Easily Restore Knee Flexion After Injury or Surgery
This week on the Unreal Results Podcast, I dive deep into the complexities of restoring knee flexion following an injury or surgery. This is a topic that I know all too well as I spent many days in PT having my knee forced into flexion and well, I still don’t have full knee flexion. In this episode, I talk about some of my favorite techniques that don’t require you to force your patient into tears to help them achieve full knee flexion. You’ll hear me discuss some of my favorite approaches including the “standard” hands-on techniques with the typical biomechanical lens of view. But you know it wouldn’t be an Unreal Results episode if I didn’t talk about the holistic side of things including how specific visceral and neural influences can affect the knee as well as the importance of hydration. This is a can’t miss episode for all of my healthcare providers who want to help their patients with treatment techniques that stick from session to session without endlessly repeating them every session.
Resources Mentioned In This Episode
Episode 8: Unlocking The Fibula
Episode 12: Rest Posture vs. Stretching vs. Mobility
Episode 21: Easily Restore Knee Extension After Injury or Surgery
Episode 37: Swelling Protocol Update
Episode 45: The Kidneys - Visceral Connections To Movement
Episode 64: Anterior Knee Pain: Upgrade Your Eval & Treatment
YouTube Video: Articularis Genu Self-Massage
Instagram Reel: Articularis Genu Mobilization
Instagram Vid: Femoral Nerve Glide
Instagram Vid: Knee Pain w/ Flexion?
Instagram Vid: Japanese Rest Posture For Knee Flexion & Plantarflexion
Blog Post: A Knee of an Old Unlucky Running Back
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Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello, hello, welcome to another episode of the Unreal Results Podcast. We are in, sorry, I got distracted saying I'm live streaming, which now I see how this is happening. I have it open on two screens, so that's why. Okay, so, um, We're here in my, in a different part of my house, still in San Diego, but, weee.
Remember how the other day I was like, oh, I love this extended summer. It's local summer. It's a heat wave. We're in a heat wave in Southern California. It's really hot. Perhaps the hottest I've ever felt it here.
Not today, but yesterday. Man, it was At my house, which is basically downtown San Diego, was 102 degrees, which is nuts. And, um, you might be like, well, Anna, you lived in Arizona for 14 years. Like, come on, it's not that bad. And you're right. It's not that bad. I'm glad it makes me like, very, feel very confident of like, that's why I don't live in Arizona anymore.
But also, you have to remember Arizona, every single building, house, apartment. Grocery store, mall, like, literally gas station, like, food mart, like, literally everywhere you go is air conditioning to, like, 65 to 70 degrees Fahrenheit. And if it's outdoors, it has misters and shade and like it is set up for trying to get as comfortable as you can in the heat.
Now in San Diego, we don't have that. Most of the houses here don't have air conditioning unless they're like new builds. My house does not. I have a little tiny like air conditioner in my living room that I try to use to cool the whole house with and it's just like, I mean, it doesn't. I have like a sequence of fans that usually cool my bath, my back room, which is where my office is and my bedroom.
Uh, so I can sleep at night and I have a bed jet on my bed, which is like.
But they can only do so much and my house doesn't have great insulation. It's like pretty hot in here. I'm grateful for the little bit of relief I do get from the air conditioner and the fans because I'm not, because I know there's other people that live here that don't get that relief. So, um, the other nice thing it does cool down once the sun goes away.
So that's nice. I went to, um, last night in the 105 degrees, I went to a San Diego Wave soccer game. The, like the peak of the heat, which I would never usually do that. But Alex Morgan announced that it was going to be her last game. She was retiring. And, um, I was like, that's, she's an icon. She is like a goat in really all of sports, definitely women's sports.
And I wanted to go support her. And I've always been a big fan. I've never actually seen her play in person. So I was like, you know what? Let's go! So, I went to the game last night, and I'm really glad I did. It was great, even though I lost, it was great to, like, just see all the celebration of her. Um, teared up, of course.
I am, like, a sucker when it comes to that, um, from an emotional standpoint, but yeah, it was hot. Um, So today is a little bit better, but yeah, it was definitely, I had to evacuate my office, which is like the hottest room in the house. Um, I had to evacuate my office around one o'clock and I hadn't recorded the podcast yet.
So I was like, uh, got to do it somewhere else. But isn't this a beautiful backdrop. You get to see some of my plants. For those of you who have been around for a while, you might recognize sort of the lighting and the wall. Even though I didn't necessarily have all the plants behind me, this used to be where my desk is when I first started online education.
