Hip Pathologies and Pilates

Chapter 1

Joints of the Lower Extremity

My name is Brent Anderson, physical therapist and founder of Pollstar Palazzos. And it's my pleasure to be with you today and talking to you about primarily the hip and hip joint pathologies and sort of the biomechanics of the hip. And more importantly, understanding its relationship to the pelvis into the knee. And if we don't understand the knee, it's a, it's hard for us to actually understand. The pelvis often say that the dynamics of the knee joints sort of determine how the hip is going to articulate with our pelvis.

So a lot of times when we see people coming in with hip injuries and hip pain, uh, we often have to look at the knee. Likewise, when somebody comes in with a patellofemoral problem, we often have to look at the hip to look at the orientation of the neighboring joints, not directly at the joint of where we see the pathology. So for our on the same page, we're gonna move forward with this. And I want to show you the first slide where we're looking at the lower extremity and we're able to look at the relationship of this kinetic chain. So everything comes from the ground and we're standing. And of course these joints are meant to bear weight.

That's their primary purpose. They have cartilage and they have capsules that are built to be able to support us in a vertical orientation. And interesting about that. This is, this is about balance. It's about things that we talk about employees all the time. Alignment, the better aligned we are, the more congruent we are, which we'll talk more about congruency later. The better weightbearing and the more efficient weight bearing we're going to have. Okay. In a word, efficiency will come up over and over again today. So one of the things that I always like to talk to people about in rehabilitation, they'll say, you know, is, is this about getting your muscles strong? I have a knee problem.

Should I get my quadriceps strong? If I have a hip problem, do I get my hip muscles and glute muscles strong before we think strength, we must think alignment and proper body biomechanics. And I think that scenario where sometimes we get a little anxious with, oh, we got strengthened that here per strain. That's shoulder. Get those back bustles strong. It's not really about getting them strong until we get alignment. Alignment has to be first. When the body is aligned, the muscles start to work naturally, efficiently. When it's not aligned, we're going in, up over recruiting or under recruiting or inhibiting or overexerting the muscles and have an imbalance in those in themselves lead to other types of injuries and pathologies.

Typically what we feel in HIPAA theology is the over recruitment of things like the hip flexors are over recruitment of the Piriformis, so we'll often say, oh, they got us so as problem or all they have a Piriformis Syndrome, when in reality those are secondary to poor organization and poor alignment. That's why Plati so naturally addresses those problems without even having to know exactly what we're doing other than working on alignment. When you address alignment and efficiency, those problems tend to disappear if you haven't done too much damage. All right, so let's take a look at some of these things. They hip primarily is a weight bearing joint. So when you look at these joints and transfer joints, so it's transferring the ground forces into the spine.

So when we think of the actual weight bearing in the hip socket with a single step in the ground force, you could be taking up to eight times your body weight passing through the hip joint. And you might ask, how does, you know, how do you get eight times the body weight through the hip joint? What actually happens is it's a matter of fall crumbs and levers. So the surface area is very small. So if my body weight is 200 pounds, a little bit more than that, but 200 pounds and I go to step on that leg, all my body weight goes through that small space. So what happens is it exponentially increases and it's estimated that somewhere just with normal walking mechanics, that it takes about eight times our body weight. And so the cartilage, the labor, and the different parts of those joints are made to withstand that force. Okay, so now here's the next question.

What happens when you run or when you jump right or you're dancing or you're moving through space, you're doing plyometric exercises are running stairs or stadium stairs or running down a trail coming down here. Right? So you're gonna imagine that our hips are made to take a tremendous amount of force when they are aligned. If we lose that alignment, then we are really in trouble. Otherwise we're, we're good. That's one of things we got to work on. Um, it is a ball and socket joint. So you've heard us talk about the type of joints. So a hip joint is ball and socket. The femur is the ball and the pelvis is the socket or the Acetabulum.

And so when that ball comes into the Acetabulum, it's a deep socket made for weight-bearing and is made to distribute for us in our direction. So a ball and socket joint, what have we say, six degrees of freedom in those 60 years of freedom means that it can move into flection extension, forward and back. It can move into abduction, abduction, it can move into internal, external rotation and it can do circumduction. So those are the range of motions of the hip. Okay. The knee joint is a by Chondra joint. We're going to look at each of these a little deeper as we go through. We'll even look at some video of it, but the bike condor remains.

There's two Kahn dials in each knee, so if you just take your knee and you just put both fist there like this, this is what that looks like. Now mechanically, if you think of the condos being like big wheels of a Dune Buggy, the medial Khan dial is always bigger or has more air in it than the lateral condyle. So it's a little bit like this and that creates the spiral of the lower extremity or the bone rhythm of the lower extremity. And how we respond to that spiral determines if we have good congruency or good alignment or not. If we allow the knees to collapse in, then we're going to lose that congruency. Are we end up losing those boundary them's up through the hip Patella femoral problems, foot and ankle problems. That makes sense. You can sort of see how that would evolve.

