Deep Dive on Tim's Low-Back Issues, How to Unlearn Painful Patterns, Movement as Medicine, and More

Tim Ferriss 0:00 [upbeat music] Hello, boys and girls, ladies and germs. This is Tim Ferriss, and welcome to another episode of The Tim Ferriss Show, where it is my job to deconstruct world-class performers from all different disciplines. My guest today is Shirley A. Sahrmann, PT, PhD. But before we get to her bio, let me just explain. Shirley is a legend in the physical therapy world. She has influenced some of the top performance coaches in the world. She's also 85 years old, going on 86, and is not only razor-sharp mentally, but in excellent shape physically. So she walks the walk. So let me get to the bio, and I will also give you a bit of 101 on some of the terms that we’ll use in the conversation. Shirley A. Sahrmann, PT, PhD, is Professor Emerita of Physical Therapy at Washington University School of Medicine in St. Louis, Missouri. She received her bachelor’s degree in physical therapy and her masters and doctorate degrees in neurobiology from Washington University, where she joined the physical therapy faculty and became the first director of their PhD program in movement science. Shirley, and she asked me to call her Shirley, became a Catherine Worthingham Fellow of the American Physical Therapy Association in 1986, and in 1998 was selected to receive the Mary McMillan Award, the association’s highest honor. She has also received Washington University’s Distinguished Faculty Award, the Distinguished Alumni Award, the School of Medicine’s inaugural Distinguished Clinician Award, and an honorary doctorate from the University of Indianapolis. She has received as well the Boling Erhardt Orthopaedic Clinical Practice Award from the Orthopaedic Academy of the APTA. She has served on the APTA Board of Directors and as president of the Missouri Chapter. Her books are iconic. They have been the initial domino that has toppled over [laughs] , so to speak, the enthusiasm, the ignition for many people to get into the field of movement science and physical therapy and performance coaching. Her first book, Diagnosis and Treatment of Movement Impairment Syndromes, you may have heard Eric Cressey mention this, it was a hugely influential book for him, has been translated into seven languages. Her second book, Movement System Impairment Syndromes of the Cervical and Thoracic Spines and the Extremities, has been equally influential in promoting movement diagnoses. And in this episode, we do a deep dive on low back pain, and that is something that for the first time really I have been struggling with for the last, let’s just call it nine months or so. Could be a bit longer.

Tim Ferriss 2:47 And we do get into the weeds with regard to anatomy, particularly as it relates to the back stuff that I mentioned. So I’d like to go over a few terms before we start the interview so you don’t have to wonder what they are and feel like you need to pause to look them up. You can get through the interview without listening to my definitions, but some of them might be helpful. Also, if you’re a kinesiologist or professional, please excuse these very simplistic and possibly slightly off definitions, but they’ll help a lot of people.

Tim Ferriss 3:14 So the first one is the iliac crest. What is that? That’s the uppermost border of your pelvic girdle. So you can think of the pelvic girdle as that large bony bowl that you see in the middle of a skeleton hanging in a science classroom or something. You can feel your iliac crest if you press your thumb into the top of your hip. That sort of bony ridge is your iliac crest. The tensor fasciae latae, and I’ve heard many different pronunciations of this, and the fact of the matter is no one really speaks Latin correctly because we don’t know if it was, you know, veni, vidi, vici, or weni, wedi, wici for those who get that reference. I came, I saw, I conquered. So anyway, it is better known and abbreviated as the TFL for a lot of people. So the TFL is a muscle at the outside, very outside portion of the thigh at the very top. So you could think of it also, people think of it as a hip muscle sometimes. You use it to balance your pelvis when standing, walking, or running. If you ever give someone a piggyback ride and a muscle gets super sore on the side of your hip, that is probably at least including the TFL. You also use the TFL for abducting your hip or pulling it away from the midline of your body compared to adducting with two Ds, which would be pulling it toward the midline. One way that I remember that, abduction, it’s like an alien abduction taking you away. So moving the, say, leg away from the body, abducting, bringing the thigh in, adduction. So like an adductor machine at a gym, one of those Susan Somers ThighMaster-type machines would be that. We also talk about muscles that assist in lateral rotation. Lateral rotation is rotating away from the center of the body. Medial rotation is rotating towards the center. So imagine if you turned your feet outwards to look like you were duck-footed, that would be lateral rotation out to the sides. And then if you turn them inward to be pigeon-toed, that would be medial rotation of both femurs inward. All right, psoas major. I also mentioned psoas major. That’s spelled P-S-O-A-S major. That is a large muscle that joins the upper and lower parts of the body, and it also contributes to a lot of lower back pain. It connects to the inside of the lower back. And if you were to take, say, your four fingers and move them four inches to either side of your navel and then press in, say, four inches, that would probably touch your psoas major, which is why massage therapy that addresses it can be so uncomfortable. For you chefs out there or hunters or people who might recognize this, this would be the equivalent of your tenderloin. So if you’re wondering what a tenderloin is, it is this muscle in many animals, and there may be other ways to use that butchering term. But psoas major, tenderloin, there you have it, used mostly for posture and so on. We also get into stenosis as it relates to my spine. So stenosis is an abnormal narrowing, and I have some stenosis around L4, L5, which is in the lumbar spine or lower spine, which puts pressure on some nerves there and causes all sorts of pain. The thoracic spine is more of, say, the middle of the back and kind of... You just think between the shoulder blades for simplicity. Okay, last [laughs] and I could say not least, but who knows? These are all kind of equivalent and useful. You have supine versus prone positions. Supine is lying on your back. Prone is lying on your stomach. If you've ever wondered what a supinated grip is or a pronated grip, supinated is palm up, and you can remember that because if you want to pour soup into your hand, you have your palm up. Okay, so that is supine. And honestly, learning the basics of anatomy and the basics of some medical terminology is, I think, one of the best, absolute best investments you can make in your health because then you can talk the talk with professionals, and they take you more seriously. They give you better advice. They give you the straight scoop. So this is all a very good investment of time. You can find a glossary of these terms and more in the show notes for this episode at tim.blog. And I do want to mention one other thing. If you want an incredible rotating view of different muscles like the QL, we talk about the quadratus lumborum. That's sort of this squarish, rectangular muscle in the lower back area that is sort of the Grand Central Station of all sorts of things. If you want to see anything, the psoas major, check out the Essential Anatomy 5 app for iOS and Android, and you can see all of this. You can also see the circulatory system and all sorts of other things. It's a great app. Really enjoyed it. And there are short YouTube tutorials that I recommend taking a look at if you end up downloading it. And that was referred to me by professional drummer Dave Elitch, who helps people improve their mechanics, technique, and much more. And, uh, there you have it. So if you want a video to go with this, I did record a video of this conversation, and I get up and walk around, and she does an assessment with me live. You can go to my YouTube channel, youtube.com/timferriss, two Rs, two Ss, and that will have some helpful graphics and so on overlaid into the video. Okay, that's quite a bit, guys, but I think it is a helpful prelude. And now, without further ado, please enjoy this wide-ranging conversation with Dr. Shirley Sahrmann. [whooshing]

Tim Ferriss 8:39 Dr. Sahrmann, Shirley, welcome to the show. It's so nice to have you with me today, and I can't wait to ask a whole host of different questions. So thank you for making the time.

Dr. Shirley Sahrmann 8:51 My pleasure.

Tim Ferriss 8:52 I'd like to begin perhaps with the connective tissue that led to you being on the show today, which is a friend of mine and a well-known, I suppose the label performance coach could be applied. He also has a background in physical therapy. Eric Cressey, he works with many Major League Baseball players, has a high degree of success with pitchers specifically. But he has written, and he also mentioned to me, that Diagnosis and Treatment of Movement Impairment Syndromes is probably the book, and I'm quoting him here, "Is probably the book that has influenced me more than any other in my career. It's worth every penny." I'm curious why it is that this book seems to have been so revolutionary for him and many others. What would you say explains that or differentiates that book?