And so this is like, where I would sit. It's actually great lighting. I do love it here. It's just, um, you know, the microphone. It's just, you know, not my office now. Um, The sound's a little bit different and I'm like in the house Cars are on the road. You would hear cars and fire trucks and things like that.
So Uh, but it works great for now and for today because it's too dang hot to be in my office and I wanted to get this recording out so I didn't screw my Editor Joe and like put his schedule behind for editing because I'm a last minute Lucy and You know, I got to keep in mind to other people's lives.
So anyways, what are we talking about today today? We're talking about the knee always a popular topic Always a popular topic my number one viewed video on YouTube actually, I believe close to if it's not the number one It's definitely the number one long video, um, watched on my YouTube and it was the podcast episode I did in 2023 on an easier way to get full knee extension.
And man, the amount of people I've heard from that still have the scenario in physical therapy where the, the physical therapist is like, forcing their knee into knee extension and forcing their knee into knee flexion and making it a very painful, terrible experience regaining their range of motion, is actually shocking to me that this day and age it's still happening so frequently because there are so many other tools to use.
So, one of the things that I got asked a lot after that podcast was, like, what is my solution for flexion? So we talked on that podcast, like, all about extension mostly and not as much about flexion. And I've been hesitant to talk about restoring knee flexion because it is Definitely a different beast, and I think, personally, it can be more difficult.
In fact, part of the reasons why I probably don't talk about it as much is because I don't have full knee flexion. I haven't had full knee flexion in a really long time. And, um, it limits me quite a bit, and I've tried so many things. And I don't quite feel like I have the perfect answer. However, we're gonna talk about that because I actually do think I have an answer to help people's knee flexion.
I just don't feel like I have the answer to help my knee flexion and this might be you. And we're talking about why I feel like mine is like a tough case. And, and, also, If I were my own patient, uh, what I would be doing to get it and what I'd be focusing on and like, because let's be honest, part of the reason why I don't have full knee flexion is because I'm a terrible patient and I'll work on it for like a week or two and then I'll stop.
And so any progress I will have made. Doesn't stick, doesn't like carry over and I'm also like fighting a little bit with age and Man, I never thought it would happen to me as a flexible person But it's true as you age your mobility Starts becoming trash and so I think I also have that sort of like on my plate a little bit too of like My mobility and my knee flexion was already limited and now add on like my mobility just and my hips is getting worse as I age.
Like it probably is the time, it is the time to make it a priority. And, um, it should be easy to fit in. Like I work out, I walk, like I'm pretty active, so I just need to be like better about it. And one of the tricks is actually, I'll talk about in the podcast, like the thing that's probably going to make the biggest bang for the buck is returning to the floor.
So all that and more in the next episode of the Unreal Results podcast. Anyways, um, no, we're in it. So let's talk about it. So there are so many ways we could approach this. If you're lacking knee flexion. I'd say there's a very good chance that it's from an old injury or a surgery you had once upon a time and you never fully got it back.
It's one of those things that is like, it's not like you just, I mean an extension was like that too. You don't just lose knee extension typically without having a major injury or surgery. So, um, Flexion is no different. Um, Some of the things that we talked about in the podcast about extension, which I'll make sure Joe links, are gonna be the same.
Like the visceral referrals, and I've done another, I've done another episode, one more episode on knee pain called anterior knee pain, the thing that you're missing, that was a little bit more like about patellofemoral pain. Patellofemoral joint stuff. I'll make sure Joe links that in the show notes. And then I did a whole episode on the kidneys and the connection to movement in the kidneys is the primary visceral referral to the knees.
So that'd be a good reference podcast to watch or listen to as well because I can't talk about the knees, the knee, without talking about the kidneys. Okay. So have you seen those, man, I'm all over the place, but have you seen those posts on, um, maybe not because it's, it tends to be more like business coaches, like my business coach right now.
She's kind of doing this, this kind of post for her business right now for a new course. She has, she's like, if I was starting all over, like this is what I would do to like build my business from scratch in 2024. So this is kind of like, kind of like that before knees, If I was starting all over with attacking my knee flexion with what I know now, this is what I would do.
So, I cannot consider anything about the knees without considering the kidneys. That is the visceral referral. In general, we can just call that urogenital, because the urogenital organs are a referral to the knees as well, and, and, specifically, the tib fib joint, the proximal tib fib joint. And the Proximal tib fib joint, Joe, here's another podcast to link, which is the Unlocking the Fibula podcast.
