Podcast Episode 61: "It's the Quadz Until It's Not The Quadz" Part 1, with Erik Meira, PT.

you know you're not gonna be assessing an injury and going man they just had way too much hip strength that's really what the problem was it's like so yeah I mean get all the hip strength you want it is a you know when you look at the biomechanics of it the hip does play a role the problem is that the hips without the quadricep creates some pretty bad situations for a specifically somebody returning after an ACL reconstruction welcome back to the clinical athlete podcast if you're not familiar with clinical athlete or a network of health care providers students and coaches who specialized in the management of athletes you can find your nearest clinic lathi provider at clinical athlete comm we also have the clinical athlete forum where we discuss and share ideas and resources related to athlete health and performance to join the forum or for potential listing on the clinic Lafayette directory and for all upcoming seminars webinars and events details can be found on the website this podcast can also be found on your favorite podcast platform and if it allows you to rate the show we appreciate you taking the time to do that so that we can get this information out to as many people as possible my name is Quinn henyk I'm a doctor of physical therapy in Orange County California at clinical athlete Newport on this show we are joined by co-host Jared Maynard who is a clinical athlete provider and the clinical athlete continuing education director and a physiotherapist at depth physiotherapy in Waterloo Ontario Canada he is also a strength coach and a competitive palate through himself and we have our other co-host John Flagg who is an athletic trainer and the powerlifting weightlifting and strongman coach at 301 strong in White Plains Maryland and the owner of rebuild stronger he is also a clinical athlete provider and lead instructor of the clinical athlete powerlifting certification and we are very excited to welcome our special guests on this show Erik Mehra who is a physical therapist in Portland the creator of the science PT website host of the PT inquest podcast and is extremely active with leadership roles with in the American Academy of Sports physical therapy this is part one of a two-part interview on all things knee and science enjoy the show John flag what's up buddy not much man happy and very excited to be talking today yeah this is gonna be a good one Jared how are you I'm good man hunkering down also excited for this conversation yeah as am i so as of like 8:00 p. m. last night the entire state of California got the shelter-in-place mandate so we're just chilling out getting acquainted with a leaf blower in the background sorry about that it's like the grocery stores are still open you know what I realized that this is probably gonna be in place for a couple months at least that's what the governor said and I haven't gotten a haircut in a couple months and that's gonna be another luck my hair is gonna be long I'm gonna have to bring back an afro man ooh that's what I think yeah that's what I thought about we are also joined by Eric Mehra and I'll allow Eric to speak more about his background but I'm just hopefully gonna make him and everybody else uncomfortable right now and just gush a little bit because Eric is he's got a website called the science PT and he's a practicing physical therapist in the Portland area and he's also a lot of our listeners are probably familiar our six listeners with the PT inquest podcast and if you're LG the PT podcast and that's what got me down a certain track of thinking and that was back in 2012 I think is when you guys started that the PT podcast and then PT and quest just kind of grew out of that but I'm not exaggerating when I say those podcasts your website and your blog changed the way that I view certain things because I was in my second year physical therapy school kind of going into my third year and I was having that kind of existential crisis that students sometimes tend to have where they're you know inundated with a bunch of information they're not quite sure what's a filter and you know what sources to trust you're in school so you expect the information to be closer to the truth but you know you read other things and sometimes it's not

and your information truly helped me and helped the way I think and so for me it's like having one of your heroes on the show like you're on our podcast now which is pretty cool so Erik Mehra thank you for being on the show oh I that's very high praise I really appreciate that yeah we I started PT podcast in 2008 2011 that recorded a bunch and then we started PTEN quest which because JW is one of my first interviews on PT podcast we decided we were gonna put that out at the beginning of 2012 I think it was in February of 2012 is when it started and so yeah we've been doing it for I guess eight years now continuously and you know as you said I had similar experience going through school you know way back in the 90s where you know I'm listening to a lot of things and I grew up with a very in a very scientific household by my mom's a schoolteacher my father was an electrical engineer and it was there are a lot of things wrong just like this doesn't make basic scientific sense I mean this is this doesn't sound right and not really getting the support of people you know and encouraging that kind of thinking and so one of the things that we decided to do is basically like plant a flag you know not to try to change the way anybody thinks necessarily put the plant to flag and say hey we're over here thinking this way and if you're also having some of these same questions let's explore this together and see if we can have some good honest conversations around some things and the way I put it is I'm not trying to change the profession I'm trying to corrupt the youth so when PT inquest is a very simple format it was a journal club and but what I loved about it is that no matter the topic because you know you always brought it back to the ACL obviously if you even if it was a paper about yeah so regardless of the topic it was also about thinking through basic principles about the my practice of science and evidence-based medicine you