Dr. Shirley Sahrmann 9:45 I think the one big objective in it-- I've actually been a, a physical therapist for over sixty years, and during all of that time, I've been through different eras of changes in physical therapy. And where I've sort of gotten to in is how movement basically induces pathology.

Tim Ferriss 10:10 Hmm.

Dr. Shirley Sahrmann 10:10 And part of trying to explain that and how it works is also developing diagnostic categories that direct physical therapy treatment. So w-what this, this book was about was a, a first attempt to really put together diagnostic categories that are based on, on movement and movement as an inducer of musculoskeletal problems. And also kind of working on the, on the background of what are the tissue adaptations that, that contribute to this. So it, it really was an organizational attempt to identify. In the first book, we covered the back and the shoulder and the hip. And so I guess the shoulder is one of the things that he must have been particularly interested in if he's dealing with pitchers.

Tim Ferriss 11:01 Mm-hmm.

Dr. Shirley Sahrmann 11:02 And the shoulder's really quite complex because you've got that shoulder blade as well as the glenohumeral joint, and it's not as easy as muscles just turn on or turn off appropriately. They've got to really be well coordinated. So I think that putting together this kind of information in a way that could be understood by a whole variety of people. In, in fact, I, I was so slow in getting it out that I was grateful that there was the internet and Amazon selling things because if it would've only been sold in medical bookstores, no one like Eric would have ever found it. And [laughs] so that was-

Tim Ferriss 11:42 [laughs]

Dr. Shirley Sahrmann 11:43 ... one of the advantages of, of being a slow writer.

Tim Ferriss 11:45 [laughs]

Dr. Shirley Sahrmann 11:46 And of course, I learned more while all of that was happening, too. So that's probably the background.

Tim Ferriss 11:53 How did that attempt or, uh, maybe not attempt, how did that organizational-

Dr. Shirley Sahrmann 11:58 No, it is an attempt

Tim Ferriss 11:59 ... approach-- Yeah, and also the maybe reframing of movement in the way that you just described differ from what came before or what was predominant at the time?

Dr. Shirley Sahrmann 12:10 Well, to be perfectly honest with you, Tim It's not like this insight has been taken over by even th- the large majority of the people in my profession.

Tim Ferriss 12:22 Mm-hmm.

Dr. Shirley Sahrmann 12:22 It's still a, still a bit of a, a struggle to have people move in this direction for a whole variety of reasons. But typically, and even though I wasn't there when physical therapy was first started, I wasn't too far behind.

Tim Ferriss 12:35 [laughs]

Dr. Shirley Sahrmann 12:37 [laughs] Typically, the role of the, of the physical therapist was the doctor figured out what the problem was, made the diagnosis, and the physical therapist really provided treatment for what I think could fairly be called the symptoms or the consequences of that problem.

Tim Ferriss 12:55 Mm-hmm.

Dr. Shirley Sahrmann 12:55 In fact, I, I am old enough that I actually saw polio patients.

Tim Ferriss 12:59 Hmm.

Dr. Shirley Sahrmann 12:59 The vaccine had just come out about when I was entering physical therapy school. So we had a role in providing the therapy for the doctor's identified condition and-

Tim Ferriss 13:14 Mm-hmm

Dr. Shirley Sahrmann 13:14 ... that's very different than what I'm proposing or have proposed with this book. And I think what's beginning to be recognized... I think the other thing that is so important about all this, and I'm sure you're a reflection of this, is in the old days, no one thought lifestyle had anything to do with your health.

Tim Ferriss 13:35 Yeah.

Dr. Shirley Sahrmann 13:35 [laughs] I always like to point out this story. My family cooked with so much Crisco, I don't know how my blood flows.

Tim Ferriss 13:41 [laughs]

Dr. Shirley Sahrmann 13:42 You know? [laughs] And, and if the green beans were too healthy, we had bacon grease to put on them, you know? [laughs]

Tim Ferriss 13:50 [laughs]

Dr. Shirley Sahrmann 13:51 But I, I was, I was very fortunate. I worked with a physician for a while who, who was really leading the way in showing about the role of exercise and nutrition in... He did what is really called translational research-

Tim Ferriss 14:05 Mm-hmm

Dr. Shirley Sahrmann 14:05 ... showing the, the cellular changes in animals and then also running studies in older people, and it was, like, an amazing insight for me to realize that your lifestyle had something to do with it. So I think that's behind what's slowly emerging as seeing movement play a different role. It's, I think, what I'd like to get across to people. It's not inevitable what's gonna happen to you, that you can do things via lifestyle to improve what your outcome's gonna be.

Tim Ferriss 14:38 I would love to come back to, I believe, and I don't wanna misquote you, but something you said, which is the treatment of symptoms. So many offices are treating symptoms, perhaps not root

Tim Ferriss 14:51 causes, and I have-

Dr. Shirley Sahrmann 14:53 Yep

Tim Ferriss 14:53 ... I have read, and you can't believe everything you read on the internet, so please correct me if I got this wrong-

Dr. Shirley Sahrmann 14:58 [laughs]

Tim Ferriss 14:58 ... but that you've [laughs]

Dr. Shirley Sahrmann 15:00 Is that a new saying? [laughs]

Tim Ferriss 15:01 [laughs] Yeah. That you've described low back pain as not a diagnosis but a symptom. And could you just speak to that? Because I, as someone who currently, for the last maybe six to nine months, has had a very perplexing constellation of symptoms [laughs] that I describe as low back pain, this, I think, will resonate with many people who are listening. So would you mind elaborating on low back pain as a symptom and not a diagnosis?

Dr. Shirley Sahrmann 15:31 Well, I mean, just what you're saying. You're, you're saying it's low back pain. You're just telling me that you've got pain, and you're telling me where you've got pain.

Tim Ferriss 15:38 Mm-hmm.

Dr. Shirley Sahrmann 15:38 That is clearly a symptom. [laughs]

Tim Ferriss 15:40 Yeah, right. [laughs]

Dr. Shirley Sahrmann 15:42 [laughs]

Tim Ferriss 15:43 I am from Long Island-

Dr. Shirley Sahrmann 15:45 Yeah, there you go

Tim Ferriss 15:45 ... so sometimes I ask the silly, silliest of questions.

Dr. Shirley Sahrmann 15:47 [laughs]

Tim Ferriss 15:47 But gotta start with the basics.

Dr. Shirley Sahrmann 15:49 Well, well, the nice part is you, you can actually get reimbursed for making that big, clever diagnosis-

Tim Ferriss 15:53 [laughs]

Dr. Shirley Sahrmann 15:54 ... so even without an MD degree. [laughs]

Tim Ferriss 15:56 [laughs]

Dr. Shirley Sahrmann 15:59 So where, where I would be looking at that problem, and I have an idea of what your problem is.

Tim Ferriss 16:05 Wow, okay.

Dr. Shirley Sahrmann 16:06 [laughs]

Tim Ferriss 16:06 Already.

Dr. Shirley Sahrmann 16:06 Well, just because-

Tim Ferriss 16:08 Hmm

Dr. Shirley Sahrmann 16:08 ... I, we can talk about that.

Tim Ferriss 16:10 Okay. Yeah, we will.

Dr. Shirley Sahrmann 16:12 I mean, I don't wanna sound too glib about it, but... And so what I would be doing is naming your low back pain by the movement that most consistently causes your symptoms, and by changing that movement, reduces or eliminates your symptoms.