The proximal tib fib joint is both part of the ankle joint and the knee joint. And so, you have to consider this joint when you are dealing with flexion or extension or just general knee stuff with the knee. So, um, those are the main visceral referrals. Now, with that said, we got to step, take another step back.
And when we think about other visceral referrals that it could be, what we want to then consider is the nerve connections to the knee joint. So, When we look at the nerve connections to the knee joint, basically the nerves that innervate the knee joint, we've got femoral nerve, branches, right? They're like, I forget all the names of them.
Genicular, that's a common word for knee joint. But so the branches from the femoral nerve, One of those also being like the saphenous nerve, the obturator nerve, the posterior branch of the obturator nerve specifically innervates the medial knee joint. The, um, infrapatellar nerve innervates the patella tendon that comes off of the saphenous femoral nerve.
So it's like one of the femoral nerve branches. Then, the sciatic nerve, or let's just call it more the tibial nerve, gives off genicular branches that innervate the posterior capsule as well as the anterior and lateral capsule as well. It wraps around the knee from the backside. And then the common peroneal nerve innervates It's the proximal tib fib joint.
And so again, when we look at the proximal tib fib joint, it has some ligaments that go from the fibula into the knee joint capsule, as well as like the meniscus. I think maybe even one of the cruciate ligaments, to be honest. And um, a rotary ligament into the capsule there, and so the fibula, you know, plays a big role.
So common peroneal nerve is big one too. So that's common peroneal nerve, tibial nerve, femoral nerve, obturator nerve, four big nerves. So then when we take a step back, we have to consider those nerves and all the other visceral organs that can affect those. So when we look at the obturator nerve alone, we see that the obturator nerve is one of the nerves that innervates the parietal peritoneum.
So like the, the sac that the visceral organs live in, especially the lower part of the, the parietal peritoneum. So that's interesting, right? Because that means any of those organs in the peritoneum could influence the obturator nerve and create some knee pain. Or knee issues, um, and issues meaning like alignment things, all right?
Because when we are thinking about, I'm gonna try to keep this like very specific to knee flexion. When we're thinking about knee flexion, especially passive knee flexion, or really, I mean active too, but just knee flexion in general, full knee flexion, it's very reliant upon a very good congruency in the joint.
In fact, I should probably Maybe I'll get my, my anatomy models to show you this. Let me pause
Wow, going in my office, it's like entering a sauna. It's kind of funny actually. All right, so we've got our three bones that make up the knee joint, the tibia, the fibula, and the femur. So you can see here just with this, if I were to fully, right, in order to fully flex, we're going to be like this. That's probably like full flexion here from a bony standpoint.
It doesn't look full because we don't see the tissue difference. Can you see though that if the alignment is off just a little bit, how the, the bony approximation would limit that even more, right? And I, of course, I'm exaggerating this, but just so you can see it, right? So if we're just off a little bit, we run into the joint.
And also you got to remember the capsules back there too. And so sometimes even the capsule can probably get like impinged, pinched on itself. And it can be pretty uncomfortable. Now, what is not even shown on here too, is like, we also have the dynamic of the patella, the kneecap in this groove that when we're in full flexion, it is in full compression mode in the sulcus, the, you know, of this, of the femur.
So too, you can imagine again from a, we got to think about like what could be like some pain generators in here and bone is very painful, very much innervated. So if that patella is not perfectly in the groove of the sulcus, you know, if it's kind of offset to the left or to the right, you know, medial and lateral, then, It could potentially like want make you have pain and limit the range of motion a little bit too.
And so, and the patella, it can be off, I hate using the word tracking, but the tracking can be off a little bit because of the patella itself. So soft tissue tensions around, um, you know, it's a bone floating, like floating, like a bone within the tendon. It's a sesamoid bone. And so it is. At mercy of the tensions around the soft tissue there, but also since that tendon attaches down to the tibia, it's going to be at mercy of any sort of rotational or different positional faults of the tibia as well.
So, um, this is why we want to consider sort of like all of the influences on all parts of the joint because oftentimes when I find people who are really truly lacking flexion is it's not one thing. One of the biggest drivers of limited knee flexion, I think, based on myself and based on what I've seen from other patients and my athletes, is pain.