know that whatever that term means to you but it was learning through those principles where it didn't really matter what the paper was about that was almost secondary and that's what I loved about it and it would just get you thinking and I think it's perfect for students and I always recommend it's always on the top of my list for any podcast that I would recommend and to get you on the show there's a plethora of things that we want to talk about and they all kind of dovetail nicely into each other but before we get into some of these topics can you tell our six listeners in case they're not familiar with you a little bit more about yourself what's kind of led you to your current interests to what you're doing now and those types of things well yeah I've been a been the physical therapist since the mid 90s I actually was a student athletic trainer at the University of Florida with her football program I like to say that the first year I was with them was their first national title so I have to assume that was my fault cause I kind of exactly and so I had one of those careers where I kind of bounced around a little bit I was never really happy at any place because every place I worked you know it was you know the volume of patients was always things that I wasn't particularly interested in you know a lot of you know chronic low back pain I actually was originally interested in that but I realized very quickly and I don't know why this seems to be like a new idea but it back in the 90s was pretty obvious this is a psychosocial issue and I remember writing my my final paper in PT school where I had to spend you know this is it's not before the internet but you know our library databases you had to go to a physical library to look up your research and we actually had a psychology library that was separate from the medical library so I had to go there and I remember that was what my all my thesis was on was the psychosocial aspects of back pain and again this is back in the 90 and so I quickly realized that a lot of what we were doing in PT was not particularly I guess interesting to me regarding that I'm a physical therapist because I really enjoy biomechanics and human psychology and there's no other profession that puts the two together and so I ended up kind of becoming fairly focused on hip mainly because there is a lot of questions around you know this what was a novelty of the young and you know the young adult non arthritic hip which we now have a lot of information on so once I realized that there is kind of a dead end there because there's also a decent amount of

psychosocial around that too I found myself really getting focused more on ACL rehab in particular the nice thing about ACL rehab is although we still have a lot of questions there's still a lot of uncertainty we published 1300 to 2000 articles a year on the ACL so there's a ton of literature out there to really go through and there's a lot of pretty good conclusions that we can draw there there's still obviously a very strong psychosocial I mean we're humans there's always a psychosocial component but to me the ACL specifically the knee and then more specifically the ACL is really a fascinating kind of survey of how physics applies to the human body I think that's a great segue to the ensuing conversation and just to anchor that a little bit you teach courses and you've taught internationally you've done that for years but recently you've put some of those out in an online version and we wanted to kind of allow those topics to steer the conversation you've got one that's applying science to practice and I thought well let's talk about that but then I said well those are just principles that are kind of intertwined within all of these other topics too so I think those principles are probably going to come up naturally as you apply these scientific principles to what we're doing and then you've got your other course on the knee that's now in online format and I thought that would actually be a great place to create some concrete examples base on some of these topics that will that we'll talk about and ACL is a good example because of what you just mentioned there's a ton of literature out there on that so our first topic or at least mine I want to get your thoughts on it is there's this pendulum swing in ACL and it seems like and really Neal and patellofemoral pain is it hips is it the hip or the quad do we want hip strength do we want quad strength well if we just look at the point of pain you know the knee and just look at the quad while we're missing this regional interdependence piece and you know that is so the pendulum swings over to the hip and the hip controls the knee and then you know maybe it swings back but you know kind of getting your take and narrowing this conversation down because I've heard you say time and time again it's the quad until it's not the quad so would you mind expanding on that a little bit yeah I mean there's a lot to unpack there because people get that mixed up to say so quad strength and it's like well if you want me to get pedantic about it I'm talking about knee extension knee extensor dysfunction now that could be limited by fear patella femoral pain that could be limited by patellar tendon general deconditioning there's so many things that can limit it but it is how does the quad interact with the world and can it is really kind of that question and so you know when we get into with that type of thing is you know when people say well is that the hip or is it the knee it's like well look it's not what I always tell people is I don't care what you're doing so if you're doing a ton of hip strengthening I don't care honestly if you're doing a ton of I don't know Reiki or something I don't really care what I care are the things that you're not doing so as long as you're addressing the quadricep or that knee extensor as a as a component then you can do all the other stuff you want you know nobody's going to be you know you're not going to be assessing an injury and going man they just had way too much hip strength that's really what the problem was it's like so yeah I mean get all the strength you want it is a you know when you look at the biomechanics of it the hip does play a role the problem is that the hips without the quadricep creates some pretty bad situations for a specifically somebody returning after an ACL reconstruction and this is difficult to do I think without a kind of a mental representation or some type of image but you can actually give a blog about this in on your website and it's titled why quad index matters and so could you talk a little bit about some of the biomechanics when it when we're talking about the quad and what the quads job is and let's say in a deceleration task versus the hip so why is it important to have the quad as a kind of a ground level foundation ok so the simplest you know we can get into you know Newton's laws you know force equals mass times acceleration so if you have force going into the system you