Tim Ferriss 16:33 Mm-hmm.

Dr. Shirley Sahrmann 16:33 And so then I'm talking to you about a real cause of the problem. Now, it's not going down to the tissue level and saying, "Well, you know, it's a disc or a facet joint," or any of the rest of it. But here again, in some ways, when you have a problem like that, you can't say in the back that one tissue's at fault because a lot of tissues have to change if you're having pain coming from your back region.

Tim Ferriss 17:00 Mm-hmm.

Dr. Shirley Sahrmann 17:00 So the expertise of a physical therapist needs to be what is the movement that's either causing or exacerbating that problem?

Tim Ferriss 17:12 Mm-hmm. So I'm

Tim Ferriss 17:13 curious... Well, maybe we can, we can dive into, you said I- that you thought you might know what my, my issue is.

Dr. Shirley Sahrmann 17:19 That's because I know you're a big exerciser.

Tim Ferriss 17:22 Yes, indeed.

Dr. Shirley Sahrmann 17:23 I mean, do you want me to just give you a, a ballpark idea?

Tim Ferriss 17:26 I do, absolutely.

Dr. Shirley Sahrmann 17:28 Okay. Well, because would you believe that abdominals can get to be too much?

Tim Ferriss 17:33 Uh-

Dr. Shirley Sahrmann 17:34 Overdeveloped?

Tim Ferriss 17:36 You know, it makes some intuitive sense, but it's not something you hear many people talk about.

Dr. Shirley Sahrmann 17:40 I know. Even within the community of physical therapists, people are really exercising big time. I mean, high-intensity exercise is, is super popular.

Tim Ferriss 17:51 Mm-hmm.

Dr. Shirley Sahrmann 17:51 Now, I'm all for it because it'll increase our patient load. [laughs]

Tim Ferriss 17:56 [laughs]

Dr. Shirley Sahrmann 17:57 One of the things that happens when your abdominals are overdeveloped, because what happens when muscles hypertrophy, they, they become stiffer.

Tim Ferriss 18:05 Mm-hmm.

Dr. Shirley Sahrmann 18:05 And, and muscles are like springs, so they have a, a... I mean, I'm using the mechanical word of stiffness.

Tim Ferriss 18:11 Mm-hmm.

Dr. Shirley Sahrmann 18:11 And so when the abdominals get to be too much, they increase the compression on your spine.

Tim Ferriss 18:17 Hmm

Dr. Shirley Sahrmann 18:18 And so the way you can check me out on this is if you look to see if you take a, a deep breath, if you go from maximum exhalation to maximum inhalation, you should be able to change the circumference of your ribcage about two and a half to three inches.

Tim Ferriss 18:32 Mm-hmm.

Dr. Shirley Sahrmann 18:33 And if you can't really do that, then it means that the stiffness of your abdominal muscles is so much it's adding to the compression.

Tim Ferriss 18:41 Hmm.

Dr. Shirley Sahrmann 18:41 And then if you have any kind of asymmetry, if, for example, if you put your hands on your iliac crest and one iliac crest is slightly higher than the other-

Tim Ferriss 18:51 Mm-hmm

Dr. Shirley Sahrmann 18:51 ... then your, basically your, your spine is in a side bend.

Tim Ferriss 18:55 Mm-hmm.

Dr. Shirley Sahrmann 18:55 And if it's in a s- in a side bend and you're squeezing on your vertebrae, they're not happy because they aren't lined up as optimally as possible.

Tim Ferriss 19:03 Mm-hmm.

Dr. Shirley Sahrmann 19:03 Do you see what I mean?

Tim Ferriss 19:04 I do.

Tim Ferriss 19:05 Absolutely.

Dr. Shirley Sahrmann 19:06 That's the ballpark idea. And, and that, that also reflects how we're looking at these problems. What is it about the way you move? What is it about the way you've exercised or done things that cause the symptoms?

Tim Ferriss 19:21 And I would love to spend more time on this, selfishly of course, because [laughs] the reason I am sitting and not standing for this interview is because of this, this lower back pain, which is actually-

Dr. Shirley Sahrmann 19:33 So, so it's worse when you're standing than when you're sitting?

Tim Ferriss 19:35 It is worse when I am standing. Now, I do have, I guess what, we can jump right into the weeds. I have a transitional segment, if I'm using the right terminology-

Dr. Shirley Sahrmann 19:48 Yeah. Mm-hmm

Tim Ferriss 19:48 ... in, in my, in my lumbar.

Dr. Shirley Sahrmann 19:50 Mm-hmm.

Tim Ferriss 19:50 So I do have quite a bit of excessive lower back sway or atypical lower back sway, just for people listening.

Dr. Shirley Sahrmann 19:56 Now, when you say sway, d- do you mean an increased curve?

Tim Ferriss 20:00 Increased curve, yeah, like lordosis and kind of guts hanging out, and with that anterior pelvic tilt, right? Standing and slow walking, say walking through a museum, tend to aggravate it the most. My brother has the same thing. Although, in the last six months or so, when I sit on a very hard surface, like a hard-

Dr. Shirley Sahrmann 20:25 Mm-hmm

Tim Ferriss 20:25 ... bench or something like that, it also causes this pain. I have had imaging, but we could, maybe we could talk about imaging, how you see some people who look like they've gone through a mulcher on their back MRI, but they're asymptomatic, and then you [laughs] --

Dr. Shirley Sahrmann 20:38 You're right. That's the whole point.

Tim Ferriss 20:40 Yep. Then you have the opposite. So I do have some stenosis around, like, L4, L5, but the pain feels, to me, localized around the SI joint. The relief, if this is helpful, I know we're getting a little technical for some folks, but the, the relief that I've had in the last week was actually from seeing a chiropractor. There's a high degree of variability with chiropractors, but he works with a lot of athletes, and he put me on a machine that, that provided some-

Dr. Shirley Sahrmann 21:06 Traction

Tim Ferriss 21:07 ... traction. Exactly. And he said, "I think it's actually that you may have a disc pressing on a nerve that runs past the SI joint, so you're misattributing the cause to the SI." And I've had quite a bit of relief. But to answer your question, standing-

Dr. Shirley Sahrmann 21:22 Yeah

Tim Ferriss 21:22 ... slow walking combined with standing, like going through a museum or a cocktail party, sitting on hard surfaces, those are the three things that hurt. Brisk walking does not hurt. And actually, that type of, I, I, and this is a primitive interpretation, but sort of repeated stretching of the hip flexors if I'm getting enough terminal hip extension feels really good to the back.

Dr. Shirley Sahrmann 21:46 Yeah.

Tim Ferriss 21:47 So those are a few of the things.

Dr. Shirley Sahrmann 21:49 Have you put your hands on your pelvis to see when you're walking if it rotates?

Tim Ferriss 21:55 I have not. I would love to know how to do that properly.

Dr. Shirley Sahrmann 21:58 Well, I, I mean, it's [laughs]

Tim Ferriss 21:59 [laughs]

Dr. Shirley Sahrmann 22:00 It's not rocket science.

Tim Ferriss 22:01 [laughs]

Dr. Shirley Sahrmann 22:02 You know where your pelvis is. You know where your hands are. [laughs]

Tim Ferriss 22:04 Yeah.

Dr. Shirley Sahrmann 22:05 Just because very often when your hip flexors are not even just not short, just stiff-

Tim Ferriss 22:12 Mm-hmm

Dr. Shirley Sahrmann 22:12 ... stiffer than your back, as you walk, it rotates your pelvis, and that's-

Tim Ferriss 22:16 Mm

Dr. Shirley Sahrmann 22:16 ... where you're gonna be getting your symptoms from.