And the last one that I wanted to bring up today is the patellofemoral joint and the patellofemoral joint. The patella is what we call sesamoid bone. It actually creates like a pulley. So in the quadricep muscles contract, this space between the actual center of the knee joint and the patella out in front creates a leverage and allows us to have more efficiency and more power. More importantly in our deceleration. So when we're walking and we have good body mechanics walking, most of our muscle activity is in the deceleration phase of, of gate. So typically because we lean forward in our gate and we have feet in front of us, gravity is our propulsion.

And so other than a little bit of pushing off with our toe off, gravity propels us. And so our quadriceps slows down. That's what the Patella does. It just allows us to have a little better control as we decelerate or go downstairs. So when somebody has a patellofemoral problem, what is the most painful for them? Going downstairs or going down hill, right? Even more than going up. Okay, good. So let's take a look inside the hip joint.

Chapter 2

Common Problems in the Hip Joint

So when we look inside the mechanics of the joint, we can see how deep that socket is. And if you look around the edge of that socket, you'll notice there's another thin layer that's your cartilage or tickling cartilage. And there's a little lip you'll see sticking out at the very end. So you see the pink and you see the white and the white is what we refer to as the laborer. The laborer is a cartilage like in the knee that we call the meniscus or what you have in your back called the disc. These are our cartilage. This material, they do not have necessarily nerve innervation or a lot of blood supply to them. So they get their nutrition through movement. Okay, so movement is important.

Sometimes people think that we shouldn't be moving through the two joints to protect our cartilage, but of our college gets its nutrition from moving. That's the only way it can be healthy. And the same thing is true with the head of the Femur, the head of the femurs covering cartilage. So when somebody talks about arthritis or degenerative joint disease, they're talking about the degeneration of that cartilage on either end, either on the femoral head or inside the Acetabulum on the pelvis. Both of those can lead to them and the most common cause of arthritis is actually not weight-bearing. Okay. Very important.

What I just said, they did a study with lambs in New Zealand in the 60s and they hypothesized that if we taped up the front limb on the right side of the lamb and it walked around as a three legged lamb, that it would have significant degeneration in the front leg that had more weight bearing when it came times for lamb chops and they're going to look at it these things underneath a microscope, right? They looked at the four knees of the lambs and they that the greatest degeneration was in the non-weightbearing them. Then it was in the overused lamb compared to the two normal lips. The question is, is, is, is it that the inflammation that causes the degeneration, there are many types of arthritis, first of all. So there are systemic arthritis, which are arthritis as a result of systemic disease like rheumatoid arthritis, cirrhosis, different types of, uh, of, of arthritises or systemic diseases that cause inflammation that causes a speedy degeneration of the cartilage. When we're typically talking in orthopedics, we often talk about osteoarthritis.

So as to arthritis often is more aware in tear than it is a disease process. However, once inflammation takes place, degeneration speeds up. So our goal is to always keep the inflammation down. And that's true within is a, is a great question actually. Um, inflammation in our body is thought to be the primary cause of most of the diseases that we're suffering from in today's world. So when you think of Crohn's disease and intolerance to gluten and, uh, digestive diseases and even heart disease and all of our joint disease or our inflammatory diseases, so why are we so inflamed? Uh, there's a good book out called earthing.

I don't know if you've read the book on earthing, but earthing talks about the idea of inflammation as a result of pent up negative ions in our body that we don't get a chance to connect to the earth and release those negative ions. Right? The earth has positive ions, they attract the negative ions out of our body and diminish. And their studies now showing James Ashman has done some studies showing a decrease in the systemic inflammation. So now they're making sheets and hotels and floors and sandals that basically get rid of that rubberized artificial insulator. They keeps the inflammation in and allows the electrons to leave the body. So I know it's a little tangent there, but the idea is that what we want to do is we want to control the inflammation.

So inflammation can cause, because by malalignment and overuse or not using it, okay, so not using it also doesn't mean it means it doesn't get nutrition. So it becomes brittle and rigid. The cartilage. So a lot of times when we were looking at dancers that were having a lot of hip arthritis as they got older, what we found was the arthritis was more on the part of the hip that wasn't underneath the acid tablets. So the walking around external rotation all the time, part of their hip was not articulating regularly. They weren't going into internal rotation.