don't want to overwhelm the system with force and so the best way to have an effect on that there's a few ways you can have an effect on it well we'll talk directly mass times acceleration first so if I'm going to reduce the amount of force coming in one of the things I can do is change the amount of acceleration or deceleration that's happening and so when you think of acceleration as velocity over time or change of velocity over time essentially when you allow and people understand this you know if you hit something very stiff so like if you know the example could be if I hit you with a baseball bat or nerf bat one of them hurts more even if they have the exact same mass and I you with the same velocity the difference is that one gives so it allows a stretching of time to occur which reduces the amount of force that's going to go into it the other one does not give and so one of the best ways that the human body can kind of give is at the knee so you think of the knee as a shock absorber now in order for the knee to do that it has to have a fairly strong quadricep in order to absorb that now the problem when it comes to ACL in particular is that if you're not flexing at the knee at the flex somewhere and you end up flexing typically at the hip and so this is what's known as a hip strategy when you use that hip strategy when it's up happening is that you end up with a very stiff knee you can only absorb so much force at the hip by going through that strategy and this is where you know where I'll say is I'm perfectly fine with somebody using a hip strategy as long as they're also flexing their knee so they're getting shock absorption from two different joints instead of just one if you overload the hip in the sagittal plane by flexing the hip then you'll have to find another plane of movement that typically is going to be internal rotation and this is your classic valgus you go into internal rotation if you leave the knee close to straight and you go into internal rotation you're essentially putting all of the load right into the ACL and this is how you end up with an injury so it's kind of a two-fold effect by having that quadricep and again I'm talking specifically people with torn their ACL when we talk about people who have no history of an ACL injury this stuff does make sense but I don't know that the literature 100% supports it I can get into that if you guys really want but you know it's you know some of these conversations in key a fairly long but what we see is basically a failure the shock absorption system and by having a quadricep you're able to allow both flexing of the knee as a shock absorber and also flexing of the knee to get away from that super dangerous 25 degrees of flexion where the ACL takes vast majority of the load during any kind of algis as you're going through that you know thinking oh this the capacity of the quad to resist an external flexion moment just that that internal extension torque having that bio motor capability then affects the movement solution down the chain and I think a lot of times that thought process is flipped where you see somebody doing a deceleration task or a drop jump or some type of landing thing and you see a valgus or some type of injury risk mechanism and then you try to correct the mechanism by simply Keeling or doing whatever and then having them repeat the movement and it seems like that's where we get into trouble because we haven't actually identified the individual constraint that's underlying all of that stuff would you agree with that thought process or what's your take on that yeah and so that's where you know I teach a lot of dynamical Systems Theory when going over this and and I will like the highlight I am NOT a mathematician I am NOT an expert on that concept but as I understand it basically you know when you look at that somebody moving what you have to tell yourself is this organism unconsciously chose this solution to to a problem and that's what movement is and so this series of things that all came together to present with this movement strategy for lack of a better phrase so you have to ask yourself why did it select that you know we're not talking about a stupid you know organism human brain either we're talking about a very

complex interrelated system that is self-regulating self-correcting doing all these things there and it's choosing this the strategy as usually in the name of efficiency so to speak and so a lot of times if you see somebody using that strategy you can try to coach them of it but the reason they're selecting the strategy is very likely you have to test it to see very likely that they lack the capacities to do the strategy you're asking them to do so before you ask somebody to do a strategy you have to kind of take stock of what the person's capabilities are individually so like we're gonna look specifically at the quadricep and I'm sorry if you don't isolate somebody down in a quote/unquote open kinetic chain way you don't know what the quadricep can do you actually have to test it in isolation and see does it have the capacities to take the load that it's going to be that is going to be requested of it during the task that you're asking you to do and so what frustrates me is where you'll see people you know professionals trying to change the way somebody's moving but not taking stock whether or not they have the abilities to do it you know they'll say well they can squat really heavy weight it's like that doesn't tell you what the quad can do that just