet training tradition- Practices that can lead to compromised performance, but no one is taught a better way of doing things.

Here is some excellent art by me, illustrating some of the silly “traditions” I ascribed to as a dancer:

Louise and I discussed that owning the full spectrum, i.e. full inhalation and exhalation, rib flare and ZOA, diaphragm contracted and relaxed- would help her to find a more “centered” place with her breath and body, and decrease the reserve of air she needs to hold on to, which would decrease the chronic hyperinflation over time. Doing so would also help her to fill her lungs more efficiently and better use her diaphragm for it’s spine stabilization function, creating higher intra-abdominal pressure, which will come in handy when she needs the support for singing the higher tones without going in an “airy” head voice.

As an inexperienced singer, my thoughts are that the reserve training is probably useful, but the minimum possible amount of trained hyperinflation to get the job done is desirous.

The reserve is similar to packing for a long hike: You want to pack as little as possible to make reduce the weight you’re carrying but not starve. Hiking without a bag at all would be ideal, but not realistic (unless you have someone trailing you with your food and water supply in a helicopter).

After the hike, you can take the bag off and unwind, and, after singing and over-breathing a bunch, it is also a good idea to unwind.

Another important thing to note is that, if Louise does try to sing with the breathing patterns we are discussing as more “healthy” physiologically, she may experience a temporary decrease in her singing abilities, which, may not be desirable if she has to perform. This is comparable to taking away an athlete’s functional adaptations. For example, if a dancer needs a lot of flexibility in her hamstrings, and stiffness in her feet, and we take this away because it is not “healthy”, she may suffer a decrease in her dance technique. Similarly, if we try to make a sprinter too mobile, they will lose the stiffness which is in part necessary for them to generate power and speed.

There is a sweet spot, which, I believe exists within the exploration of the spectrum: Can you inhale and exhale? Can you play at the extremes without losing sight of “center”? And can you play with the bits in between without losing sight of the edges?

Ultimately, I believe that working on the diaphragm + abdominal control, deeper more efficient filling of lungs, and being able to exhale more fully will provide her with more options for how to use her breath, and more opportunities to unwind from the stresses that singing can have on the body.

Stiff spine and effect on larynx control, tone, and pitch?

Degree of spinal mobility and neck positioning can have an impact on, and be impacted by, breathing and ability to use the larynx effectively (and visa versa). This is something I am just starting to put together, and may need to revise this section later. Bear with me now and please correct me if I’m wrong.

Louise is stuck with a fairly flexed thoracic spine that doesn’t know how to extend, and a extended cervical spine that doesn’t know how to flex. As a strategy to extend her thoracic spine, Louise retracts her scapulae together excessively in an attempt to create spinal motion, a common strategy for stiff spines that I frequently see.

For singers, being able to flex and decompress the C spine is necessary to modulate the quality of their voice. This is due to the larynx, which houses the vocal folds, being located around level C3-C6.

The larynx is suspended from the hyoid bone, which is what Gary Ward (author of What the Foot) has classified as a “dangler” (technical term). This means that its gross movement is primarily due to the movement of another proximal structure (for example, scapulae are also danglers, suspended on the ribcage, the jaw is a dangler, suspended from the cranium). In this case, the hyoid is closest to the cervical spine and skull and so hyoid, and thus, larynx, movement can be mapped based on C spine and skull movement.

The hyoid also has a pretty cool connection to the scapulae via the omohyoid muscle (which I just learned about yesterday). This means that there could be some tricky strategies going on between Louise’s hyper-retracting scaps, stiff spine, and hyoid/larynx, that may have an impact on her voice.

Another thing worth noting is the the closing of the glottis to increase sub-glottal pressure, sometimes known as the Valsalva manoeuvre. This allows greater building of air pressure to stiffen the abdominal cavity and is useful to protect the spine for higher threshold activity, like lifting heavy things, but also at lower thresholds it serves to stabilize the spine during simple limb movements. Some people may tend to overuse the muscles of the hyoid/larynx to create this stabilizing pressure rather than being able to use their diaphragm and abdominals (TVA + IAO) effectively for IAP, which can mess with the larynx’s role in air pressure modulation and resultant vocal quality.

For someone like Louise who does not use her abdominals effectively to create IAP (as a belly breather), she may be overusing her hyoid and larynx musculature to create it, or, locking into bony end range at her C spine, in an attempt to create a sense of stability, which will impact on how well she can also use her larynx to modulate her voice.