So they were not getting good nutrition into that capital for years and years and years. So 30, 40 years of not getting nutrition or that it becomes brittle. And so when they went in and saw the degeneration, that generation was more on the part that was non weight bearing than the part that was bearing. So important. Um, there also has been insurgence of diagnoses of this label tear. So you hear it more and more. Now people talking about an internal derangement in the hip. Well a labour or tear is often caused again by some kind of malalignment.

So typically if I stand with my hips externally rotate and I weight bear, my femur head is pushing on that Labor. And so the Labor would be lining the capsule here and it would be pushing that labor them forward. So then if I go down to a deep squat or I would move my hip in a funny position when I'm actually rotated, it's possible that I tear or start to traumatize or inflame that, um, that laborer. Okay. And that's why often in things like soccer, golf, in dance, you tend to see a high incidence of labeled tears. Okay. The Arthur one manifests with a deep clicking inside the joint. They don't like internal rotation. The sweep test, we swiped their leg through a range of motion and they can't bring their leg in or sweep it up. Um, I actually had labeled here and had it repaired about 12 years ago.

So arthroscopically, but, uh, I've torn it, uh, doing the dance, some dance activities and so that, that label, now I don't have the labor in there anymore. So now I'm at higher risk of degeneration. So anytime there's a little bit more movement than we want inside the joint, there's a higher risk of degeneration, that cartilage. All right. The other thing we look at in the hip joint as we look at the bony format formations around the neck of the femur. So sometimes because we are abusive to our hips, you'll start to see a little bony spurs around the neck and that will often pinch.

And so you hear people talking about getting pinching in their hips or pinching when they actually rotate that pinching off and can be caused by a little bony malformation. Just like you hear people talk about in the shoulders or in the spine, it's a little bone spurs, right? So there are some great surgeons out there now that are doing some cleanup that if it gets addressed early enough and they have the blessing to work with somebody who knows how to reeducate them to move. So a good [inaudible] teacher, they can in turn avoid having a total hip replacement early. So these were the very things that caused the hip to degenerate so much that by the time people were 60 70 they had to have a hip replacement. Okay, that makes sense. And there's a normal looking if there's no disease in this hip right here.

When we look inside the hip, you can see this a little bit better here. This an example of a labral tear. You see that little plug that got torn off the top there. Now my labeled tier, I lost 75% of my labor them. It was a big bucket handle tear that tore off from a subluxation in my hip.

But what happens is you can see how valuable that is as the cushion and the absorber of that force coming through the knee. So again, if I have bat alignment and that hip is pushed forward, what happens, right? I put all that stress on that labor and that lay room has a higher risk of being injured or torn. And that's what we're seeing here. We look at the knee, I talked about the two condos. So here we see the two con dials. We always know what side's medial and lateral by where the fibula layers.

So if you've ever tried to make a reference very quickly, you look on the picture, you see the fibula, you know that's the lateral side and the medial side actually is a bigger wheel than the left side. So you see how the lateral, the medial sides touching in the lateral side is not touching there. There's a spin to it. And I want to do a little exercise with you right now just sort of understanding the mechanics of this. So if you take your hands as if they were your knees, when we bend our knees, the Femur is going to spiral back, glide forward and laterally spiral. When I straighten my knee, I'm going to immediately or spiral anteriorly rotate and slide back. That's straightening the knee. Yeah. So let's stand up and try it.

So right here we're going to bend the knees. So we're going to have that post to your spin and to your glide lateral spiral and then it's going to medial spiral and tear. Spin post to your glide. That makes sense. Try it one more time. Cause what we could, we tried to do it the opposite and you'll feel it. You'll feel it not work. Right? So if we try to bend our knees and we're going to do an anterior spin trying to bend our knees, trying to get the bone to do this while you're bending your knees, your knees won't bend.

If you spin your femurs in while you're trying to bend your knees, it won't do, it either needs to be a ladder or spin. Can you feel it? Just let it spin. And it's not a rotation like we think of in our hips. It's actually literally the bone spirals going down and spirals in to come up out to go down and to come up. Okay, good. And here we see the same thing, right? We see the weightbearing joints, you see these deepening cartilage, the Munis guy that actually create a bowl, right? To maintain the alignment and the congruency of the condyles.

And then we have our cruciate ligaments and lateral collateral ligaments that maintain the stability. So when people start losing the integrity of these ligaments, right? Or having their Munis guy removed, what happens? What happens to them? What do they lose? They lose cushion and they lose congruency.

So they start to have some sloppiness in there. So now that femur can move around a little bit on top of that Tibia and started causing havoc, right? Because we know we're gonna get a lot of weight bearing through there cause we walk on those all the time. But if there's just that little bit of give in there, instead of being nice and controlled, we start seeing pathology.