tells you that they can squat you know when you wouldn't you know the thing I also say a lot of times is the test what the tests test so if you testing somebody's ability to squat you're testing some of these ability to squat and that is it you're not testing their ability to generate torque out of their quadricep that takes another very specific you know test to do that and so before you ask and what you're getting at is you know when you look at the deceleration test in order to decelerate with a flexing knee it what happens when you do that is you create a very large external knee flexion moment from a ground reaction force and it's that's not as complicated as it sounds if people feel overwhelmed by biomechanical phrasing it's just saying it's a very large lever arm bending that knee and so it basically is asking the quadricep to give an equal and opposite reaction to that and if the quarter cept doesn't have the capabilities to do that it's gonna have to find a strategy that shortens that lever arm so that the quadricep doesn't have to work as hard and that's where we see that hip strategy come in where you know they throw their shoulders for they flex at the hip they're trying to move their center of mass forward so that the ground reaction force comes more vertically gets closer to the knee and ask less out of the quadricep and so you know you can bark at them all day long to flex an a it just ain't gonna happen and then the secondarily to that is the visual biomechanics that you see trunks way to the ipsilateral side in you know hip and termination knee abduction all these things that we try to a foot pronation all correct and it sounds like what you're saying that's just your body's way of dampening forces because it wasn't going to get it from the quad so it's just got to do that somewhere else so I think that confounds the whole notion of valgus in general you know yes it's this kind of boogeyman where the pendulum swings on that to where valgus it's all about valgus and then as swings now to oh you know let's just we don't worry about valgus we just let them move you know any movements beautiful movement because we're all and that's what so can you clear up some of the fringe on that and kind of bring us back to the middle on valgus yeah so those the question you have to ask is why valgus not whether or not valgus is good or bad August it's just more force or less force and so if you're seeing valgus with a stiff knee that we can say and I'll actually let me define that a little even a little more if you see valgus with a stiff knee at a high rate of change of velocity you know what rocket scientists will call delta v which is actually different than acceleration if you see valgus with a lack of knee flexion at high velocity that is a dangerous strategy there are potentially some freaks of nature out there who can do that and somehow have enough hip strength and enough control that they can handle that but that's not something they were taught that's something that a developed naturally and this is where I get into the person who's in never torn their ACL if they're using that strategy and they are a high level athlete who has been performing this for a decade like that I'm probably gonna leave that alone because they know how to do that but when I see it and again

specifically in somebody who's post-op ACL you know we there there's a study out there we covered on PT and Quest I can't remember the citation right now but it's in one of our episodes where they looked at the amount of force that goes through the body when you land with a soft core so in other words you're not engaging your core versus really contracting and stiffening your core as much as possible and guess what when you stiffen that trunk the amount of force that goes into the system goes up and that's because you've taken away some of that dampening as you noted there so you know when we see you know and I give the example when I do the course I show the example of somebody landing from a drop vertical landing so they're just dropping off of a 30 centimeter box landing on one leg and it's that instant where they're sticking that landing and they have a huge trunk lean they've got internal rotation at the hip with a deduction they've got pronation they have all these things going on and people are just looking at that going oh that looks terrible I need to clean up that trunk the hip I need to clean up what they're missing is that the knee is not flexing and so if they're gotta find that dampening somewhere well you'll notice though is a high-performance athlete especially somebody that that's elite they will stiffen all that stuff up and they're gonna start taking some pretty big forces through that knee well so that's the question is it a trade-off of performance to reducing risk because you know ask a basketball player who's got to do like a double or triple jump to go up for a rebound you know repeatedly boom boom okay land softly no you're gonna land stiff so you can take advantage of that elastic property and then spring back up or you know if you're on the field landing from a jump and then cutting you know laterally and creating a pretty immense amount of stiff and that in a instant of time so is that soft landing queue can that be trumped to say we'll just flex your knee you can still land hard and like put a lot of force into the ground but just try to bend that knee a little you know and we say more than 30 degrees or so because it seems to be that 25 to 30 degrees is ACL mechanism is that kind of a yeah is that a trade-off we can get away with to try to keep performance so if you were gonna teach somebody and I'm not saying it's impossible to teach somebody but if you were to cheat somebody strategy my feeling would be you'd want them to make their initial contact with a flex knee ready to explode out of that and so the idea there is though be flex at like 30 to 40 degrees and ready to hit that stiff because that stiff stiffness is gonna give them that kind of bounce off so to speak so allowing the muscle to kind of give you that kind of recoil from that now that being said I think a lot of ACL tears happen in a situation like it and you see it all the time in sports specifically soccer and an American football