Now, this makes sense too because And I'm not talking about like pain all the time. It's not like knee replacement type of issue. Like, my knee literally hurts all the time. No matter what I'm doing. I, you know, that deep, bony, aching pain. I'm sure that can be a thing too. But like, For me, at least, the pain is when I try to go into knee flexion, the pain gets very extreme.
Sometimes it's better, sometimes it's worse. When it's better, I have more range of motion. When I'm more, in a more relaxed state, my knee flexion improves. This is what, what messes with my head sometimes, is I'll notice there's certain situations when my nervous system is in a different state. I'll let you, I'll let you, like, imagine what I'm talking about to keep this podcast PG 13 and like, not too much information.
But there's certain times when I'm on my knees full flexion and I don't have pain. And I'm, it's always like mind blowing to me cause I'm like, why can't I access this knee flexion in other times of the day? So I think there's a big inhibitory thing going on with the pain. And it makes sense knowing what's going on with my joint, because I think two scenarios are happening.
The primary one, I believe it is for me, is I have a very large chondral defect on the back of my patella. And so when I go into full compression in that sulcus, it is very painful. And that's right where the pain is. Like, it almost feels like, man, if I could just remove my kneecap, this would feel so much better.
Whereas sometimes the pain's more posterior and like more of that feeling of like the incongruency and the pinching. Though I'd say that feeling to me is more of just like my knee won't go. So the interesting thing though, remember like I said, is when the patella is, is, is limiting it, there can, it can be like that because of some torsion going on in the tibia as well.
So,
so again, I mean, this is these. These podcasts can be hard because it's like, I'm talking about like theoretical patients slash myself. And it's like, you know, everybody could be different. So it's a little bit of like, if you're watching this and I know some people watch these because they have, like they have the problem, right?
They're like mine. I can't flex my knee. Help me help me. I'm poor. But I'm also like, well, these podcasts are for clinicians because I actually want you to go to your clinician and your clinician to do a thorough evaluation to see what's going on for you, you know, and that's where we go back to the viscera and the nervous system pieces is like.
Maybe it is the kidneys for you. Maybe if we got your kidneys to move a little bit better, the tension would be better via the femoral nerve, and your knee would flex no problem. Maybe it won't. Don't know until we evaluate, right? This is why an evaluation is so important. An evaluation that considers the viscera and the nervous system.
Not just orthopedics, not just the biomechanics, not just the pain provocation and the bony things, right? And even too, like, in my scenario of like, not just knowing that I have some sort of internal derangement in my knee joint, because the other thing that goes on in this specific knee joint, not only do I have that very large cartilage defect, but I have no ACL.
I have had a torn ACL for at minimum 12 years, if not longer. It's been torn, retorn. It was torn, repaired, bad repair because it was done in the 90s when they all failed because it was in the wrong angle. Um, and I never got it redone. And so, you know, I have a lot of set up for one arthritis and two, just a lack of our good arthro kinematics and congruency in the joint.
But also we don't want to just like assume that's the problem, right? Because MRIs, they don't tell us what the actual problem is. They just give us a picture of the inside. So maybe we have a story about how it could be related. So I would still need to do an evaluation to see what other things are going on.
Okay. My quad and hip flexor tissue quality is very poor and limited in mobility too. And so part of that makes sense, right? Because I haven't been able to flex my knees since 1998 fully, except for various times here and there, but for the most part, I've had pretty much a limited range of motion for a really long time.
So part of it is like, well, yeah, I can't stretch my quad because I can't stretch my, I guess I can't flex my knee. It's a nasty cycle, right? But there are ways that I can get into those positions to feel a stretch sensation and make a change in mobility. And it's all about meeting the body where it's at.
And I'm going to share those. So there's a limiter, but so first we got to make sure like, okay, is my femoral nerve free to move and act and do its part? So femoral nerve, common entrapment sites, right at the base of where the quadriceps sort of turn into a tendon. That's the first spot, kind of like that articularis genu spot, which there's a YouTube video that shows you how to release articularis genu.
That's a great, Place to start for this as well. So I'll make sure Joe links that in the show notes But that's right around where the femoral nerve sort of becomes more superficial and slides to the fascial slip So that's one entrapment site spot. It could be the adductor hiatus. That's a common entrapment spot area, it's not quite at the adductor hiatus, but it's right nearby where the infrapatellar nerve gets entrapped.