Tim Ferriss 22:18 Hmm.

Dr. Shirley Sahrmann 22:19 And evidently, when you go fast enough, you're not staying static and you're causing enough equal movement. But-

Tim Ferriss 22:25 Mm-hmm

Dr. Shirley Sahrmann 22:26 ... that would be the big thing. When you stand up and you're in this anterior tilt, can you contract your abdominals enough to get out of the tilt?

Tim Ferriss 22:33 I can. Yeah.

Dr. Shirley Sahrmann 22:34 And then does that decrease your symptoms?

Tim Ferriss 22:37 It does decrease my symptoms.

Dr. Shirley Sahrmann 22:38 Right.

Tim Ferriss 22:38 So if my back is bothering me, I'll very often do basically a forward fold or a full squat and then round my back and get into that flexed position.

Dr. Shirley Sahrmann 22:48 Yeah.

Tim Ferriss 22:48 I, I have, the, the flexed position and even mild extension does not bother the back. If I do a compression test, like a heel drop test, or I pull myself into a chair, it's, it's standing straight up and with compression that shows the, that type of intolerance, and I get that pain kind of directly on the lower spine.

Dr. Shirley Sahrmann 23:08 The other thing to try, Tim, is when you stand up, put your feet apart.

Tim Ferriss 23:13 Mm-hmm.

Dr. Shirley Sahrmann 23:13 Separate them out and see if that changes your symptoms.

Tim Ferriss 23:16 Hmm. And what is that doing?

Dr. Shirley Sahrmann 23:18 Number one is this little thing I referred to before. If one iliac crest is higher than another-

Tim Ferriss 23:23 Mm-hmm

Dr. Shirley Sahrmann 23:23 ... and it's a test for what we call relative stiffness.

Tim Ferriss 23:27 Mm-hmm.

Dr. Shirley Sahrmann 23:27 So if, if you're, one of the big hip flexor that's problematic is called the tensor fasciae latae-

Tim Ferriss 23:33 Yes

Dr. Shirley Sahrmann 23:33 ... iliotibial band. And it's an abductor.

Tim Ferriss 23:37 Mm-hmm.

Dr. Shirley Sahrmann 23:37 So if you put your feet apart so your hips are abducted, it takes the stretch off of that band.

Tim Ferriss 23:43 Mm-hmm.

Dr. Shirley Sahrmann 23:43 And any kind of asymmetry that you would have, particularly with a transition vertebrae, would be playing into the symptoms. Do you see what I mean?

Tim Ferriss 23:51 I do.

Dr. Shirley Sahrmann 23:52 And then if you put them together and your symptoms increase, then you would know that that's what's playing a role in doing this.

Tim Ferriss 23:59 So I'll add a, a few more things just because this is a rare opportunity to get to talk, talk with you about this. So my TFL is very, tends to be very tight and sensitive.

Dr. Shirley Sahrmann 24:11 That's what I... Yeah.

Tim Ferriss 24:12 The piriformis, also very tight. A piece of this that may or may not be helpful, but what gives my back also some release is working on the spec- very specifically the iliacus and then some of the adductors, so on the inside of the thigh.

Dr. Shirley Sahrmann 24:27 Tell me what that means.

Tim Ferriss 24:28 Well, having someone really dig Into the abdomen to have me say-

Dr. Shirley Sahrmann 24:34 Okay

Tim Ferriss 24:34 ... extend the leg. Oh, almost like-

Dr. Shirley Sahrmann 24:35 It's not you working on it, somebody else is working on it.

Tim Ferriss 24:37 No, it's somebody else working on it.

Dr. Shirley Sahrmann 24:38 [laughs]

Tim Ferriss 24:39 And then it's not very pleasant for people who are listening. And then some of my adductors, I don't know if it's magnus, longus, or whatever, but also very tight and seemingly potentially weak. But to come back to the, the h- the height, maybe the asymmetry of, of the iliac crest, my right side seems to get hiked up a lot.

Dr. Shirley Sahrmann 25:00 Yeah.

Tim Ferriss 25:00 And doing wall sits to try to press them maybe back into some symmetry seems to alleviate some of the symptoms as well. I don't know if any of this makes any sense.

Dr. Shirley Sahrmann 25:10 See, you've just confirmed one of my thoughts is that if your right iliac crest is higher than your left-

Tim Ferriss 25:16 Mm-hmm

Dr. Shirley Sahrmann 25:16 ... but then I would also bet that your right TFL is stiffer than your left. So if that's playing a role, then when you put your feet apart, your, your iliac crest should level out.

Tim Ferriss 25:25 Mm-hmm.

Dr. Shirley Sahrmann 25:26 And that should help with your symptoms.

Tim Ferriss 25:27 So historically, when I've been recording podcasts, I basically end up in that really wide stance. I mean, that's useful for maybe temporarily relieving the symptoms if I'm recording a podcast. In terms of corrective measures-

Dr. Shirley Sahrmann 25:41 Have you ever tried anything where you're in, in the quadruped position?

Tim Ferriss 25:45 I have actually. A long time ago, I did a lot of movement in quadruped position. But I would be curious to hear what you have in mind.

Dr. Shirley Sahrmann 25:52 Well, y- because part of what happens when one iliac crest stays higher than another, and I, I'm not, to be perfectly honest with you, I haven't quite figured it all out yet, but-

Tim Ferriss 26:01 Mm-hmm

Dr. Shirley Sahrmann 26:01 ... there's some adaptation of the other hip muscles. And I've just found that if you do this in quadruped, you just rock back-

Tim Ferriss 26:11 Mm-hmm

Dr. Shirley Sahrmann 26:11 ... often it will improve the asymmetry-

Tim Ferriss 26:15 Huh

Dr. Shirley Sahrmann 26:15 ... that you have.

Tim Ferriss 26:15 So b- basically being on hands and knees?

Dr. Shirley Sahrmann 26:17 Hands and knees, right, and let your hips drop-

Tim Ferriss 26:20 Mm-hmm

Dr. Shirley Sahrmann 26:20 ... to about 90 degrees. You don't have to go back all the way. You just need to go back a, a, a little bit. And go back by easily pushing with your hands.

Tim Ferriss 26:28 Mm-hmm.

Dr. Shirley Sahrmann 26:28 Because otherwise, if you activate your hip flexors, it, it could pull it, contribute to your problems.

Tim Ferriss 26:34 Right.

Dr. Shirley Sahrmann 26:35 And then, and then c- can you tolerate prone?

Tim Ferriss 26:39 Yeah, I can tolerate prone.

Dr. Shirley Sahrmann 26:40 And then you need to just do, like, just flex your knee.

Tim Ferriss 26:43 Mm-hmm.

Dr. Shirley Sahrmann 26:44 And then you need to laterally rotate your hip. So you're letting your, your knee flex to 90 degrees-

Tim Ferriss 26:49 Mm-hmm

Dr. Shirley Sahrmann 26:49 ... and then let your foot go in towards the other leg. That's lateral-

Tim Ferriss 26:53 Mm-hmm

Dr. Shirley Sahrmann 26:53 ... rotation.

Tim Ferriss 26:54 Yep.

Dr. Shirley Sahrmann 26:55 And that kind of motion will help to elongate the, the TFL, ITB.

Tim Ferriss 27:00 Interesting. And you're doing that leg by leg?

Dr. Shirley Sahrmann 27:03 Oh, yeah, yeah, one leg at a time.

Tim Ferriss 27:04 One leg at a time. Okay.

Dr. Shirley Sahrmann 27:06 Yeah. And you do everything bi- bilaterally.

Tim Ferriss 27:09 Mm-hmm.