Chapter 3

Congruency and Bone Rhythms

So we're going to look at the relationships now between the anatomical segments of the femur and the pelvis. I'm going to show you those videos.

They sort of represent that aspect of that movement. And then we're going to do a little lab to practice it. That's our intention today. So when you look at what the Femur to pelvis does, it moves fluxion extension. So if you just stand up, let's just feel those movements, right? We have flection and extension. So if I turned sideways, flection extension. Okay. So we have that motion. We have abduction, abduction, right? We have internal and external rotation, internal and external rotation.

And then we have circumduction which is a combination of all of those. Okay. On the oral down. Okay. That's the movement of the hip. So let's take a look at this movement. Let's see where I can find my law rather. Yeah, you are good. So notice again the relationship here, and this is going to be key for us to understand is that the femur is moving in one direction.

That means that the pelvis has to relatively be moving in the opposite direction, right? So if I was doing the same movement and I was keeping the weight born still on the leg, abduction will look like the pelvis doing abduction. It'd be the opposite movement. Flection of the femur would look like doing extension of the pelvis. So you'd see how the pelvis moves over.

The last view of this is actually my favorite when we see it from the top down. And you can sort of see the relationship of the axial load through the femur right here. So you'll see where all the directions and you see the space between the sacrum and the head of the femur. Is that a lot of space for a little space, a little space. That means that there really doesn't have to be a whole lot of transfer in our weight to maintain ourselves vertical because the sacred is here and my hips right here. So the amount of space is literally maybe couple half a centimeter.

It's not that far. Okay. We come down and we look at the the knee and here we see what we were talking about. This is really what we call arthro kinematics, the bone rhythms of the knee. And I'll show this one a couple of times cause this is a quick one. So that lateral spin, anterior glide, right?

You see that it's going to spin forward, glide back and medially spiral right there, boom. And we see that spiral. We see that relationship coming back home. We call it the screw home mechanism. Boom, back in place. So when we're walking and that legs extending, absorb that next step. Toyota makes it so it's a boney landing and absorption to slow us down.

If we don't want to slow down, then we don't want to land on our hill. So you've seen the transformation recently of going from heel base running to midfoot and barefoot running. That's because there's a lot less beading and pressure coming through the bones when we do a midfoot run. So you're absorbing through your soft tissues and not through the bony tissues. So we will see less arthritis, more soft tissue injuries with that running style. All right, so relationships between anatomical segments, the Femur, the Tibia is the other segment, right? We just saw that. So the Tibia, when I am weight bearing, right, is mean that the Tibia is going to move in relationship to the Femur, but relationship in the opposite way. So if my femur is spiraling laterally, what is my Tibia doing? Relatively spiraling immediately.

So what does that look like? Straight, right? When I see deviation in alignment, then I know the bone rhythms are not working correctly. So when we use our, I automatically as [inaudible] as teachers, we're automatically looking at that alignment. Aren't we? We want to see hip over knee over ankle, over second toe, right? So we're looking for that alignment. If we don't understand the bone rhythms inside that alignment, we often get in trouble. Okay.

That's one of the things we're going to practice today and that'll make a lot of sense to us. Let's take a look at, again, sort of the biomechanics here. So we said that the Femur to pelvis, our objective is to maintain the congruency between the head of the Femur to the Acetabulum. So what does that mean? How if you've come from the ballet world, for example, I remember getting hit in the butt with a stick because my butt was sticking out when I was doing a play, right? So my natural reaction getting hit in the back in the butt when I was going down to my plea a was to Tuck it under, right? Well that poster, your motion, they're coming down to my plate, stops the movement in my hip, right? Cause what I'm trying to do is I'm trying to turn out my pelvis and my femur at the same time, which means if both bones are moving in the same direction, there's no movement here. So the movements can come in my knees, my feet, and my sacred Yak and my lumbar because there's not happening here cause I got a bad cue. So sometimes as pilates teachers, if we come from that world and you see a lot of plies teachers teaching that methodologies who are coming from the old school of ballet and alignment and misunderstanding that when you're doing foot work on the reformer, if you go into a posterior tilt to do your footwork, you are challenging the natural biomechanics of the femur and the Acetabulum. When we do that, it's the same thing with our femurs and our tibias and we're thinking that we're turning everything out. We no longer have the spirals.

And so we actually decrease our available turnout and we decrease our available flection for the player. That makes sense. Can you see what I'm talking about? So what happens then when I want to go into a healthy play, right? So I'm here and I'm feeling the knees and the femur spiraling out. I actually want to feel my pelvis spiraled in. It's not that I'm going into put into an anterior tilt, I'm just allowing this space to come in here and now it opens up that range of motion for me to get into places that I normally can't. Why? Because I maintaining congruency. So let's give that a try.