What all that means is that one’s potential vocal range and ability to modulate pitch and tone is somewhat dependent on spinal mobility, internal pressure regulation, scapulae movement, as well as freedom of hyoid movement (to dangle).

Image result for larynx

Where things get interesting is when we look at how larynx movement can affect pitch and quality of the voice:

Larynx elevation = higher pitches (stiffens vocal folds)
Larynx depression= lower pitches
Larynx anterior tilt (forward over cricoid)= higher pitches (lengthens vocal folds)
Larynx posterior tilt= lower pitches

To correlate this to C spine and skull movement:

Skull anterior tilt + C spine flexion = larynx elevation + anterior tilt=stiffer, longer vocal folds= higher pitches (also opens airway)
Skull posterior tilt + C spine extension= larynx depression + posterior tilt= lower pitches

However, as Louise has explained to me, the movement of the larynx may have more to do with the quality of the voice, regardless of the pitch, due to how it modulates air pressure. A higher larynx will tend to raise the air pressure and make the quality of the voice less airy, and so is useful for getting high notes to sound less “heady”.

Here is yet more excellent art by me:

When the larynx tilts forwards over the cricoid (anterior tilt) and raises, this lengthens and tenses the vocal folds to create higher pitches. However, altered neck position and resultant muscle tensions can limit this anterior tilt.

Here’s where things get more fuzzy for me. I have read that relying on moving the neck and skull to move the larynx is not as effective as being able to use the intrinsic muscles of the hyoid itself to move the larynx to modulate pitch and volume.

A lower resting position of the larynx is said to be more desirous and healthy than an elevated one. I suppose this makes sense as this means that should one need to push into a more headier voice, there is actually somewhere for the larynx to go. However, I would also reckon that too low is not great, especially if stuck there. Like any other structure of the body, I suppose the holy grail is to find “center”, and to do this we must also know the extremes.

When it comes to using intrinsic muscles of the larynx, I am not entirely sure how to train this because I’m not the one who’s a vocal coach with the experience in that domain. However, I can imagine that unlocking the neck and spine mechanics, breathing mechanics, and ability to co-contract abdominals, diaphragm and pelvic floor to create IAP will free up the muscles of the hyoid and larynx to perform their vocal manipulatory role more effectively, which will have a spill over effect into vocal training.

Taken from “Recognizing and Treating Breathing Disorders” By Leon Chaitow

Here’s what’s currently going on with Louise:

C spine stuck extended= Larynx stuck in posterior tilt (potentially)
Skull stuck in posterior tilt= Larynx descended (potentially)

Because movement of the c spine is also quite dependent on movement of the thoracic spine, we must also looks at Louise’s current set up:

Thoracic spine stuck flexed= C spine stuck extended= skull stuck posteior tilt= larynx stuck in posterior tilt and descended (as in the lovely picture on the right I drew, above)

This could potentially be impacting her range and comfort into higher notes, but also into lower notes, as her larynx could be hanging out in a descended position all the time with nowhere lower to go (and indeed, she admits lower notes are tough for her to hit).

Because Louise attempts to extend her T spine by squeezing together her scaps, the more she sings with this as a postural strategy, the more she may experience shoulder and neck tension as she attempts to create a more elevated, anterior tilted larynx position for higher notes by tensing her shoulder blades, with an extended C spine.

Yet another interesting piece of Louise’s puzzle is her high arched, stiff, inverted feet. In the foot map of the body, developed by Gary Ward and Chris Sritharan of Anatomy in Motion, the metatarsal rays (1-5) are seen to be correlated in structure to the ribcage and thoracic spine. In Louise’s case, they share the same shape: Flexed (rounded) T spine with arched (rounded) feet- Both stuck in primary curves. As we attempt to teach her feet how to pronate, or, “extend” through the arch, it will be curious to observe what this could free up in her thoracic spine and ribcage into extension and impact on her breathing and neck alignment.

Displaying Screenshot_2016-03-21-15-25-50~2.png

Louise and I discussed how a diaphragmatic breathing pattern can help to mobilize the spine: An inhalation will slightly extend the lumbar and thoracic spine, exhalation flexes them. Could her belly breathing pattern be the main contributing factor to her stiff spine via never quite mobilizing her T spine? Or, could her stiff spine the be major contributor to her belly breathing pattern? I suppose it will be both until we know for sure.