and basketball as well but I see this a lot in these sports where an athlete you know let's say American football you got a wide receiver catches the ball they were focused on catching the ball now that they've caught the ball they go to make an athletic move what they commonly call in an American football a movement athleticism and so they start to explode into a direction that they're going into and a lot of times as they're making that exploding change they'll realize that there's a defender there that they're about to engage with and so what's already happened is that they've initiated that movement towards the defender and now what they're saying is oh I need to change directions away from that defender or get tackled and so once I've got myself in that motion what may be the only strategy to get me out of that situation is to plant my foot brace with my knee relatively straight and just propel myself out of that in another direction now if I don't have the capacities to do all of that what will happen is the system will get overwhelmed and the ACL will get torn now that person does not have the history of knowing that this is bad and even if their brain knows it's bad they have no way to stop it from happening and so this is where a high performance athlete if you get them in just the right situation you know the injury is going to happen and there's not in my mind there's not really anything you can do anymore than you know I mean we've seen it an athlete making a move and they're like snaps okay well how do you prevent that I mean you just say you know the bone snapped I mean it's just so that once it gets an upload it's just gonna happen and so you know it's just the

system trying to find a solution that's gonna work for it not realizing that catastrophe could be around the corner but again I don't see that that's something that's you know you could train away so to speak we actually I think we talked about it an exact example of this at CSM I think it was Tyrann Mathieu Tyra Matthews when he played for LSU and yeah no place for the Chiefs but he in college he went up and intercepted the ball and the receiver was on the ground below him and so he had to do kind of do a maneuver to avoid because the receiver was trying to reach up and grab his legs and he had to plant really hard and he's a super explosive athlete and then it was boom it was a suti landed with a super stiff leg if he hadn't a torn his ACL he probably would have sprung five yards the other direction then went for a touchdown but it was yeah it was that moment that was just not avoidable but again it's a high-performance athlete whose brain is telling the body do every under no circumstances are you allowed to get tackled here do everything in your power to avoid getting tackled and unfortunately the only path through that is in and if you gave this situation just right the way I put it is that person's ACL is already torn before their foot hits the ground like everything is in place that the ACL is going to get torn there's nothing they can do about it at point other than just completely give up the play which no athlete consciously is going to do that they're not thinking about that this is also why it's really difficult to you know a lot of the training that we do to don't quote fix mechanics or kinematics is to is what we call an internally focused situation so the person you know is focused what their knee is doing in space and so you know when an athlete is on the field that lesson they should be thinking about is what their knee is doing in space they're thinking about the defender the ball the you know where do I need to be positioned how can I get from point A to point B as explosively in fact quickly as possible and again it's none of this is thinking about what that knee is doing so unless you're training somebody in a completely distracted environment and people will say oh I do lots of distraction training ah not finished completely distracted environment at a hundred percent speed you're not training and in not to mention ideally it should be on the exact playing surface in the exact environment that they will be engaging in during their actual sport and so the difficulty of that is so high and again I'm not saying not to what I'm saying is first and foremost make sure they have those capacities in place to allow them to have those strategies that they're gonna pull from be a little safer because at least they have the capacities to do them can you remind us and the listeners how fast the ACL tears from foot contact to boom so the best study for that was Koga I think 2010 where they took they'd use video analysis of two different angles and of people tearing their ACL so they just collected anybody who tore their ACL over the course of a certain time span that had two video angles of that ACL tearing so they could create a three-dimensional model and that's how they recreated the the exact mechanism of that ACL tear and then of course Carmen and did the the amazing cadaveric study in 2014 published in 2014 showing the exact actual force profile going through the knee when the ACL tears in exactly what position the knee needs to be and that's how we know this but Koga showed that the ACL tears and for one hundredths of a second from an initial contact to ACL being torn is for one hundredths of a second and so that's faster than I mean your foots in contact and the ACL is torn before your brain has any chance to actually tell the need to do something different than what it's doing by far well you gave that you give an example in your course that from the time that Usain Bolt is in this his stance and the blocks gun goes off he makes his first move from gun to first move is 13 milliseconds or 13 I know hundreds of a second there's a 1,300 second so three times as slow as your ACL going and that's him making that's it making his first twitch that's not him making any sort of athletic move that's him initiating any now somebody would say well he's a very fast runner he might not be the fastest initiator but still he's a superhuman elite athlete the idea that you're gonna have