Dr. Shirley Sahrmann 27:09 Yeah.

Tim Ferriss 27:09 Okay. Very interesting.

Dr. Shirley Sahrmann 27:11 So you can try those things and let me know.

Tim Ferriss 27:12 I will. I will do

Tim Ferriss 27:14 both of those. So let's, if we zoom out just for a moment [laughs] Thank you for that, by the way. We may come back to it. How would you describe the movement systems syndromes approach, so the MSS approach? What would the sort of lay description of that be?

Dr. Shirley Sahrmann 27:31 In 2013, the American Physical Therapy Association adopted the movement system as its identity. And, and to me, what's really important about all of this is that it's a way of trying to say to the public that there is a body system called movement, the movement system.

Tim Ferriss 27:51 Mm-hmm.

Dr. Shirley Sahrmann 27:51 And it's not like the traditional anatomically defined systems like the cardiovascular system or the muscular musculoskeletal system or the nervous system. It's a system of systems.

Tim Ferriss 28:05 Mm-hmm.

Dr. Shirley Sahrmann 28:05 But that's just like, in my mind, the immune system, wh- which nothing is more important in medicine these days than the immune system, and it's a system of system. It uses many of the different organs-

Tim Ferriss 28:17 Mm-hmm

Dr. Shirley Sahrmann 28:17 ... in its function. Metabolic system is the same way. When you think of it as running from subcellular on all the way up to how do you move in your environment, movement is, is critical. [laughs]

Tim Ferriss 28:28 Mm-hmm. Yeah.

Dr. Shirley Sahrmann 28:28 When movement stops, everything stops. And so I think we take it, in some ways, to me, it's like a parallel to the nutrition system-

Tim Ferriss 28:37 Mm-hmm

Dr. Shirley Sahrmann 28:37 ... the, because we take for granted [laughs] doing it, and yet there's right ways and there are wrong ways.

Tim Ferriss 28:46 Mm-hmm.

Dr. Shirley Sahrmann 28:46 And so the whole idea of this is to realize that the movement does involve a, a system. And just like we were talking about before, movement, if you have a lesion in a system, like you have rheumatoid arthritis or something, or you have a stroke, then you've got pathology in your movement. But as I indicated, movement can also induce pathology. In fact, we know if people don't move enough, they develop the metabolic system syndrome and other, other kinds of things because for lack of movement.

Tim Ferriss 29:18 Mm-hmm.

Dr. Shirley Sahrmann 29:18 So how important it is to move, this is related to the lifestyle issue-

Tim Ferriss 29:23 Mm-hmm

Dr. Shirley Sahrmann 29:24 ... and doing it right. One of the things I always loved doing with, with patients was saying, "So who taught you to walk?" And they say, "Nobody." And I say, "That's the problem." [laughs]

Tim Ferriss 29:34 [laughs]

Dr. Shirley Sahrmann 29:34 Just because you're doing it doesn't mean you're doing it right.

Tim Ferriss 29:37 Yeah.

Dr. Shirley Sahrmann 29:37 You're just doing it. [laughs]

Tim Ferriss 29:39 Yeah.

Dr. Shirley Sahrmann 29:39 Just like you. If you're walking and you're getting lumbopelvic rotation, that's playing into your problem.

Tim Ferriss 29:45 Right. And also if I'm, if I don't have, which I don't think I do, this is a one pattern of diagnosis with me that I think is accurate, that I'm, I don't have much terminal hip extension, so when I walk, I'm using my lower back to fake-

Dr. Shirley Sahrmann 30:00 That's what I'm telling you. That's exactly-

Tim Ferriss 30:01 ... hip extension.

Dr. Shirley Sahrmann 30:02 See, that's what I'm saying. You, and you really can't do that. I mean, there's no way you won't keep injuring your back if you keep walking

Dr. Shirley Sahrmann 30:09 like that.

Tim Ferriss 30:10 And how do you re-pattern or help people to adopt so that they can use it subconsciously new motor patterns or new movement patterns? Right? Because I've been doing this for God knows how many decades.

Dr. Shirley Sahrmann 30:24 Well, not that many. You don't look that old. [laughs]

Tim Ferriss 30:26 [laughs] Thank you. Thank you. I appreciate that, my new best friend.

Dr. Shirley Sahrmann 30:29 [laughs]

Tim Ferriss 30:31 How do you help patients to get to that point where they've changed something as fundamental as how they walk?

Dr. Shirley Sahrmann 30:38 In my mind, it's, it's twofold And one, we know it, it takes a while. Just like if you're learning a sport or you're learning to do anything, it takes time and it takes-

Tim Ferriss 30:48 Mm-hmm

Dr. Shirley Sahrmann 30:48 ... attention, and it takes specificity.

Tim Ferriss 30:51 Mm-hmm.

Dr. Shirley Sahrmann 30:51 And so one is just like we're talking about with you. What are the most important kinds of exercises? What, what are the issues that are an impediment to doing it the way you should do it?

Tim Ferriss 31:02 Mm-hmm.

Dr. Shirley Sahrmann 31:02 What are specific exercises that can help you, and minimize those? And then what's really important is showing you in your everyday activities-

Tim Ferriss 31:13 Mm-hmm

Dr. Shirley Sahrmann 31:13 ... what you should do. For example, if you already know that your hip flexors, y- you're calling it the iliacus, i- is problematic, then even when you're sitting, making sure you're not pulling with your hip flexors-

Tim Ferriss 31:27 Mm-hmm

Dr. Shirley Sahrmann 31:27 ... to stay forward-

Tim Ferriss 31:28 Yeah, I'm probably doing that right now [laughs]

Dr. Shirley Sahrmann 31:29 ... when you're sitting. I know. I've been watching you. [laughs]

Tim Ferriss 31:33 [laughs]

Dr. Shirley Sahrmann 31:34 It's how you even roll over or get out of bed.

Tim Ferriss 31:36 Mm-hmm.

Dr. Shirley Sahrmann 31:37 We go through every one of these things, teaching you in your everyday activities so that it does become automatic. But, you know, it obviously takes participation on the, on the patient's or the subject's part-

Tim Ferriss 31:50 Mm-hmm

Dr. Shirley Sahrmann 31:50 ... as well to learn it, and then you know it's gonna take time.

Tim Ferriss 31:55 Mm-hmm.

Dr. Shirley Sahrmann 31:56 I think it's important for people to realize they can't just do 10 repetitions or three sets of an exercise and then they're gonna move differently. I think that's been part of what's been picked up in my, in my book, is that you have to bring people along, show them how to do that, and that exercise won't change the way you move. You have to change the way you move, and that can improve how muscles function.

Tim Ferriss 32:19 Mm-hmm.

Tim Ferriss 32:20 You mentioned the psoas. I'd, I'd actually like to come back to the psoas. In my particular case, because I have been an aggressive athlete, or was for several decades, and accrued an impressive number of fractures and surgeries and so on, I get manual-

Dr. Shirley Sahrmann 32:32 [laughs] Oh, really?

Tim Ferriss 32:33 Oh, yeah. So I get manual therapy once a week, some type of soft tissue treatment. And what I found for me personally is it seems like, like psoas major and so on, when someone does a manual release, for whatever reason, when they get sort of inside that pelvis a bit more to what I've been told is the iliacus, that's when I feel the most symptomatic relief for my back. But the psoas seems to hold some importance. I don't know if you could speak to that, but in terms of the role of psoas overactivity as it relates to, to back pain, is that something that you still feel is something people pay too little attention to?

Dr. Shirley Sahrmann 33:16 I don't think it always is a cause, but it can certainly be an exacerbator because the psoas attaches to the lumbar vertebrae.