Stand up for a second and let's just give that a try. Again, looking at going to a little bit of a second position and think of the femur spiraling out. The pelvis spirals in the end where I think of the spiral and you could think of it too, one of two ways. You could think of a marshmallow between your pubic bone that you put a little pressure on or you can think of your sit bones widening like a fan opening as you go down. Okay. And then do just the opposite. The femurs are going to spiral in and the pelvis spirals, apt pelvis spirals in femur spiral out, femur spiral in pelvis spirals out. Now if we do it the opposite way, this our how is testings to see if they're true or not.

We can look at it and say, let's try it with the femurs spiraling in as we go down in the pelvis, spiraling out and you'll find that you sort of get stuck. Let's try both of them out. Femurs out, pelvis out, back to ballet one-on-one. Right? Can you feel that right? Or let's have them both go in, right. So feel the pubic bone and the Femur Sproul. And also you're blocked. Can you feel the difference in the naturalist now that the femur spiral out in the pelvis, spiral in. And you notice how easy and how deep it is to come down.

So one of you come up here as a volunteer when to do this as the lab, you're gonna volunteer. Great. So come over here and I'm going to keep you facing sideways. So just like this, like this. Perfect. And go into that second position. Yup. Good. So what we're going to look at, you're going to do this with each other is as she comes down, she's going to bend and we're going to allow that. That's what I want right there. Okay. And then we go. Just the opposite to come up. Few spirals out, pelvis spirals in good, good. And you feel how that starts deepening, right? Because the hip, when we saw the video, the Femur is doing this, right?

It's coming in and spiraling and she's allowing that to happen by the Acetabulum. Moving over the top of it. Okay, now keep the ribs over. That same thing now and now just imagine the pelvis being a little more still in space, but allowing the movement of that Femur to move in the Acetabulum. So it come down. That same thing sound like the sit bones are widening now. There you go. Why new? Why new wine? Good and back up. Okay, so that's going to be the femur moving on the Acetabulum. Now we come down to femur on the Tibia. So now the femur spirals out, the Tibia spirals in.

So you notice what I'm trying to do is keep the alignment of the knee over that second toe coming back up. Just the opposite. And again, that's it. There it is. Good. And I can feel inside her joints sort of the releasing of maybe some preconceived notions that she couldn't move that far. Can you feel that? It's more letting go like, Oh yeah, I'm getting more movement. Yeah. Good. So let's practice that with each other. There's four of you. Two, one, two. And let's just take a minute to get that feeling of the internal, external rotation and the relationship between the femurs and the hip. Okay, so one of you down on the ground and putting your hand on the femur and on the pelvis in guiding that motion, right?

So we're going to feel the femur spiraling in as the femur spirals out. And then just the opposite as it comes up. And again, the image could be the sit bones widening as you come down and narrowing as you come up. And the key here is, there's a special word, it's called allow. So if you allow the joint to do what they're meant to do, you'll start noticing that range. We'll deepen that range will increase and you'll actually find that you're using muscles that maybe you haven't used forever, which is sort of a nice thing to find. You have a new range, so when we're working with dancers to bring their leg up into movement in their body, we want to get that hip range. We can do this now. Can you think of an exercise in the [inaudible] apparatus that would re you could really reinforce that you can do on footwork, on the reformer? Good. What else? You can do it on the strap.

Work without change it from an open chain or close chain to open chain thinking. If something is a little more close chain or pseudo closed chain on the chair, chair's a great place to start teaching those bone rhythms. Now I like to do it in the lunch, so it is truly a closed chain where the foot is up on top of the chair and the assistance comes from the back leg. But really looking at that relationship as a, they're coming up and down on this leg of what that bone rhythms doing. I had a professional basketball player that had seven surgeries on his left knee and he wanted one more season, one more season, and the surgery was very good. So I mean it wasn't really a surgery problem.

It was loss, appropriate ception awareness and function because of so many surgeries problem. So on the chair, within about five minutes, we were able to just reeducate that alignment and that can ruin unsee. And within a week he said he went from where he could barely touch the rim to where he could put his elbow inside the basket. Now granted six foot seven. But the point is is that he was able to, just with a little bit of congruency, right, just a little bit of congruent assay in the bond rhythms, the muscles came back naturally. Now he had to condition them and train them so they could work for a whole game.

But do you get the idea that a lot of times if I would've just done strengthening exercise with him, we would have missed the boat. It wasn't about strength with him. It was about congruency and alignment and that bone rhythm, yes, I'm talking about the lunge on the chair. So the amount and climbers, those kinds of things where we're actually placing our foot on top of the chair, our back leg is on the pedal and it could be sprung. The heavier it's sprung, the more assistance it is. Right. And if we use our hands on the handle, that's more assistance. So eventually you'd like to think that you could just do that with no hands and no springs. That'd be the optimal, right? That'd be the strongest position.