a high school athlete do this is and let's be fair I work ACL a long time I love my ACL patients a lot of them you know a lot of this has to do with training age so it's a matter of they're trying to do a fairly high level sport that they don't have a ton of experience with quite yet and so that's a lot of our high school athletes they're just not trained enough yet and so I would imagine their reaction time being a whole lot slower than 13 hundreds of a second I mean and again you know if you sit through just that knee course that's it that's a whole you know plus the applying science to practice in the whole knee course that's nine and a half hours and it takes me you say it's the courts until it's not the quads and that's essentially what the whole course it get people from there through to that conclusion it takes nine hours it really does well I'm about 3/4 of the way through and I remember at CSM where you talked about kind of dislike you're leading them through this path and if you just start with it's the cause until it's not the quads you know if somebody doesn't just believe you right off the bat they're just gonna ignore that but what you do is you lead them to that conclusion we're really you just teach them how to think and you know the logical explanation is address the thing that has the most effect on the thing and that happens in regards to the knee and especially post-op ACL happens to be the quads but I think if it were anything else the first three quarters of the course it didn't have to be a knee course it could have been about anything like to do that's right and I'm a very strong believer and you can't teach anybody anything they have to believe that they thought of it themselves and so what I'm doing is just trying to lay out this path and I'm kind of watching the audience for the occasional they got it they got and they got it but I'm not telling it to although I'm trying to walk them through it and then when it when I do the big reveal it's obvious it's like oh you clearly hey guys Quinn henyk here we hope you're enjoying the interview so far with Eric if you didn't know Eric has for online courses right now on his website the science PT one of those is called applying science to practice and the others are complex understanding for simple solutions of the hip and knee or you can just do hip I can personally vouch for any information that Eric puts out but these courses in particular are phenomenal I've taken them and I've learned so much you can find the link in the show notes also go and subscribe to Eric's podcast PT inquest now like right now pause this one subscribe to PT inquest and then come back here speaking of online courses Jarrod maynard's pain science course is currently free for anyone to take we can't guarantee how long that will last but it's at least going on right now go to the link in the show notes and use the coupon code community speaking of free two more things we've launched free training programs with coaching right now we have a home based training program for those without traditional gym equipment and we have a powerlifting program to get the free programs and join the free Facebook community you can find the group link in the show notes hashtag squat up lastly we just finished a five-part webinar installment called the adaptable business where we do interviews with a live audience all about creating agile and sustainable business solutions all five webinars are free and they can be found on our website head over to the show notes ok back to so valgus you know valgus is its general term of different movements you've got a combination of hip internal rotation and tibial rotation and knee abduction and kind of all those things are what you've manifest to see like oh valgus and then secondarily trunk lien and foot pronation weirdness all that type of thing so it matters because it's it is a way to tear the ACL when there are other constraints in place like a relatively straight knee 30 degrees or less so what matters in that sense what the difficulty it sounds like is it's hard to change it it's hard to necessarily prevent it in certain high performance situations so then the there's this school of thought of well why don't we train purposely train into valgus to build the low tolerance of

the tissues or perhaps even build the structural resiliency of the tissues that are at risk so that it is more ecologically valid on the field what are your thoughts on purposely training into these positions progressively loading yeah that's a thing that it was brought up a while ago there was actually a Division one college program that was actually training their linemen to squat into valgus because they were trying to give them strength in Vegas and the idea being that if they find themselves in Vegas they have the strength to get out of it if need be and so they were doing their you know they would do their squats and deadlifts on that kind of stuff in a you know more corn quote normal fashion and then they would do it in two valgus as well with fairly heavy load just have them work through that and out of it now I'm not saying good or bad I think we have to ask ourselves what the purpose of the exercise is that's always the question that needs to be asked so if I'm having somebody doing a heavy squat I just you know sometimes my goal is I just want to put as much load on this system as I can so whatever strategy gives me the heaviest weight that's why I'm we're gonna use that maybe the goal but it may be the goal of all I want to get as much quad as I can both I'm going to change the biomechanics of that movement so it's more quad now if I'm saying I'm trying to expose them to avow this load well yeah I mean and that would be how you would expose them to a valgus load now the question being is do they need it or is that helpful i honestly don't have the answer to that to me when I think of a limited time that we have in the weight room with an athlete I don't know I'm gonna spend a lot of time going into that you know this is where you know some of you may be working with somebody who you know you have a strength coach that's really into like a you know sometimes we're like CrossFit type thing we're an SF ma type FMS type corrective program or they're like PRI or whatever and to me it's like you know we've got you know we have strength coaches that I work with that it's their profession they're