Victory Friday | Issue 35
Victory Saturday! • Why They're Not Getting Better • Lacrosse Rehab • The Hyper-Hypo Teeter-Totter
“Suffering is part of our training program for becoming wise.” ~ Ram Dass
Victory Friday is a weekly digest of reflections, insights, and tools from the world of functional manual and performance medicine. It is a free weekly publication. To support Victory Friday with a paid subscription, see below.
Happy Friday! Lots to celebrate this week as we dive into summer. I did some things, and I hope you did, too!
Be The Patient: “Victory Saturday!” Last weekend, I did a thing:
I finished an ultramarathon.
What used to happen every few months, had not occurred in three years.
I did not run fast. In fact, I was a laughable 65 minute slower at a race that, prior to Saturday, I’d only finished first or second.
But I ran it. Every step. And I ran strong. I ran consistently — running every step of the fifty kilometers of the McKenzie River Trail Run, the gem of the Oregon ultrarunning scene.
Lastly, I felt good.
Nerve tension stole away a lot from me: mobility, capacity to run fast and far, but also joy. Running was stiff. Running was painful. But worst of all, running was mostly miserable.
Indeed, I truly believe that profound neurofascial tension pulls on your brain. Thus, when you over-engage that fascia tension, the “pull” on the central nervous system makes you feel miserable.
And that’s how badly running felt, for so long.
But not any more.
It felt strong. It felt good. And it felt like I could keep going. The joy to persevering — to move forward, beyond fatigue, and deeper in the flow — has finally returned.
Even better? These lessons — these painful and brutally frustrating challenges — will directly benefit my clients, present and future.
A single race is not the finish; it’s just the beginning. But it’s a great start.
What I’m Into: Why They’re Not Getting Better. This happens to every manual therapist, almost every day:
You perform a skilled manual therapeutic intervention, and get outstanding results: improving mobility, strength, motor control and/or pain.
Yet, it fails to sustain. Mobility regresses, strength diminishes, motor pattern is inefficient, and pain returns.
What did you miss? Here’s my list, in order:
Treating the Effect, not the Cause (too low on the Pyramid of Why). This is the easiest — but most overlooked — cause. You treated the effect(s), yet the root cause remained. Thus, with time and activity, the same dysfunction re-accumulated. I always say, tongue-in-cheek:
The most financially-successful orthopedic practitioner is often extremely good at treating symptoms.
They do an amazing job treating symptoms…that return a short time later. Many long-suffering people are satisfied with serial (monthly, semi-monthly, even weekly) treatment to alleviate pain.
Yet, most of the time, the root causes is never truly — or completely — addressed. The Top of The Pyramid of Why1 has not been found.
Not Enough. Often, a stiff area has pervaisive and stubborn tissue restrictions. Did I “get it all” in the first treatment? Or did enough linger that it “pulled” the joint and surrounding area back into the dysfunctional state?
Like a rusty hinge sprayed with WD-40, was it “lubed enough”, or did I leave enough rust that it re-solidified?Rule of Thumb: Just because you “did it already” does not mean you did it enough.
Out of Sequence. Sequencing is an art-form. So often dysfunctions in the body require a Rubik’s Cube-like approach that is far out of reach of most silo’d specialist practitioners, most of whom are slaves to “The Evidence”.
My approach to cranial treatment developed out of necessity: when trying to correct torsions in the ribcage and pelvis, any attempts to push on either area were resisted. I literally got no resolution and could feel the body resisting my intended movement. Effective and sustained:
• hip mobilization required pelvis treatment, first• pelvic motion required the ribcage (diaphragm, lungs), first
• ribcage mobilization required cranio-cervical treatment, first
Thus, we can do a logical treatment, execute it well, get a good outcome…that does not last (even a few minutes): because we did not free a related dysfunction, first.Lacking (Fascial) Combination. This is an interesting one. Especially when dealing with fascial connections, a single dysfunction often has two (or more) “bookend” anchors — one local, and one distal.
Thus, local mobilizations often require combined strategies: pinning a dysfunctional area, then adding tension, distally.
This is central to many Institute of Physical Art “functional mobilizations” — applying a mobilizing force while something moves. Doing so creates a fascial tension between the local tissue — a bone, joint or system — and, usually, an extremity.