The more springs, the easier it is and the handles give you balance. Okay. So what typically happens when somebody does a lunge on the chair for the first time is their knee will collapse in and their hip will hike down. So you'll see this kind of a collapse on them, on that chair coming up instead of being here. The reason being is they haven't learned the bone rhythms of doing a lunch. Does that make sense? So the Avion, if somebody wants to do a squat with their weights, right, are our power lifters really have to understand those bone rhythms to be able to go through those ranges safely without hurting themselves.

And a dance with this landing big lands from a job and doesn't know how to decelerate through that range of motion is actually sending a tremendous amount of harm for force through those joints. That makes sense. Good. All right. What I wanted to do is, um, I want to take one of you through a little exercise. I know one of you has a little bit of problem with your hips, so we're going to pause for just a second. We're going to change our set around and we're going to come back on the trapeze table and I'm gonna show you some good exercises for the hips.

Chapter 4

Practical Exercises for the Hip

So now I'm here with Nia dra and we're going to take a look actually at her hip.

She's had a long history of, we call medial impingement of her left hip. So when she brings you, lay across her body or tries to internally rotate it, she gets restriction if not pain and been around forever. Right. Okay. So we talked about this in the very beginning. We said there's possibilities of what we call internal derangement and something that I forgot to talk about is what we often refer to in orthopedics as the c sign. So when somebody comes and they sort of talk and they put their hand in a c position on their hip and their sort of complain of pain there often means that they could have a little bit of a problem deep in the intra articular joint.

So that's inside the joint, inside the capsule. And I'm getting a feeling with nature that that's sort of what's there. And I want to do a couple quick tests first of all and see what's there. And then I'm going to take a do three exercises on the trapeze table to sort of help us and help her deepen the congruent with that socket and maybe get rid of some of that compression that she feels on the insert. I'll give her some home exercises to do for that. Okay.

So I'm going to come behind you. I'm going to lay on your back and as they got, and the first thing I want to do is just, and again this is a orthopedic test that we would do, but just to sort of rule out what sort of going on inside knee address hip. And the good news is I actually do have some, some movement in this plan. So when it's really bad, I can't even cross the neutral plane. Right? So I've had, I have clients where I just can't even get across or come up into 90 degrees. So this is good, right? Here's about where I'm getting resistance from her, right? A little bit of internal rotation. Good.

And the other thing I want to just test is the muscles themselves and see how much of it is muscles that are blocking it versus the joint itself. And the muscles actually don't feel too bad. So that's, yeah, so we want to play with that. So what I'm gonna do first is what we call our 90 90. So 90 90. I'm going to take her left hip and I'm going to suspend it in the trap ease table. So I'm using the ankle and the, uh, the thigh cuffs to be able to suspend near his leg. And this is really important because what it does for me as the plot is teacher, is it frees up my hands to be able to move her leg while her leg is supported in the air from the address. Just going to feel incredibly good.

Now the hardest thing about this exercise is getting people off the machine because they don't want to get off the machine. There we go. Then you just [inaudible] good. So now what I wanna do is I'm just going to take a post to your glide with, remember I said, how much weight can a hip support eight times her body weight? Right now I'm heavy, but I'm not eight times as heavy as nature. So her hip should be fine. Long as she's not feeling pain with that.

And where do you feel that? Okay. So we're just going to continue to work in that direction there. Am I out of the painful area now? Yeah. And let me just let that sink in there. And what I'm trying to do is over the years, because of her background, the talking and having that pelvis underneath the post here, capsule has become tightened. Okay?

So what that means is that her hip is being pushed forward in the socket. So when the hip is pushed forward in the socket, you're not going to have a lot of internal rotation because it's going gonna Pinch. That makes sense. So what do I have to do is I have to get that femur to deepen and drop into that socket without it, without it a pinching that front of the hip. So we're just gonna do a little bit of stretching and movement on the back. Oh, that joint feels amazing. So good. Yeah. Yeah.

But I do externally rotating like that. I'm not, um, I'm just keeping you parallel. Okay. And I'm just trying to massage into the back of that capsule. Okay. So I'm sneaking into ad duction and internal rotation there. Little by little.

Yeah but that's the beauty of the 90 92 so you can bring them up here if they're in a lot of pain just being in this position and you just be able to guide them through some movement is also very nice too without having to do any kind of joint mobilization per se with any force is just to get her to start doing a little bit of stirring the pot. So think of your exercises that you would do in the mat where you getting ready to do hip circles and the circles you can prepare her now. She probably doesn't like doing those exercises cause bringing the lady across the, the central plane is could be a little tough. So you'd probably cheat somehow figured it out. Well it goes into my, my knee, I've had knee and foot injuries.