So that's another key spot. It's on that same video of the YouTube video. Then we got to look higher up. Well, one, just like what's the tissue quality. And we're going to talk a little bit about the tissue quality because I want you to like, consider that. Yeah, I'm a big fan of self massage and I'm a big fan of massage in general, but the best way to rehydrate tissue is actually through movement.
especially fascial tissue. So we're going to talk about that a little bit too. But then, so, then we got in the next primary entrapment spot, anterior hip underneath the inguinal ligament, iliopectineal ligament. So this is one of the key spots of the swelling protocol. So, What can I do there? Femoral nerve glide is really great for that spot.
I'll link that in the show notes, Joe. And then, um, also just changing the tension on the inguinal ligaments. So I talked about this in the swelling reduction protocol course. When I have a really tight ass, right, when I'm stuck in posterior pelvic tilt, putting a ton of tension through those inguinal ligaments, which sometimes over compresses the neurovascular structures in the front of the hip, causes problems.
Okay, so then the next spot, where can the femoral nerve can get entrapped, not really any more entrapment sites per se, but a whole lot of stuff between the inguinal ligament and the spine that can irritate the heck out of the femoral nerve. And that's the organs, the kidneys, the intestines, both the small intestines and the large intestines Fascial spaces related to the
vascular structures, like the inguinal, not inguinal, the iliac vessels. The, um, fascia between the peritoneal and the retroperitoneal space right there, like, that's a really, like, All that stuff in there. It is a, let's just say it's a very big congestion area that can irritate the femoral nerve. So again, looking to my own case, I'm like, Hmm, starts to make sense to why my quad and my knee just stay tight because I've got a lot of pelvic congestion, gut congestion from food issues, from me not following.
a gluten free diet all the time, even though I know I'm like sensitive to wheat, from just a general fluid congestion standpoint, which goes back to, it's without saying, without saying, you have any little bit of fluid in your knee, if your knee is swollen at all. You're not going to get full mobility out of it and extension or flexion.
So just like I talked about in the extension podcast, I will say here at this point in this conjuncture, I probably should have bled with it, but like this swelling reduction protocol sometimes is all people need in order to be able to flex their knee fully because it was swollen. Sometimes we go so long with swelling in our knee joint.
We forget what it actually feels like to not have swelling in there. So don't. over considered like, like, I don't know what the right word is. Don't like leave that out. It's so powerful. There is a reason why the lymph love regen session is the number one, one I recommend people to get is because it's so powerful.
Making sure our fluid systems are flowing freely and not getting congestion influences everything, but especially the knee joint. So that's a big one. And then the next area is where it comes out of the spine, the neuroforamen between L1, L2, L3. All one, two, and three. Maybe even four. Forget. I forget all the nerve roots of the femoral nerve, but definitely all one, two.
Maybe three, definitely not four. Um, so what's going on there? Like for me, I know like I have a big segmental instability right around L2. It's like a big sheer spot for me. Part, partly because my, um, pelvis is tall, but also just like over the years of gymnastics, being a sway back posture, right where all of my mobility has driven through, so that could be a common area that's getting entrapped too.
So that whole length. It's a problem. And that's just one of the nerves, right? So then we look at the common entrapment sites and influences from the other nerves. The tibial nerve and common perineal nerve. Great, good news. They're like above the area of the knee, the sciatic nerve, just two nerves, one sheath.
So we've got a few spots that it can get entrapped. Five fingers above where the posterior knee joint is, is sort of like a main entrapment spot, and then up at the piriformis. Um, and then right below the piriformis, sort of as it comes through the groove between your greater trochanter and your ischial tuberosity, there's a little sciatic groove that the nerve goes through.
That's another common entrapment site too. And then again, when we go further up the sciatic nerve, guess where that whole thing is? That nerve is sitting in the bowl of the pelvis. So again, at mercy of the urogenital organs. The intestines, the colon, and any bit of congestion, any bit of congestion in the lymphatic or vascular system can irritate the entire sacral plexus.
Lots of options for problems. And you probably may have remembered another podcast that I did, or maybe you're new here and you are just, you know, getting your mind blown, but there was a podcast talking about left or right shoulder pain and left sciatica because of the relationship between the liver and the sigmoid colon from a fluid balance standpoint.
So if your sciatic nerve is irritated because of this congestion thing, we might also then go and look at the liver and see what's going on. So this means that my liver can be a driver of my knee pain. And so I'm not sorry, I don't want to say knee pain, my lack of knee flexion. And again, I hope you see how I'm like, blowing my own mind because I'm like, Oh yeah, my liver.