LET’S GET VAGAL

Of course I’m going to bring up the polyvagal theory. Because I think too much.

The vagus nerve (cranial nerve X) is intimately related to the processes of breathing, vocalizing, and the striated facial muscles, making singing what Dr. Steven Porges may consider a “neural exercise”: One that combines the various functions of the vagus and serving as a portal for ventral vagal stimulation, and easier, quicker access to parasympathetic state of health, growth, restoration, and positive social engagement. Porges has described that both singing and playing wind instruments are ideal examples of neural exercise to “tone the vagus”.

Having just finished reading The Polyvagal Theory prior to working with Louise, I was curious about how singing could be used as a method of neuroregulation (which is one reason why I also wanted to study it). However, I was also curious how could this be affected by some of the inefficient habits I’ve observed in some singers, like poor breathing patterns, hyperinflation, over-breathing, spinal immobility, and poor internal pressure regulation, all of which in themselves can be correlated to a state of inhibition of the ventral vagal brake as stressors on the system, increasing sympathetic, fight or flight activity.

For example, a state of chronic hyperventilation (breathing in excess of metabolic demands, which can easily happen with the amount of mouth breathing involved in singing) could contribute to inhibition of the ventral vagus and increase sympathetic activity. Too, a state of chronic hyperinflation (common for singers who hold onto their reserve and never practice complete exhalations) is related to sympathetic activity due to the resting inhalatory (contracted) state of the diaphragm and exacerbated by the correlated extended position of the spine and ribcage.

In order for singing to be a portal for increased ventral vagal activity, do the mechanics of breathing need to be “optimal”? I’m sure they don’t need to be perfect, but for how long can one sing with inefficient mechanics until there is a negative effect? What is the sweet spot?

In other words, is the vagal stimulation via the act of singing- coordination of the various structures innervated by the ventral vagal branch, a sufficient counterbalance for these “non-ideal” breathing and postural habits (as we’ve been discussing in Louise’s case)? Or could enhancing the body’s fundamental mechanics, helping to make singing and breathing make singing less of a strain to the system, transform singing into an even more nourishing experience? And, much like an athlete stuck in a pattern of training that could be leading them to injury, does the act of singing in itself serve as an escape from noticing the poor habits associated with it until it is too late?

For me, dance was an escape from “reality”, and I imagine singing could be an escape for some individuals. Though I was a good dancer, I had shit for fundamental movement mechanics. Though I felt “good” while I was dancing- the escape into the flow state of the music, the movement, and my body, I was using this feeling an escape, and I ignored the symptoms of this (everything hurting). Eventually, ignoring the symptoms that dance was no longer nourishing me began to hurt enough that the escape was no longer even a possibility.

Could singing be similar? Do singers burn out the bodies in the same way that dancers and athletes do? Curious…

I’m probably just thinking too much. But if I don’t write down my thoughts here, they will fester and rot in my brain.

CONCLUSIONS?

It is lovely to reflect on the interdependent nature of all structures of the body like this. Lovely to attempt to map it with the Flow Motion Model (FMM). I am still questioning a lot of what I just wrote, especially the stuff about the larynx movement. If you know things that I don’t, I want to hear them.

Louise is an incredible singer already, but she has been noticing an increase in “support” while singing since working together. She also has had the realization that maybe she doesn’t need to take as big of breaths as she does, doesn’t need to hold onto as much air as she does, and can sing just as well, if not better, with healthier breathing habits. Apparently, what she’s been working on with me has also been useful for some of her students, too.

Very cool stuff. I’m interested to see how things go for her, both with singing, and her movement/strength training practice.

Louise is also my vocal coach, and I’m sure I will be pestering her to go into agonizing detail about the use of breath and larynx while ~~trying not to embarrass~~ ~~myself~~ singing.

Apparently, I have now agreed to be the terrible singer in a terrible ukelele and brass band. My only condition was that I get to keep the beat on a triangle, and that we perform only Wonderwall. Watch out, Toronto.

A Farewell to Orthotics

Tracy (not real name) is a lady I first met while she was waiting to get knee surgery (meniscus repair). We began working together to help her build strength and prepare her body for the procedure.

https://www.youtube.com/watch?v=jpems5aWrt0

That was NOT the kind of surgery Tracy got… I just like/am traumatized by that video.