Sure, sure. So already I'm coming across the plane a lot more. She's letting me do that. So our goal is going to be to get the femoral head to drop down in that socket and minimize that. And I don't have a positive clicking on you that I would expect if there was an intern, if there was a actual tear of the labor. So I'm not saying that there is or isn't, but I'm not getting a positive sign for one. Excellent. Okay.

So the pinching sensation that I have at the top is more of a lack of congruency. Oh, so your hip is pushed forward and so these structures get pinched when you go into a lot of flection internal rotation. That's so okay. Sounds right. And it's probably been doing that for a long. All right. Okay. So these tissues have adapted to that. So that's why, you know, a nice combination with what you're doing with your pilates would be to get, you know, maybe some mild fascia release or those things. But in conjunction with, so like right now I'm doing a little bit of a Fascia release on this lateral tissue here. That's amazing. That is so amazing.

That feels so correct. I remember anything that we do is manual therapist. Um, even though it's not in the scope of practice of the plot's teacher, the movement themselves, if their movements are taught correctly, eventually we'll have the same effect as somebody doing the manual therapy on the tissue. So, you know, it's not, it's not as say applies to you. You can do the manual therapy, but just even giving gentle guided movement in the circles for them and understanding the biomechanics or what has to happen. So the next exercise we're going to do is going to be one in quadra paired and on hands and knees. That's going to make a lot of sense now because we're going to think of that femur pushing back. Okay. So I'm gonna take you outta here. I know, sorry. It's one of those things, people love it.

I think this is also a great exercise for low back. So I'll put on both legs. If somebody's kind of really acute low back pain, just strap him up in that and they almost immediately feel relief and can get rid of some of the spouses that they're dealing with by that distraction. I do both legs. Now I'm going to have you go into hands and knees. Yep. Just like that. Yep. Perfect. Okay.

Now remember we said the femurs coming up, the Acetabulum sits on top of it. If she goes into wide knees, right? She's in a relative external rotation, right? So that's going to be the loosest pack position for her. That's going to be the easiest for her to move, and the basic got back into this position. Okay? Not much resistance is going to be met there as I bring the knees closer, right? So let's go parallel first, right? So just about there. Yeah, come back and we'll see a little difference. Now what I'm doing is I got my hand on her sacrum and that right there stopped them and I feel that sick. I'm start to tilt. That's as far as I want to go.

Okay. Now she's going to bring this into alignment with that good, and just gently push into that range there. And what I want you to imagine is that Femur head is coming right through this area, stretching out that capsule. So you're just sort of nicking that resistance. Who now this, I tell people sometimes get your kids to sit on top of your sacrum while you do this exercise. Okay? Just get a little bit of weight in there. Okay. And you can even just put your hand or you can put like a little five pound weight on there. You're not going to do any harm with that because remember how much weight that can hold, what not in sorts.

Anterior tilt. I just don't want her to go into a post to a till. So what I'm telling her is cause what, what she do as soon as she got to the end of that range, what did she do? Bloop. That's how she got around it. Which is if you're standing and you do that, where are you taking all your force? L five s one SACROILIAC. You're four oh five right. So that's why we see people that typically have restrictions in their hips start manifesting back and knee problems, ankle problems.

It'll be absorbed somewhere else for the feeling. Is it my hip to actually widen? Yeah. What I want you to feel is like the back of the capsule of your hip. So here's the capsule, your hip and you're filling it. Doing this like a pure form us is opening up and the back capsule that Femur is pushing towards that opening up cause right now it's closed, right? Right, right. So that hip is pushed forward in that socket. So it can't, it can't go into medial rotation as it deepens in the socket.

Now it can do internal rotation. Okay. Okay. So now the next step from here is we start going into internal rotation. So bring your knees together, leave your feet out. Let's use the same rule. So I'm going to keep that pelvis quiet and now go back up right there. Do you see how fast we got there?

So this is where you start listening and just be patient with it and glide into that space and you're going to nick that little resistance each time. Not producing pain but just before pain. Does that make sense? So I can feel pain my friend. Groins. Yeah, pretty right at the beginning. Say like. And did it decrease or does it stay the same? Does it get better? Okay. So let's see if we can move through that a little bit.

Cause it's been there a long time. Yes. A lot of it too is muscle memory. Now what we'll see is when we go back to parallel, you're gonna notice you can go a lot further. So go back to parallel now [inaudible] and I'll go back. Oh Wow. You feel the difference? Oh my goodness. Yeah. So again, we're just going to play this game of getting, see how nice that goes back. Now go back into internal rotation and again, you're going to lose that range.

