​Most of my clients come to the clinic because a certain movement or activity is causing them pain. For example, it hurts when they go down stairs or it hurts when they are bending forward to brush their teeth. A certain way of moving and a certain pattern of muscle activation is setting off the alarm signals. In these moments, we need to unload and unwind the nervous system. Keep moving, but without triggering the pain response. The way to accomplish this is to gradually move into and around painful ranges of motion. Controlled movement around the pain slowly desensitizes the painful movements and teaches the brain that movement is safe.
 
This whole experience is a learning process. Many movement patterns become so habitual that they go unnoticed. We don’t think about how our knees bend when walking down the stairs or how the spine bends when we brush our teeth. Movement becomes automatic and subconscious. When pain occurs, movement all of a sudden becomes very conscious. Painful movements are sensitive movements, and the body develops new patterns to minimize pain. 
 
The process of identifying pain and retraining it can be complex. At times, the learning process can feel like pushing a large rock up a mountain. The more chronic the pain, the longer that rock has settled into the earth. Just as the rock doesn't want to budge, our old habits can be hard to change. To help someone out of pain, we need to identify the specific pattern causing someone’s pain and retrain a new pattern. We need to unlearn certain movement habits and engrain a new muscle memory. This entails calming things down and gradually building them back up.
 
In this post, I am going to share several of the movement principles I incorporate with my clients to help them calm down symptoms and gradually learn new movement habits to get out of pain (and prevent injury in the future).

​Movement gives our brain tons of input about location of our joints, amount of pressure, speed of movement, and more. This input is important for body awareness and preventing injury. If the input comes in too quickly, the body has to react to the movement and no learning occurs. One of the ways to slow down the input to the brain is to slow down the pace of movement. A slower pace helps someone feel when and where a movement starts hurting. Controlling the speed of movement helps control the speed of learning. In the clinic, I’ll use a TRX or some other form of assistance to help slow down a movement to make the learning curve easier.

​Breaking down a compound movement into smaller parts is a highly effective strategy for retraining movement. The process of disassembling then reassembling allows us to separate the parts from the whole movement. During this process, you can identify a weakness or inflexibility that is driving the problem. For example, if someone has pain going down the stairs, we can isolate the major joints performing the motion. Instead of multiple joints receiving input, we can train each joint how to move without triggering pain. Joint by joint we rebuilt the entire sequence. 

The sensors within muscles, tendons, and ligaments are constantly providing the brain with feedback about position, pressure, pain, temperature and more. This barometer is important for how our muscles adapt and react to the outside world. Starting with a stable surface allows these receptors to find a set point. In the clinic, I’ll start on a solid, firm ground before training on unstable surfaces. I make sure the client can find their balance and center of gravity on the ground before adding a more complex variable.

​As our movements get bigger and our tissues stretch further, we put strain on the input sensors that I’ve mentioned above. When these sensors are repetitively strained at their end-ranges, their ability to provide reliable information becomes hypersensitive. When getting out of pain, we need to start in a range of motion that doesn’t aggravate these joint sensors. Beginning in a neutral position where our muscles are strongest is typically the best way to calm down symptoms. In the clinic, I'll start people in an open joint position where there is the least strain on the joints and soft tissue. As their pain subsides and tolerance increases, we gradually start challenging their nervous system through full ranges of motion. 

​Using these principles (among others) allows clients to understand which movements, postures, and environments are causing their pain. By starting slow, small, and simple the learning process can occur with less distraction. This allows us to calm down symptoms while keeping the patient in control of their symptoms as they gradually retrain their nervous system! 

​In the post below, I am going to discuss CrossFit world champion Tia Toomey's 1 repetition max (RM) clean and jerk from the 2019 Crossfit Games. When watching the lift, it is apparent that her knees move into valgus (collapse inward) while accelerating upward from the front squat. I am using this video in particular because it has gained some attention as an example where movement biomechanics are not related to pain. In other words, the video demonstrates that a high level performer can have a ‘movement dysfunction’ without any pain. While this statement is absolutely true, it is important to take a broader perspective when discussing the multi-faceted subjects of pain and biomechanics.

​Watch the video below and continue reading!

When analyzing movement, context is everything. In this video, Tia Toomey is performing a 1 repetition max lift at the Crossfit Games. The context is a very heavy lift with very high stakes. In these moments of maximal output, we see the extremes of human potential and the capacity of the human body to find any possible strategy to succeed. Her two options for this movement are 1. fail the lift or 2. win the event. Tia Toomey utilizes knee valgus on this lift because it is an all out, 100% max effort event. Under normal circumstances Tia Toomey does not valgus every time she squats. If you watch her front squat on a non-1RM lift, her form is biomechanically clean and efficient. Valgus doesn't cause pain, but let's not confuse it to be a good movement pattern.

You may notice that I use the word efficient. Below, I will discuss how movement efficiency minimizes stress and strain on our tissues.