I am writing this piece about Tracy because it is a lovely case-study of a few things:

a) How someone who is relatively unfit can see a surgery as an impetus to get in shape, address movement mechanics, and go on to hike in the mountains pain free 6 months later.

b) How surgery can sometimes be a very good idea, not only because it can reduce pain symptoms, but that is can sometimes reveal the true underlying cause of WHY there was an issue in the first place.

c) How learning to pronate the foot, and removing an arch supporting orthotic can be a major piece of the knee-pain puzzle.

d) How focusing on symptoms prevented me from seeing the root cause of the issue as quickly.

PRE-SURGERY TRACY

At first, it was Tracy’s left knee that bothered her (primarily with flexion), and she was scheduled to get surgery in a few months.

In an assessment, her center of mass was shifted to the right, and she found it very difficult to shift her pelvis to the left, which, made perfect sense at the time, her left knee being in pain, wouldn’t you want to shift away from it?

As part of our process pre-surgery, my goals for her were to see if we could help left knee flexion feel a bit safer by exploring the mechanics of weight bearing on her left leg (learn to pronate and supinate the entire foot, hip, knee- lots of suspension/transition). Her goals were also to build full-body strength, to be in better condition going in to the procedure.

Two of our outcome measures were kneeling on her left knee, and a quadruped rockback (putting it into deep knee flexion).

Week by week as we plugged away, she noticed some good changes in how much range of motion she could access pain-free, and felt stronger over-all going into the surgery (that was April 2016).

I had my doubts about surgery. I always do, as it is a last case scenario- Avoid unless absolutely necessary. However, in Tracy’s case, the surgery was a very, very, good decision.

As it turns out, her left knee wasn’t the issue. It was just making the most noise. The squeaky wheel gets the grease, as they say.

What should have tipped me off from the beginning was that in our initial assessment I was drawn to give her the AiM right “strike” exercise (replicate the phase of gait at which the right heel first hits the ground), which significantly improved how her left knee felt in both outcome measures. Not perfect, but not bad for a few minutes of work.

Why did an exercise for her right hamstring help her left knee? In Tracy’s gait, a stand out feature was that she did a massive side bend to the right but never left, which seemed to be a counterbalance help her to get her center of mass left but not right. So to me it seemed logical to get her to do the opposite and see what would happen: Left side bend, right heel strike, effectively shifting her mass off of her left leg, getting it onto the right.

(To be honest, I can’t quite explain why I was drawn to right strike… There was more information at play than just the ride lateral flexion, but right strike seemed like the shape her body was craving).

In hindsight, I probably should have followed that thought process further, earlier on, rather than spend so much time working on the left knee mechanics.

WHY exactly did right strike seem to help her?

What in particular about that movement was so useful?

But I got sucked into the symptoms. That, and I had just learned a bunch of cool stuff about knee mechanics and wanted to explore that. Very selfish of me.

That said, the work on left knee mechanics did come in handy as she rehabbed her knee, so, I suppose it’s impossible to say that I “should” have done anything differently.

So, Tracy’s surgery was successful, but, it became very clear what the root of the left knee issue was after the procedure.

POST-SURGERY TRACY

After the surgery, her left knee felt great. Rehab went smooth, and by June I began working with her again to continue strength training. It was at this point that her right knee started bothering her. The left knee felt better than ever- she could kneel on it, do a deep knee bend without pain. So why the issues on the “good” side?

From the start, there were hints that Tracy had trouble weight bearing on the right (right strike being helpful), but these were drowned out by the noise from her left knee. Now, however, it was clear to see that she could not shift her center of mass to the right.

To me this was strange. Generally, after an invasive procedure, people will have issues weight bearing on the side that was operated on. But Tracy had no problem with that.

Was the reason her left knee got beat up because of a long standing inability to weight bear on her right leg? And why was she having trouble getting her weight to the right?

Here’s what we found…

Tracy’s right knee was not externally rotating with flexion. A go-to to check in with when there is knee pain- Is the knee rotating is is flexes and extends? As the knee flexes, the tibia and femur should both rotate internally, but the femur should rotate farther, creating tibial external rotation under the femur (knee ER). Tracy’s femur and tibia stayed stuck together, the femur never quite getting internal of the tibia, flexing with an internally rotated knee. It was likely that the two bones sticking together, not gliding smoothly, was what was causing her knee discomfort. That would certainly create a strategy to avoid weight bearing on the right.