And if you're up here you could see to a little bit of the asymmetry in the address pelvis. So I sort of see a little bit of a shift when shooting that internal rotation. So I know that that capsule is really tight in there and that's why I was saying this for her to get some nice deep mild fascia release coming across this area and just opening that up for her, right is going to be really good for her. Wow. And I'll just shift back, like you're going to push into my elbow with your FEMA [inaudible] and back out of it and back in it. So I just speed things up. That's all I do. Okay.

She'd get the same thing from doing herself. There you go. See some more range just as we're, you're knowing where to let go of that, right? Yeah. I changed the emphasis from the groin in the front of the hip to the back. That's what I want. There we go. Good. Okay. Now I'll go back into parallel again and see what happens.

Right? So we just get another 20 degrees. So you get the idea that for her, it really is about this back. I'm tempted to say it's changing so fast. It's not even the capsule that has really the soft tissue in the Fascia tissues around the, the posterior hip and that could just be from years of holding this, right? So you think of dance and in classical pilates and those to where we get a lot more of that and now we're going to allow that, that opening and really filling the space that the muscle that we're looking at goes from the tro cancer over to the sacred and actually in the inside of the sacrum and all of those, the [inaudible], Gogo cues, all the rotators, right? We're getting those to open up, right? Yeah. Yeah. So your immune is great with it. See, this is almost, hasn't changed at all, that relationship now lay on your back one more time near do with your head.

Yep. So I have you left like good and let's just see what it looks like now. Just sweeping your legs. So just give me the leg and can you see that? Now a lot of that was just you, right? Doing that. So again, a lot of times when we understand where the movement comes from and where we're not allowing you to come from, right? So when you realize, oh, it's a bone rhythm. This isn't this fascinating to me because I'll look at somebody who is, you know, 30 years. I have never do a plea AA. My heel cords are so tight, you know, I can't get down into a squat position.

Those kinds of things are hills pop right up and you do the bone rhythms form up in their hip and up in their knees and all of a sudden their heel cord becomes nice, long and supple. So it's telling me that a lot of times these are things that are strategy, not structure. It's not real. Even though it seemed, it manifested, it looked and smelled like a tight fuel court. It really wasn't. It was a poor strategy because they didn't allow that spiral to happen. They compensated by grabbing with those muscles in the soleus and the gastrocnemius. It didn't allow her to go in there. And it's the same thing that's happening here.

All of a sudden now we're starting to, you can see this range that you're getting now. It's going to be a process. So the idea is that every day practice that quadruples exercise, right? And just get used to being able to really send that femur into the socket. And even when you're doing things like leg circles, wait for the train to pass. So even when you are thinking about doing legs circles for example here like feet and straps go and straighten out, it's a little high, little strong, but I want you to think of is letting the hip sink into the socket rather than thinking of reaching the leg out. Can you feel a difference in that?

Now think of reaching the leg out like sometimes we cue that in polite, it's a bit of reach that leg out into it and when you reach that leg out, right, what you're really doing is you're pushing it anteriorly and you're closing capsule in the Bat, right? When you allow it to sink in, all of a sudden your range of motion increases, your power increases and the movement, you can see how you're going through a nice ad duction now. And a nice internal rotation with very little restriction feels to me like my leg is very slightly turned out. You're actually parallel that what I was just taking through, I was holding your leg parallel through the whole thing. Yeah. But you know your, your frame of reference is out here. Yeah. And what's happening now is I've been able to get another 15 degrees of internal rotation. So where your limit is now, right?

Where you're used to feeling like you can't get even the parallel and the parallels and arrange your turnout. Now I'm pulling you parallel but you're not filling the end of range. So you think you're turned out. Does that make sense? So it's, your proprioception is changing. Yeah. Wow. Okay. So all we're thinking of now is we just want to keep sending that femur back into the socket. Yeah.

That is thinking that that's where they quadrupled exercises. So nice hands and knees. Yeah. Good. Alright. So again, understanding strategy as applied, his teacher is crucial because a lot of times it's not a structural restriction, which means it doesn't need a structural therapist. A lot of times this strategic problem and it needs a strategic therapists and applied. This teacher is a strategic therapist. You are working on the alignment, the bone rhythms, all those things are fair game for you.

It doesn't necessarily need to be manufactured, released, or manipulated. Okay. Even when it appears like it does, a lot of times this try your bone rhythms and those kinda things in the hips, in the knees and you'll find some good things. All right. Against Dr. Brandon Anderson and plot anytime. Thanks for allowing me to come back and we'll see again in the future.