Squatting is a complex motion; and therefore, it has complex biomechanics. Many joints equals many parts simultaneously moving. For this reason, breaking down the squat into phases, joint actions, and muscles simplifies the equation.
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During the deceleration phase of the squat, the knee flexes as the hip flexes. With knee flexion, the tibia naturally and involuntarily internally rotates. This is commonly known as the unlocking phase of the screw-home mechanism. Tibial internal rotation provides access to the subtalar joint and medial arch of the foot. This trio of joint motions- knee flexion, tibial IR, and controlled subtalar pronation- are important because it unlocks all the main rotational joints from the floor to the core. These movements are functionally significant because rotational leverage is our means of generating torque and power. During the squat, the quadriceps, adductor magnus, and glutes are our prime movers. Using good mechanics, including but not limited to a hip hinge, knee flexion, and ankle dorsiflexion, allows for these muscles to function at an optimal muscles length to tension relationship. Good biomechanics don't waste extra metabolic energy. They are efficient!

The Set-up Position: Deceleration Phase
In the Toomey Technique video, she loads the weight properly down into her squat (see picture right). Toomey maintains an upright spine, good hip to ankle alignment, and strong posterior chain tension. Her proper mechanics during the deceleration phase allow her kinetic chain to load symmetrically and maintain her center of mass over her feet. This is important because we are our strongest when rooted over our center of gravity. Additionally, this position maintains stability around the pelvic ring, which functions to disperse forces throughout the body. Maintaining integrity through the pelvic ring allows the sacrum to wedge deeper into the ilia, which creates a more stable base to generate torque from. 

​This wedging mechanism is the reason that the sacrum is shaped like an upside down triangle. As load increases, the ability to balance force and form closure of the SI joints becomes increasingly important.

Maximizing Elastic Tension
From her bottom position, she then lightly bounces the weight 1x to take up more posterior chain tension and position herself directly under the bar. Then, Toomey uses the timing of the bounce to accelerate and spring herself upward. Much like a loaded spring, the bounce and catapult action leverages the elastic components of her myofascial system. 

If the bounce was removed, she would lose her kinetic energy and momentum would be lost. The kinetic energy would turn into thermal energy absorbed into the tissues. Too much heat leads to stress on the tissues and fatigue is felt.
 
Load and Explode: Acceleration Phase
As Tia Toomey accelerates from her light bounce, the weight of the bar is near her maximal myofascial force capacity. For this reason, Toomey’s hips adduct and internally rotate as she pushes herself upright. This creates the valgus position at her knee and momentarily puts her joints in a relative closed pack position. The valgus compensation functions as a means to seek stability. She momentarily ‘locks’ her joint structure so that her muscles can pull through the most challenging range of the movement. 

The transition from up-phase 1 to up-phase 2 (pictures below) utilize all the built in rotational torque of our joints. The transition from pronation, tibial IR, and femoral IR TO supination, tibial ER, and femoral ER was controlled. These joint motions essentially ‘screw home’ the movement up the entire chain. The knee valgus is Toomey’s strategy to find stability in the low phase of the front squat to complete the goal-directed movement.

I would argue that asking ‘good or bad’ is the wrong question. When discussing valgus (and all ‘movement faults’), we must have a clear definition of valgus. So, what is knee valgus? Is knee valgus from femoral internal rotation or femoral adduction and/or a flat footed posture? What degree of alignment do you classify valgus vs. normal alignment? And, maybe most importantly, does your client always squat with valgus or is it because of their current context? These contextual factors are essential to determining quality of movement and likelihood of injury. 

With that being said, typically valgus positionally inhibits the glutes, impinges the anterior hips, and collapses the arch. It is not a strong position and it locks out regional joints. These consequences of valgus decrease our degree of freedom, which could increase a person's risk of injury. For Toomey, the valgus is an exaggerated position of the normal mechanics. As her hips clear her knees, the knees return to their original stacked position. Since the technique video is a 1 rep maximum lift, it should be expected that her form and mechanics will be pushed to the limit.

In my opinion, valgus should be a movement strategy that we can tolerate, but it should not be our primary strategy.

It is well established that isolated movement faults do not cause pain. However, this does not mean that pain and movement biomechanics are unrelated. How we move determines where physical stress transfers into our body. If I squat on my toes, I use my quads to a greater degree. If I squat on my heels, I am more likely to engage the posterior chain. In either scenario, some tissue is going to take on stress. Stress creates disturbance and imbalance, and too much stress of any kind decreases our recovery capacity and increases our risk of injury.  
 
When someone chooses an inefficient movement as the primary strategy, the joint mechanics, muscle-length tension, and torque capacity all suffer. Does this cause someone pain? No, not in the moment, but it adds stress into the system. We need to have very strong primary movement patterns, and also resiliency to deviate outside of those patterns!