I know I'm congested, and I know my liver gets overwhelmed really easily. Again, with a lot of dietary things and just like, toxins. I'm on planes all the time. Planes are pretty toxic. Airports are pretty toxic for, for many reasons. But let's just say the only reason is the jet fuel. But that's not the only reason, there's many reasons.
So, um. That could be part of what's going on with me because again, it's my left knee. I'm fitting a picture in a very like complex case of all the things, all the factors that could be related to my knee flexion, not always flexing all the way. Besides the orthopedic piece, I think for me, the orthopedic piece is a big part of it.
But if I could peel back all these other related layers, then I'm, what I'm left with, the orthopedic stuff I'm left with is easier to manage. And that's the name of the game. So, um, we talked about sciatic nerve. Oh, and then the segment. So what segments of the lumbar spine, right? We got L4, L5, S1, S2. Those are all the segments of the lumbar sacral plexus, which the lumbosacral trunk turns into the sciatic nerve and then the common peroneal nerve.
So, um, again, like, and we look at like the most common, like, spine segments to have disc issues and some like foramen stenosis type issues and those are it and and I hate to like blame age because that's not like that's not all it is but it's like yeah you get to a certain age and your body has had a lot of miles and like those are the discs and even Jean Pierre Barrault believes that every every every issue in the discs above L5 is sort of imprinted almost like I don't want to say 3D printed, but like imprinted into the L5 disk, which is why the L5 disk takes all the brunt.
It is the bottom of the load, right? So, um, this is part of the issue. Again, I'm not saying this as like, oh, there's no hope for you. I'm saying like, oh, so we might have to do some work at the disk at L5, S1, or the disk at L4, L5 to make a change. on our knee flexion. And here, again, like adding to the complexity of my own knee flexion case, you know when it got worse after my back surgery.
You know where my back surgery was? I had a disc herniation at between L3, L4, L4, L5, and L5, S1. Not surprising I have major issues on this left side. But again, I know how to address all of this stuff, right? And I know, I know it's complex. And probably all compounded. But this is, the beauty of this, the other side of knowing it's complex is seeing all this complexity as all this opportunity for change.
So if I don't get more knee flexion with just doing, like, foam roll on my quad, and stretching, I got a lot of other options. Okay? So then, we're looking at obturator nerve. That's another, the last of the nerves that innervate the joint that we didn't talk about. It's going to be very similar to the femoral nerves, except for the entrapment sites are a little bit different.
So you, there can be a entrapment site just within the superior fascia, excuse me, of the thigh. On that medial side, very similar. Well, two spots, one right around where the sensory component of the anterior branch of the operator nerve is, and then also on the posterior side, there is a spot where it sort of comes through in this space between like gracilis and adductor longus, adductor mangus right there.
Um, kind of just anterior, I'm trying to think. anterior and lateral to your sits bone. The obturator nerve sort of pierces through that area as it splits in two because we got to think about, we got to think about, um, and I guess I'll give you the femur for lack of not having the pelvis next to me, but we got to think about 3D ness when we think of the nerves, right?
So you have the obturator nerve, the obturator nerve comes down right in front of the anterior SI joint. This is very medial, right in front of the anterior SI joint. Spoiler alert, it innervates the SI joint as well as the peritoneum. This is why the SI joint is such a visceral joint. I'm doing a, I'm doing a free class on this coming up.
The Missing Link. It'll be linked in the show notes. This is what it's all about. This is the anatomy of it. Anyways, the obturator nerve comes down in front of the SI joint and then as it comes out the obturator foramen, it splits anterior and posterior. And so it comes. Like this. Right? And then this posterior side comes down to the medial knee joint.
The anterior side stays anterior medial and innervates the skin and the adductors. It's a mixed nerve. It has cutaneous like sensation as well as motor function and sensory to the joints. The SI joint and the hip joint and the knee joint. So all three joints. So um, common entrapments of the obturator nerve.
Those are two of them. kind of on the medial upper thigh adductor area that spot right in front in medial to the posterior side and then the right at the sort of at the at the pelvis at the pubic bone itself right before it splits to the anterior and posterior branch right there around the operator foramen right there is a really common entrapment site that one We'll feel a lot like a labral tear of the hip and then you can actually get an entrapment from the SI joint too if you have any arthritis in the SI joint.