tasked with a job it's not my job to do their job and so where I would say and this is getting back to what I talked about before I don't care what they're doing I care what they're not doing so it'd be here's a list of some basic things that need you guys doing in the weight room I need them I need athletes being exposed to a heavy load I need them working close to their max effort so that they have experience whether or not they make gains is a little less of a concern of my I just want them to have exposure to working with heavy weights so that when they're in the middle of a sporting task and they're asked to engage their muscles at max capacity they have experience with that as opposed to their muscle not knowing whether or not they can generate those types of forces and so that's what I think is extremely important now if those things are getting accomplished hey man blow up balloons all you want I don't care work on the vowel gets position and try to make them more resilient in valgus you know we used to joke about you know we see the strength coach having our seven-foot basketball Center doing a Turkish getup with a kettlebell we're like man it looks like a baby giraffe being born what are you even you know why I don't know why they have to do that but you know what as long as you ate your vegetables and and your main serving they're you know do all the have all the dessert you want over here on the side and so yeah so it's just opportunity cost it's not that any of those things are bad as standalone it's just a few if that imp Rises your entire session and you've not tested the tissues with adequate loading them that are simply not prepared well I can just hear Scott Morrison on my ear yelling tissues have adaptive ceilings there's his thoughts it's like you can only load into valgus so heavy that's not gonna be heavy for any of the other tissues and my god can you imagine in the clinic like oh we're doing drop jumps or something off a 30 centimeter box and I'm like alright I want you to really drive that knee in there and they do what I say and man they just happen to combine it with a really stiff knee and so if that oh Lord well what's funny is so Christian Thornburg's group they did a study where they looked at people who had progressed into elite athletics but never torn their ACL and then had them to drop vertical jumps as a test they were a subset that polanco failed the drop vertical jump because they went into a pretty significant valgus but when they actually tested then they had insane hip strength because we always think oh well they go into valgus because they don't have enough hip strength it's like you know a great way to strengthen the hips land in Vegas because when you land in Vegas if you don't go through to complete collapse it's your hip muscles that have to that

are getting loaded you look at the biomechanics of it and you're creating a fairly large moment arm for the hip abductors when you go into valgus and so it's a great training modality for the hip abductors if you wanted now again as we're talking about here I don't know this is like and I'm not going to teach my post-op ACL had to use a hip strategy I'm not going to teach them how to you know yeah let's go ahead and go into valgus and work on you know just having enough strength there are lots of other ways to go about that but yeah I mean that's the thing is you know I say that too is a great way to have really strong hips they have a really weak quad and go try to do stuff well there's some prospective literature on that with patellofemoral pain if I'm not mistaken or I think that those who went on to develop tell femoral pain actually had stronger hips and more of a dynamic valgus at the knee I think I've ever seen something like that kind of crossing over yeah so a strong hip allows more valgus if that makes sense because the more dogus you go into the more hip strength you need to be there otherwise you're gonna collapse all the way and so but the problem is that when you're in valgus you're putting a higher stress at the anterior knee there is more developing more contact stress when you're in valgus now again the question is this patella femoral joint condition to take that and the answer is yes then it's not a problem if the answer is no well it doesn't matter how strong your hips are it matters how much load the patella femoral joint is taking and how much you can tolerate taking and so people talk about oh well you can do a hip strengthening program and that's gonna you know reduce their patella femoral pain and they think it's cuz it's gonna change the tracking it's like it doesn't change the tracking at all that's not why they go into that position what you've done is you've unloaded the patella femoral joint while you're doing a bunch of hip strengthening stuff it calmed down and then you let them go back to stuff but it didn't quote-unquote fix anything as far as mechanics most likely is there a point where we're cueing somebody explicitly cueing them out of valgus question 1 and question number 2 can we actually even change that strategy ultimately when we when they go back to a you know their sporting environment well I don't think verbal cues so if you're giving somebody verbal cues to stay out of algis I don't want to say that doesn't do anything you know and so I'm talking like an internally focused type situation what it's doing is preventing them from going into valgus so now you're loading different structures and so if your goal is to put load into structure to condition those structures you know an internal cue is a great way to do that so internal focus now if you want to have somebody learn to choose a different strategy other than valgus during a task you have to find a way to make it so that they don't go into valgus even when they're not thinking about it and that the feedback that they're getting is automatic and inherent meaning that if they go into valgus they have to know they went into valgus without them actually thinking about their knee position in other words something would there would have to be something that their need would hit or something to tell them oh don't be in that position there so we use some strategies or we use like different types of gates that they have to