For example, my cranial outcomes were better and faster when I identified and utilized relevant tensions elsewhere in the body. “Pinning” corrective pressure at the head, while the client moved an arm, leg or trunk often get the most potent and sustained improvements in the whole system: in the cranial alignment, as well as the limb motion and neuromuscular function (all things that occurred with my “Grandpa Joe” client several weeks ago2).Failed to “Re-Educate”. This has three meanings:
A. We fail to perform a neuromuscular re-education, to train the brain to “own” the new motion in a strong, coordinated way,
B. We fail to re-train complex motor control strategies in an efficient way. The client goes back to his/her “old” movement pattern, recreating the dysfunction.
C. We fail to “educate” on activity limitations — character and quantity — that can be performed on a sensitive system. The client “over-does it”, causing a regression.It Takes Time. Lastly, sometimes improvements also take time.
Small regressions in recovery are a normal part of the healing process. But being comprehensive in both approach and troubleshooting can minimize delays and provide both you and the client piece of mind!
Cool Exercises I Like. Lacrosse-Specific Rehab! More great content from colleague Seth Blee, demonstrating whole-body post-op strength for lacrosse players. No one emphasizes the importance of connecting the upper and lower body through a strong core, better than Seth.
Joe’s Articles. Free the Hamstrings! As described here a few weeks ago3, here’s my latest from iRunFar — with video — on how to mobilize the thigh in three dimensions to improve hamstring (and all thigh) mobility.
Victory Friday. The Hyper-Hypo Teeter-Totter. A fun and quick one this week:
A client returned after a six-week break, with an improved neck — our treatment focus — but a sprained thumb. She had been on vacation until two weeks ago, then was immediately thrust back into eight consecutive days of nursing work.
Midway through those shifts, she began to experience thumb pain: proximal inter-phanageal (IP) joint on medial (ulnar) side.
There was no mechanism of injury: no acute over-stretch, no trauma.
A orthopedic physician assistant noted laxity in the ulnar collateral ligament of that first IP joint, and noted that she “might have to have surgery”.
That may be, but — absent trauma — why is that ligament lax?4
I looked “upstream”.
The adjacent metacarpal-phalangeal (MCP) joint was hypomobile: it lacked nearly a third of the motion of the unaffected thumb. Thus, when she gripped wide objects, the proximal IP joint was over-stretching — making up for the stiffness in the MCP
Then, the “Oh, yeah!” moment:
“I hit that thumb hard a few months ago!” she remembered, causing a lot of pain and stiffness. In doing so, it likely resulted in sustained mobility loss to the proximal thumb.
Myofascial work to the thenar eminence and “opening” (abduction) mobilization to the first MCP joint restored the motion.
Now, any potential treatment to the IP joint — bracing, strengthening, injections, or (as last resort) surgery — is more likely to be truly effective.
Take-Aways. A big rule of thumb coming at you:
When there’s hypermobility, there is often adjacent hypomobility.
Examples and novel concepts include:
Lateral ankle instability from: fibular dysfunction (“stiff” into a depressed position), medial ankle hypomobility, foot hypomobility.
Sacroiliac joint laxity from: hypomobile opposite SI joint, hip, ribcage (diaphragm and fascia), even the ankle?
Upper cervical instability from: mid- and lower cervical hypomobility, cervicothoracic stiffness, and…craniocervical fascial tension?
Even with trauma-induced laxity, check for adjacent stiffness. Balancing motion and function is crucial to allowing the collagen fiber of hypermobile areas to either heal or “stiffen”, naturally!
Issue 35 is in the books! Please share any feedback, comments, ideas and suggestions!
Thanks for reading, and have a great weekend,
Issue 5: The Pyramid of Why describes how potentially multiple different — and often disparate complaints (pain, stiffness, movement issues, dysfunctions — both orthopedic and non-) are driven by a singular — and often distal and “quiet” — root cause. And only by treating “the Top of the Pyramid”, are all those issues sustainably resolved.
Issue 24: The Grandpa Joe Effect: performing a single craniocervical mobilization on a man post-head and pelvic trauma resulted in an immediate improvement in posture, functional mobility, shoulder motion, and foot strength and sensation (to name a few things).
Issue 32: Freeing the hamstring via three-dimensional thigh (quadriceps and adductor) soft tissue mobilization.
How can we get more orthopedic practitioners to ask “Why”? If we don’t ask “why”, we may miss the root cause. And no treatment, including surgery, may be effective unless the root cause is determined, and rectified.