It's called obturator nerve entrapment. It's a thing in the literature though it's the least common of the spots because it would need to have a osteophyte. Um, and then as it comes up again, it comes through the bowl of the pelvis through the posterior abdominal wall. So it has potential to be irritated by all that congestion again, and all those organs, the urogenital organs and the, um, kidney as it goes into its, um, It's nerve roots at the upper lumbar spine, 3.
So the obturator nerve too, like I said in the beginning, it innervates the parietal peritoneum. So actually any of the organs in the peritoneum can influence the sensory information in the operator nerve and therefore the nerve information downstream from that, AKA the knee joint. So, so many things. And that's just the visceral and the neural connections.
So back when I started this podcast, I said, number one thing, number one visceral referral to me is the kidneys. And when I think kidneys, I think the kidneys move us. This is a quote from, well, it's not a quote. It's a extrapolated quote from Philip Beach, the author of Muscles and Meridians. He says, the mesoderm moves us, and the kidneys are part of the mesoderm, and I talk about this in that podcast, The Kidney Connection, or whatever it's called, because the kidneys are very much linked to our bipedal movement of rotation.
They're part of our helical field, influence our fluid field quite a bit, and they're very linked to our musculoskeletal system. And so one of the things that's probably a little bit out there, but if you're lacking knee flexion, I would work on trunk rotation. and rolling patterns and see, does that change your knee flexion?
That's a good way. So like, I think kidneys, I think rotation. I think kidneys, I think of unloading the guts in a decline position. I think kidneys and I think of functional medicine and hydration. Like, what's my electrolyte balance like? My life literally changed when I had potassium in and everything in my body felt better, including my knee.
So can't discredit that. Now. Let's take a step, I don't want to say a step back, but a step more in traditional thought process of knee flexion. Instead of forcing the body to flex the knee in positions that are uncomfortable and high level of tension, we're going to meet the body in a more comfortable position of a rest posture that's associated with knee flexion, and that is a Japanese sit or a toe sit.
And, with the Japanese sit or a toe sit, we're going to use as many pillows or pads or bolsters as needed to prop ourselves in a position where we don't actually feel discomfort. Where we can hang out there for a while. And remember at the beginning I said it's a, me losing my mobiilty is a, is a, message to my brain of like, Anna, you know, need to spend more time on the floor because spending time on the floor is my body's intuitive way of knowing that I am resting and granting me that relaxed nervous system state to then maximize me actually gaining more mobility in my knees.
I did a whole podcast episode on that. Joe, I'll have you link that in the show notes too. It's all about rest postures in Phillip Beach's work. That's a big game changer. The other one is, you know, taking us out of that classic prone quad, um, stretch and putting us in a different one. One of the ones that I found very helpful was doing like a, um, I guess it's called the couch stretch like in PT world in, in yoga, it's called like King pigeon, but putting your tibia vertical on the wall and then working your way up to a kneeling position.
Now, right now I can't work my way. So this is not about the endpoint. This is about the journey from the start position and getting to there So you have to again the biggest thing with any stretching or mobility work You have to meet the body where it's at so it can be comfortable and not force it as soon as you start forcing things And you start moving through pain or moving to forceful a painful thing, the body is going to tighten up and resist you.
And so it's like you got to be creative in all the ways you can support these ranges of motion without forcing it. And this is where Phillip's Beach work, Phillip Beach's work comes in so beautifully. Um, and then the next thing that I'm just going to touch on,
okay. So the last thing that I wanted to touch on, which is actually is going to probably lead us into next week's podcast episode really well, is a little bit more about like exercise and fascial fitness. So remember I said, one of the best ways to like change the fascia to like, is not necessarily self massage, but movement.
So this comes down to like understanding the laws. I don't know the principles of fascial fitness and one of the most important principles of fast fascial fitness is elastic recoil. And, um, also with, within the elastic recoil is the loading parameters that are best for like fascial turnover. Because again, if we look back, if we, if we're considering like the shortness or tightness of my quad, because of just the years of not being able to flex it, The, um, you know, rest postures will help, but, but the thing that can probably be a big game changer with me, and this is what I'm going to have to like test out, and actually I've tested out a little bit and it does make things feel better and does improve my mobility, is elastic recoil, which is plyometrics.