go through but I'm not concerned about valgus I'm concerned about knee flexion and so I can get knee flexion by basically just restricting the space they have to operate in so it forces them to have to flex or need to do the task but they need a quad for that Eric yeah and so I can't do that until they have a quad and then so the funny thing is that you know as smart as all that sounds like to create gates and all this stuff we did that and what we found was that it was only a challenge for them if they didn't have a quarter set but the second they had a quarter set they're like this is stupid this is not so there again the reason their strategy is crappy is because they don't have a quad and if you know I have and then that's what we just read I just released some free case studies from the course so the case studies section of my course I just posted online most of it is online for free it's about 40 minutes worth and I show forced time curves and fourth position curves on people's quadriceps over the course of their of their treatment basically their their dysfunctions so to speak and you can see and neither one of them the cases I presenter or ACL is a zone animal these are like without from all pain or microfracture that kind of thing and you can see how it takes months and months even years to restore full knee extensor function and so you may be

telling yourself well it's been six months their quality is plenty strong I'll tell you right now it's not generating the torque necessary and it can't tolerate those loads and so you know when you say well their quality is strong that's why they're showing me these bad coordination or dysfunction what I'll tell you is until you show me a true test I'm going to tell you that it's not strong enough well just the jump in I think that's why I found one of the reasons why I found your articles really helpful and why I haven't spoken a whole bunch here and now just because this is maybe an example of what you were talking about before we started recording about you know the art of teaching is that you got to make it seem very obvious when you come back around to the main point it's got to seem very common sense and you kind of lay the groundwork before you get there but when it comes to testing the quad and just making sure that it is where it needs to be for us to then expose these athletes to these other stimuli so that they can make that return to sport better and you know we can essentially do our due diligence in serving these people we're doing a pretty piss-poor job I think across the board and as I was reading your article why quad annexed matters of Quinn reference before you laid out most of the objections that I've heard or would anticipate someone saying and just you know someone saying the quad strong how do you know what have you done to test it when we've done single leg squats okay and then you break down what the force vectors look like and how they don't look anything like what they need to be able to withstand when they're trying to decelerate pivot and then accelerate again and why you know something like leg extension or an inline in line test maximal exertion is a better measure of what we care about initially and making sure that they can tolerate these they can tolerate stresses or produced force in these lower speed contexts and then be able to transition into these higher speed higher effort context to so I don't know it's just been really helpful for me to contextualise where I think we are or at least the environments that I've seen to find myself in as I treat people and as I see other people treating athletes and just how we need to get better yeah and that's you know you mentioned so like in the course that I do it starts with the scientific method that's what we have to start with and then it goes into dynamical systems theory basic like force position before Stein curves what is what do we even mean by force what do we mean by torque what is peak torque what is rate of torque development what is impulse you know these basic concepts of biomechanics and so all that gets laid out and so that's why the title of course is complex understanding for simple solutions because once you understand oh I need to look at some very simple things first and make sure that those are kind of checked off and that I think is giving the people to understand that a very simple concept like this person likes extensors you know knee extension moment in turn on the extension moment as simple as that is if that is rooted in a very complex understanding of what's really going on with this individual and you know again the dynamical systems model is that you don't try to wrestle the system is way too complex and way too smart for you to constrain it enough to make it do what you want it to do without a lot of work and the likelihood is you're probably missing something and so when you attack and this is dynamical systems across the board not just with human movements so we talk about economics we talk about weather we talk about all these things when you attack a dynamical system you attack it at the inputs where you can so you try to constrain or allow certain inputs so can they use the quad can they not use the hip can they not use the hippie take away things and then you give it abilities and that's where you actually have an effect on that system more than anything and that's you know understanding that I think is you know really key we'd like to thank Eric for being on the show check out the show notes to find Eric's website and courses and remember this is only part one of this awesome conversation and of course thank you to my homies Jared Maynard and John flag for steering this ship alongside me and thank you the clinical athlete community all six of you for joining us on this journey of knowledge and improved practice of both the gym and clinic if you want to dive even deeper into the clinical athlete community you can check out all but the clinical athlete forum

has to offer which includes our clinical athlete Academy courses amazing discussions and networking with professional clinicians and coaches as well as students and just our overall hub of knowledge and regards to athlete's health and performance thanks everyone and talk to you soon