Tim Ferriss 33:22 Mm-hmm.

Dr. Shirley Sahrmann 33:23 And it also attaches to the i- intervertebral disc.

Tim Ferriss 33:26 Mm-hmm.

Dr. Shirley Sahrmann 33:27 So it's, it's a muscle that's constantly pulling on your, on your back and pulling it in sort of a translation motion.

Tim Ferriss 33:33 Mm-hmm.

Dr. Shirley Sahrmann 33:34 Iliacus is attached to your pelvis, so it, it's not directly acting on the vertebrae the same way the, the psoas is.

Tim Ferriss 33:41 Mm-hmm.

Dr. Shirley Sahrmann 33:42 In fact, m- people that truly have a, a herniated disc and they're in that acute phase, I try to have them do nothing w- [laughs] with their iliopsoas. If they wanna lift their leg up, use your hand to lift your leg up and-

Tim Ferriss 33:55 Hmm

Dr. Shirley Sahrmann 33:55 ... to put your shoes on, or to cross your legs, or get into the car or something if you're sitting down already. So you minimize that use. And just like we were talking about in quadruped, if you are in quadruped and you wanna rock back, you will probably use the psoas to do it.

Tim Ferriss 34:15 Yeah.

Dr. Shirley Sahrmann 34:15 And that's why I suggested to you to push with your hands-

Tim Ferriss 34:18 Mm-hmm

Dr. Shirley Sahrmann 34:18 ... so you go back and you don't use that muscle. Well, these are small samples of what I'm talking about as far as identifying what are the factors that are contributing, and how do you change that in your everyday activities?

Tim Ferriss 34:30 What would be some other repeating culprits that you see? Let's just say someone has the symptom of low back pain. You take them through an assessment or identify that they have an overactive psoas. What might be some other low-hanging fruit, uh, with respect to helping them to identify common patterns or positions that contribute to that overactivity?

Dr. Shirley Sahrmann 34:57 I would be looking more specifically at which particular movements do it.

Tim Ferriss 35:04 Okay.

Dr. Shirley Sahrmann 35:04 And then try to identify. For example, it would be hard for me to believe this, but if your hip flexors... And, and it makes a difference. Like, we're, the tensor fasciae latae is a hip flexor.

Tim Ferriss 35:19 Mm-hmm.

Dr. Shirley Sahrmann 35:19 But it has a rotational component that's much stronger than the, than the psoas does. The psoas has more anterior pull.

Tim Ferriss 35:26 Yep.

Dr. Shirley Sahrmann 35:26 The, the tensor fasciae latae is gonna pull more on the pelvis. And I will tell you that in my judgment, and I don't think I'm way off on this, at least 70% of the people with back pain, it's because their hip's not moving optimally.

Tim Ferriss 35:41 Mm.

Dr. Shirley Sahrmann 35:41 And you said it yourself.

Tim Ferriss 35:43 Mm-hmm.

Dr. Shirley Sahrmann 35:43 "My hip is not moving and then it, it bothers my back." Well, that's exactly what goes on. And it doesn't take some big structural fault to have that. Just a difference in the passive tension.

Tim Ferriss 35:54 Mm-hmm.

Dr. Shirley Sahrmann 35:55 So usually with younger people, if I'm gonna generalize about back pain, it's related to their spine flexing because when you're younger you're more f- you're more flexible.

Tim Ferriss 36:07 Mm-hmm.

Dr. Shirley Sahrmann 36:09 And I think the, the other thing that's tied to that while we're talking about the hip is they're identifying more and more that hips, what they call femoral acetabular impingement, hips aren't flexing as much. There's structural changes going on.

Tim Ferriss 36:23 Mm.

Dr. Shirley Sahrmann 36:23 So if your hip only flexes 90 degrees, then you wanna bend over, you're gonna do it much more in your back because your hip's not doing it.

Tim Ferriss 36:30 Mm-hmm.

Dr. Shirley Sahrmann 36:31 So I wanna know all the things that relate to flexion. In the older person, then it's more related to extension, just like the stenosis thing. Stenosis is That's when you really can't extend. That's why you see old people walking bent over, why they need a walker-

Tim Ferriss 36:49 Mm-hmm

Dr. Shirley Sahrmann 36:49 ... when they're bending over. And then the element of rotation. And because it's not just is it one iliopsoas that's problematic or both of them, one tensor that's pulling more strongly than the other. And that's the passive tension, not just the active tension.

Tim Ferriss 37:06 Mm-hmm.

Dr. Shirley Sahrmann 37:06 And that's what you have to know.

Tim Ferriss 37:08 Hmm. Now, you were asking about my breathing and the, the deep breath.

Dr. Shirley Sahrmann 37:12 [laughs]

Tim Ferriss 37:12 When I, when I met with Eric, and I, I'm pr- I could be totally screwing up this terminology, so you may need to [laughs] rein me in.

Dr. Shirley Sahrmann 37:20 Okay.

Tim Ferriss 37:21 But he had me take off my shirt, and he's... I think it was I had a very low, it might be high, but infrasternal angle. So I have a bit of a depression in the chest. I have a very minimal ability to expand my ribcage. I, I'm a belly breather, and, uh, I've had a number of people note that it's likely when I breathe, I kind of rotate my entire ribcage backwards, which also causes that excessive-

Dr. Shirley Sahrmann 37:51 S- symptoms

Tim Ferriss 37:52 ... exactly, that excessive hinging at the, at the lumbar. What do you do with somebody who's got this type of predicament or pattern?

Dr. Shirley Sahrmann 38:02 Well, usually, as I was saying before, if your ribcage doesn't expand, then it's often because your abdominals are too taut.

Tim Ferriss 38:11 I see.

Dr. Shirley Sahrmann 38:11 So one of the ways is to elongate them. So arms up over your head and taking a deep breath.

Tim Ferriss 38:19 Mm-hmm.

Dr. Shirley Sahrmann 38:20 And just trying to increase the... I mean, you probably know that with breathing, you've got two modes of movement. One they call pump handle, and the other is, uh, bucket handle.

Tim Ferriss 38:31 I'd love for you to elaborate on that.

Dr. Shirley Sahrmann 38:33 Okay. Well, pump handle means the front of your chest, your sternum is going up like a pump.

Tim Ferriss 38:39 Mm-hmm.

Dr. Shirley Sahrmann 38:39 And bucket handle is like the sides expand.

Tim Ferriss 38:42 Mm-hmm.

Dr. Shirley Sahrmann 38:43 And so with arms up overhead, you wanna really think about lifting your chest as well as pushing your ribcage out.

Tim Ferriss 38:51 Laterally, you mean?

Dr. Shirley Sahrmann 38:51 Yeah, laterally.

Tim Ferriss 38:52 Yeah, mm-hmm.

Dr. Shirley Sahrmann 38:52 Like, it's all going up. Yep. Can you do that? Can you take [inhales and exhales] Yeah.

Tim Ferriss 38:59 Yeah, it's at... Yeah, I don't have much. It doesn't do much-

Dr. Shirley Sahrmann 39:03 Yeah. Yeah, I know

Tim Ferriss 39:03 ... uh, as it stands right now. Yeah.

Dr. Shirley Sahrmann 39:05 That's what you need to do. And then-

Tim Ferriss 39:07 Mm

Dr. Shirley Sahrmann 39:07 ... here's the other thing, that if you stand with your back against the wall-

Tim Ferriss 39:11 Mm-hmm

Dr. Shirley Sahrmann 39:11 ... and then you try to do a, a side bend. But, but, but you wanna make sure the side bend, you're moving through, that the axis of rotation's through your chest, not in your lumbar spine.