And, or, doesn't have to be plyometric in terms of contact time, but elastic recoilness of rhythm. So, another one of the principles of fascial fitness is rhythmic movements. And this rhythmic movement that is playing with the pain free ranges of motion that I have is the best way to rehydrate these, the connective tissues.
throughout my body and also I'm going give some information into the joint that it's safe, you know, and I, I talked about it in the beginning how there's sometimes when I do, I can get more knee flexion. and that's when my nervous system is in a different state. And so this concept of rhythmical elastic recoil and like playing in and out of the ranges of motion that my body can, so my body can get used to it and feel safer and overcome this.
Like feeling of not being safe is key And this is actually like I said why I'm so excited for next week episode because I actually have a guest coming on podcast I have Matt McInnes Watson coming on the podcast talking about Exactly this, plyometrics, deep tier movements, working on rhythmical movements to overcome the body's resistance towards positions of mobility or positions of movement that feel threatening to the nervous system in a way that safely loads the tissues.
And what I love about it is not only is he coming. to it from a like nervous system standpoint, but also it covers those, these parameters of fascial fitness, which has been shown to remodel the fascial tissue within six to 24 months, which is, that's a big window, but this is because it takes it. I hate the, I hate the term.
It takes time, but in this sense, like it does take time to remodel connective tissue. And I. I have tested this theory once before when I started running. I wanted to experience running in a more efficient state. So I ran only within the beats per minute, the cadence, of what's been documented as most efficient, which is like 175 to 185 beats per minute.
Like, if you watch all the runners, And the world, the, the, like, they all run within that cadence, regardless of how fast they are, because how fast you are is not only cadence, but also power output into the ground. Right? So, but that cadence is the most efficient cadence that keeps us in our elastic recoil properties of our connective tissue.
And when I did this return to running program with this metronome and stayed in that cadence, Not only did I feel great running and it was fun, but for the first time in a long time, I gained range of motion into ankle dorsiflexion. And that was when it really like hit home, like how powerful. We can use movement as remodeling the connective tissue in that way because I was doing all the mobility work in the world around my ankle dorsiflexion not really shifting it until I started doing this type of tempo running which was basically like deep tear work for a lot.
I mean, it was not deep tier, I guess it was actual plyometric cause it was quicker off the ground, but with these same concepts that Matt's going to talk to us about. And so
there is some potential here to make some really big gains on knee flexion too. So if I were to like wrap up this episode and like what you should focus on to improve people's knee flexion, figuring out if there is a visceral and a neural driver to it, or using the viscera and the nervous system to change some sensory information to the area to get to get some change in range of motion, meet the body where it is with props, use the floor rest postures, and some other positions.
And I didn't even mention it, but kind of even play around with the other body parts that are connected to the quads. So if we look at the quads from an embryological standpoint, right, cause that's going to be the, the tissue that's limiting our knee flexion is our quads is, um, the quads are an extension of the back muscles, all of the back muscles.
So that is the actual back, right? The erector spinae, as well as the dorsiflexors. And so, I'm curious too, is like if you add in some spinal flexion mobility, do you see an improvement of knee flexion? If you address your dorsiflexors and improve plantar flexion in your foot, do Do you also see an improvement of knee flexion?
This is why I love the Japanese sit so much because it incorporates it all. If you do the Japanese sit with a bow, which is called drinking posture. Now this incorporates length through the entire back muscles. And I'm talking about embryologically back muscles because there's three layers of muscles embryologically back, front and middle.
And so the quads are part of our back muscles, along with our back and our dorsiflexors. And so a drinking posture maximizes that range of motion in all of it. So again, adding in rotation to, to see how the kidneys influence, right? Trunk rotation. And then also like knowing all those segments. So what's the lumbar spine mobility like?
How can we influence the nerves that influence the joint? How can we influence the viscera that influence the joint? How can we approach this from a more holistic organism standpoint? And then how can we use the understanding of fascial fitness and the understanding of remodeling of connective tissue to make gains in old problems, in old tissues that probably are extremely dehydrated from years of not moving through that full range of motion.
And ultimately too, how do we meet the body where it's at and, and convince the body that it's safe to grant us that mobility and that we're not going to be threatened with pain or like injury by not forcing through it and then doing certain drills to down regulate our nervous system, but then also sort of progressively load us in a way that the body can get used to being like, okay, I'm safe here.
I'm safe here. I can go a little deeper. I'm safe here. And this takes time. Probably one of the only times you've heard me say it, but it takes time. I know this was a long episode and maybe a little all over the place. That's how my brain works. I hope you followed along. Lots of links for you. Thank you to Joe for always sorting that all out.
And, um, I look forward to the next episode. It's gonna be a good one.