Tracy also has a bunion formation on her right foot. I hadn’t been able to see this before because I was too focused on her left side. Doh. Note to self: Don’t chase symptoms. Bunions can be seen as a functional adaptation, for example, to stop pronation. Pronation and knee flexion/ER happen at the same time in gait, and so the bunion could have formed to stop the knee from bending and externally rotating by blocking the foot from pronating.

Tracy had also been given an orthotic years ago to support the arch of her right foot to block pronation and keep the pressure off the tender bunion, which, in my opinion, seemed to be compounding the issue, not solving it.

In summary:

Right knee not externally rotating= painful knee

Pelvis shifts left, but not right = not able to get mass onto right leg because of right knee feeling unsafe to flex

Right bunion= blocking pronation and knee flexion

It’s nice when the information lines up like this.

THE NEXT STEPS

In the words of Gary Ward, we proceeded to “pronate the shit out of” her right foot.

The next paragraph is for the dedicated AiMers.

The method we chose was a modified suspension in which we could simultaneously:

decompress her bunion
pronate her foot
flex the knee and externally rotate her knee

At first, I simply got her to bend her knee as I guided her tibia inwards and pulled on her first met. This decompressed the bunion, opening up the medial side of her foot, and encourage some dorsiflexion and abduction of the forefoot, allowing her foot to pronate. We also needed to wedge the lateral edge of her foot to close the space between her lateral arch and floor, helping her to feel her full foot in contact with the floor, and to experience a real pronation, not eversion.

Then, to encourage more knee external rotation, I got Tracy to rotate her pelvis as far to the left as she could, to maximally internally rotate her right femur as I blocked her tibia from rotating further medial than her big toe, helping her to get her femur to internally rotate beyond her tibia, and creating knee external rotation.

Then, I stopped pulling on her toe to see if she could pronate without my manhandling, and we used a medial forefoot wedge to help her foot get frontal plane opposition.

There was no knee discomfort during this process even though she was bending her knee farther than what would normally reproduce pain.

Tracy is a woman of very few words and, when I asked her how it felt, she told me it felt “good”.

After this, we got her to try some step-ups, something that was bugging her knee to do, and there was no discomfort. Yay!

DITCH THE ORTHOTICS?

It was clear how pronation was a nourishing experience for her right leg, yet she was wearing an orthotic daily that prevented her from accessing it. I am often tentative to ask people to try removing their orthotics. Many people feel unsafe without them, even when they could be keeping them in pain.

Floorthotics over orthotics. The ultimate pronation floorthotic

Fortunately, Tracy came to this conclusion on her own. “So… Maybe I should take out my orthotic?” she said. I told her, “Yeah, try it. If it feels awful and dangerous and your knee hurts you can always put it back in, but try spending some time without it and see what happens, as an experiment”.

Typical… The solution is often to remove something, not add more, just as there is nothing you can buy to make you better, more complete, but so much to gain in letting go.

The following week I asked how things were feeling without the orthotic. Woman of few words says, “Fine”. Any knee discomfort? I ask. “Nope”.

Wonderful.

Tracy is a rare kind of person to work with.

Laughing as she moves into spaces where her body feels off balance and falls over.

Determined to try everything I ask her to do, completely trusting the process.

Smart enough to suggest taking out her orthotic before me trying to persuade her to even consider it.

For every woman like Tracy, there is a client who refuses to face their issues head on, choosing to move around them, not trusting in themselves or in their guide, opting for passive therapies entirely or simply ignoring the issues as long as they can.

CONCLUSIONS?

Writing out this case study helped to cement a few important lessons for me:

Remember to ask why is the body doing what it’s doing. Ask, how is this serving the individual? Ask the 6 questions: What is happening? When does that happen? Why is that happening? How is that happening? Where is it happening? and, What if we…?
Remember not to get sucked into the symptoms. Interview the whole body.
Surgeries aren’t all bad.
Change can’t be rushed. People will be ready to take away crutches like orthotics when they are ready, and when they see the value in it.

And lastly, I wanted to write this to remind myself to enjoy every second of working with people like Tracy, because not everyone is as open to trying the weird shit I ask them to do as she was. People like me, who recommend to train your feet to pronate and throw away the arch supports, are the minority.