Tim Ferriss 39:23 Yeah, that'll make my symptoms worse.

Dr. Shirley Sahrmann 39:25 And you wanna be sure, Tim, that you don't just pull yourself over. You wanna try to fall like you've got a, a heavy elbow. In, in other words, don't contract the muscles on the same side, but try to get these to elongate. So like-

Tim Ferriss 39:39 Right, on the opposite side

Dr. Shirley Sahrmann 39:39 ... you're falling over.

Tim Ferriss 39:41 Mm-hmm.

Dr. Shirley Sahrmann 39:41 More passive elongation rather than an active contraction.

Tim Ferriss 39:45 Mm-hmm.

Dr. Shirley Sahrmann 39:45 Now, you're not gonna go real far initially unless you got a really heavy elbow. [laughs]

Tim Ferriss 39:51 [laughs] Yeah. So the axis of rotation should be-

Dr. Shirley Sahrmann 39:55 Through the middle of your chest

Tim Ferriss 39:55 ... or the fulcrum should be in the middle of the chest.

Dr. Shirley Sahrmann 39:57 Yeah, right.

Tim Ferriss 39:58 Okay.

Dr. Shirley Sahrmann 39:58 And don't-- I always like to say, "I don't care how far you go. I care how you get there."

Tim Ferriss 40:03 Yeah. Okay.

Dr. Shirley Sahrmann 40:04 And so don't push it for big range, and just make sure you're not moving your lumbar spine and that you're doing your thoracic spine.

Tim Ferriss 40:12 And are you breathing in those positions, or is this stretching your intercostals, or what is the, the objective of the, the side bend?

Dr. Shirley Sahrmann 40:19 The objective is to elongate those abdominals that are not letting you.

Tim Ferriss 40:22 Oh, I see.

Dr. Shirley Sahrmann 40:23 And, you know, the, the other thing is just even when you were doing this, you don't have any symptoms at all when you're sitting there

Dr. Shirley Sahrmann 40:29 right now?

Tim Ferriss 40:29 I have a little tightness in my low back. I am sitting in a chair with lumbar support.

Dr. Shirley Sahrmann 40:35 Why do you do that when you have too much lumbar curve anyway?

Tim Ferriss 40:39 Well, because I've, I've noticed that for whatever reason, symptomatically, I get relief with a small amount of, of lumbar support.

Dr. Shirley Sahrmann 40:46 Oh, a small amount. Okay.

Tim Ferriss 40:47 If it's a flat back chair and I end up kind of falling forward and flattening my back, it, it ends up hurting me much more later.

Dr. Shirley Sahrmann 40:56 Yeah, because you're getting a translation motion. Yeah, I could. But, okay, what if you put your arms up over your head and take a deep breath? Does that decrease your symptoms at all?

Tim Ferriss 41:06 I would say n- doesn't noticeably. I don't have any s- severe symptoms right this instant.

Dr. Shirley Sahrmann 41:11 No, but, uh, but it doesn't-

Tim Ferriss 41:12 But doesn't worsen it, for sure.

Dr. Shirley Sahrmann 41:14 But it doesn't make it any better either.

Tim Ferriss 41:20 It might lessen it slightly.

Dr. Shirley Sahrmann 41:22 Okay.

Tim Ferriss 41:23 The degree of pain right now, I would say, is pretty low, so it's hard for me to-

Dr. Shirley Sahrmann 41:27 Well, that's good

Tim Ferriss 41:28 ... to monitor.

Dr. Shirley Sahrmann 41:28 And again, if you look at it from the standpoint, the more you move someplace else besides your back, the better off you're gonna be.

Tim Ferriss 41:36 Yeah. Definitely.

Dr. Shirley Sahrmann 41:38 So that's part of the whole strategy is make sure-- Because usually the problem is that motion that's problematic is occurring during all of your activities.

Tim Ferriss 41:48 Mm-hmm.

Dr. Shirley Sahrmann 41:49 The body follows the rules of physics. It takes the path of least resistance. So if it's easy to move there, it keeps moving there.

Tim Ferriss 41:56 Right.

Dr. Shirley Sahrmann 41:56 And that's what you're trying to change, to make it easier to move at other places where you should be moving more.

Tim Ferriss 42:03 This seems to me to be very, very, very important, so would you mind just saying that again? Just reiterating that the body follows the path of least resistance, so if you have a worn groove and it's leading to pathology, you need to sort of grease a different groove. Could you, could you just speak to that? Because I, it strikes me-

Dr. Shirley Sahrmann 42:20 You, you're doing a beautiful job yourself.

Tim Ferriss 42:22 [laughs]

Dr. Shirley Sahrmann 42:22 I don't think you need me. [laughs]

Tim Ferriss 42:24 [laughs] Well, you know, I'm, I'm great at pontificating. I just need to change my movements.

Dr. Shirley Sahrmann 42:29 Okay.

Tim Ferriss 42:30 [laughs]

Dr. Shirley Sahrmann 42:30 Father Superior. [laughs]

Tim Ferriss 42:32 [laughs] No, I just, you know, I c- I, I talk a good game. I just have to fix my movement patterns and my breathing.

Dr. Shirley Sahrmann 42:38 [laughs]

Tim Ferriss 42:38 But I like how you phrase it. I mean, it's the body is going to take the path of least resistance.

Dr. Shirley Sahrmann 42:44 That's it exactly.

Tim Ferriss 42:45 I'm gonna follow these, these exercises. I will, I'll experiment with the elongation. I wanted to add one more data point, which is if I do, for instance, Pilates classes with someone who's very technical, if I'm in that flexed position, which tends to be more comfortable for my back, if I'm experiencing a lot of symptoms-

Dr. Shirley Sahrmann 43:07 Tell me, are you supine?

Tim Ferriss 43:10 I am supine, yes. Mm-hmm.

Dr. Shirley Sahrmann 43:12 Okay. You're supine. And then what are you gonna do?

Tim Ferriss 43:15 Basically, what I'm trying to sort out for myself is if the overly contracted abdominal resting state can contribute to the symptoms I'm experiencing. What I have, what I've also experienced is if I do a workout that seems to be focused or is focused on a lot of core musculature and, and pelvis work and so on, that my low back doesn't bother me for a few hours after that workout. And I don't know how to interpret that. Maybe these things are not at odds. Maybe they can both be true for different reasons.

Dr. Shirley Sahrmann 43:51 I mean, it depends what your workout is. What, what would be bad in the long run is if you're doing a lot of holding your legs up and moving those around-

Tim Ferriss 43:58 Mm-hmm

Dr. Shirley Sahrmann 43:59 ... while you're supine. Because, again, you're gonna be using your iliopsoas and it's gonna be pulling on your back.

Tim Ferriss 44:05 Yeah.

Dr. Shirley Sahrmann 44:06 The big thing is for you to be able to contract... I'm getting the picture from you that I didn't have before that here you are, uh, with an increased lumbar curve-

Tim Ferriss 44:16 Mm-hmm

Dr. Shirley Sahrmann 44:16 ... and that your lower abdominals aren't as taut. And lower abdominals, I mean external obliques, not just the ones that are, are lower.

Tim Ferriss 44:23 Mm-hmm.

Dr. Shirley Sahrmann 44:24 And when you contract those muscles, that they tend to flatten your back and decrease your symptoms.

Tim Ferriss 44:30 Yes.

Dr. Shirley Sahrmann 44:31 And so that would be to me what the advantage is when you're supine and starting to do the exercise.

Tim Ferriss 44:38 Mm-hmm.

Dr. Shirley Sahrmann 44:38 What would be not, not the long run good is if you're holding your legs up and, and trying to do something with your legs while you're holding that position.

Tim Ferriss 44:50 Right.

Dr. Shirley Sahrmann 44:50 Because you're building in too much activity from the iliopsoas.

Tim Ferriss 44:54 Mm-hmm.

Dr. Shirley Sahrmann 44:55 So if anything, in that position, I would just have you slide your leg down and try to keep your pelvis

Dr. Shirley Sahrmann 45:00 from tilting. Put your hands on your... Like, I'm sure you probably know what ASISs are. Anterior superior iliac spine.

Tim Ferriss 45:07 I do. On the front of the hip.

Dr. Shirley Sahrmann 45:09 Yeah. And just make sure they don't tilt.

Tim Ferriss 45:12 For people who are wondering, could you just describe what that is?

Dr. Shirley Sahrmann 45:15 It's a little bony prominence on the front of your, your pelvis.

Tim Ferriss 45:18 Mm-hmm.

Dr. Shirley Sahrmann 45:19 And s- some of your major hip flexors at- attach there.

Tim Ferriss 45:23 Mm-hmm.

Dr. Shirley Sahrmann 45:24 But it's also an indication of what your pelvis is doing as far as tilting forward or tilting backward.

Tim Ferriss 45:30 Mm-hmm.

Dr. Shirley Sahrmann 45:30 And w- in your case, what you wanna do is not have it tilt forward.

Tim Ferriss 45:34 Mm-hmm.

Dr. Shirley Sahrmann 45:34 So the importance of that exercise would be that you can move your legs without your pelvis tilting anteriorly.

Tim Ferriss 45:41 Got it.

Dr. Shirley Sahrmann 45:43 But I wouldn't put a big load on them. I would only have them slide down, like you're sliding your heel along the supporting surface.

Tim Ferriss 45:50 Got it.

Dr. Shirley Sahrmann 45:50 Get it all the way down on one leg with no tilt. See if you can do the same thing with the other. If you have difficulty, from what we've talked about before, if you take them out in abduction, you should be able to get them down easier-

Tim Ferriss 46:01 Mm-hmm

Dr. Shirley Sahrmann 46:02 ... because your tensor is gonna be pulling on your pelvis as well.

Tim Ferriss 46:06 Right. So for people listening, if I'm interpreting this correctly, if your legs are separated so your legs end up more in a snow angel type of position-

Dr. Shirley Sahrmann 46:13 Right

Tim Ferriss 46:13 ... as opposed to directly in front of your hips. Now, is that predominantly a diagnostic or is it also a training move, that sliding of the heel?

Dr. Shirley Sahrmann 46:21 All of the above.

Tim Ferriss 46:22 All of the above.

Dr. Shirley Sahrmann 46:22 All of the

Dr. Shirley Sahrmann 46:23 above.

Tim Ferriss 46:23 Okay.

Dr. Shirley Sahrmann 46:24 I mean, that, that's the nice thing about going through an exam in which you're looking for this path of least resistance, the, the motion that is occurring too readily.

Tim Ferriss 46:32 Mm-hmm.

Dr. Shirley Sahrmann 46:32 Because it'll occur too readily with all of the activities.

Tim Ferriss 46:36 Mm-hmm.

Dr. Shirley Sahrmann 46:36 And, and it goes back to what we were saying before. Then you try to make sure that you're either not getting that motion or you're moving where you should be moving. And when you're taking s- people through the exam, and I think this is what's so valuable, is you're also showing them how to be in charge of their symptoms.

Tim Ferriss 46:52 Mm-hmm.

Dr. Shirley Sahrmann 46:53 Because nothing is more scary than, "Here comes the pain. What did I do? How did I do it?"

Tim Ferriss 46:58 Yeah.

Dr. Shirley Sahrmann 46:58 "How do I get out of it?" And if you're showing people, "If you go this way, it hurts. If you do it this other way, it doesn't hurt," and, and that's helps also with people following the program that's recommended because their symptoms are, they're in charge of them and they know what to do to decrease them.

Tim Ferriss 47:17 Yeah. This personal experience has been incredibly frustrating and kind of horrifying because it's the first time in my life... If, if you tear a labrum in your shoulder or you break a, break an arm or break a collarbone, it's oftentimes reasonably straightforward, or it seems that way.

Dr. Shirley Sahrmann 47:35 [laughs]

Tim Ferriss 47:35 Whereas with this lower back pain, I would feel better for three days and then I would wake up and I would just be in incredible, like, eight out of 10, nine out of 10 pain. And I could not-

Dr. Shirley Sahrmann 47:46 Wow

Tim Ferriss 47:46 ... identify what the cause was.

Dr. Shirley Sahrmann 47:48 Wow.

Tim Ferriss 47:48 And there have been times when, you know, my QL and my external obliques and so on are so locked up in the paraspinals that I can stand for a few minutes and I have to sit down, find something soft.

Dr. Shirley Sahrmann 47:59 Wow.

Tim Ferriss 47:59 And that's not the case right now, but the recurrence of symptoms has been so unpredictable on some level that it's... And a, a friend of mine who's in the medical profession said, "Oh, how long have you had that?" And I said, "Nine months." And she said-

Dr. Shirley Sahrmann 48:14 [laughs]

Tim Ferriss 48:15 ... "Well, you technically qualify for someone with chronic pain." And I was like, "Oh my God. Is this the new normal? This cannot be the new normal." Which is why I appreciate you taking so much time speaking about this. W- when someone comes in and they have not identified anything, they come to you for help, or someone who's trained in your system, what does the exam look like? What does the, what does the session look like?

Dr. Shirley Sahrmann 48:44 First, it's, it's looking at what they look like. [laughs] I mean-

Tim Ferriss 48:47 Yeah

Dr. Shirley Sahrmann 48:47 ... it, it, for me, it just, like, if I saw you standing, I would know a whole lot more than just looking at you sitting because-

Tim Ferriss 48:53 Mm-hmm

Dr. Shirley Sahrmann 48:54 ... all of these things that we've talked about indirectly, I would see immediately. So one is just looking at alignment. And believe me, that's, that's a roadmap to a whole lot of things. And I think it, it's also worth noting that it's why people stand the way they stand, is to minimize energy expenditure.

Tim Ferriss 49:12 Mm-hmm.

Dr. Shirley Sahrmann 49:13 So you can see what the passive tensions are-

Tim Ferriss 49:15 Mm-hmm

Dr. Shirley Sahrmann 49:16 ... which are reflective of how hypertrophied a muscle is. And then it's simple motions, Tim. Have people forward bend. Does their back flex too much? Does it not reverse its curve with you? And how, how much do their hips flex?

Tim Ferriss 49:32 Mm-hmm.

Dr. Shirley Sahrmann 49:32 And typically in men, there's more of a problem of excessive lumbar flexion than there are in women, just because the center of gravity's higher, the hips are stiffer, et cetera.

Tim Ferriss 49:42 Mm-hmm.

Dr. Shirley Sahrmann 49:43 So how do they forward bend? How do they rotate? Because many people will twist rather than be- really be able to rotate.

Tim Ferriss 49:51 Mm.

Dr. Shirley Sahrmann 49:51 And then side bending. Does it hurt? W- Where do I see the motion?

Tim Ferriss 49:55 Now by twist, you mean their pelvis follows them-

Dr. Shirley Sahrmann 49:58 No

Tim Ferriss 49:58 ... instead of that-

Dr. Shirley Sahrmann 49:59 See, that's the other thing that's interesting is because I'm sure with you that people have looked at what your range of motion is in your hips.

Tim Ferriss 50:06 Mm-hmm.

Dr. Shirley Sahrmann 50:07 But when you're standing, you don't have that same range of motion. Your pelvis won't rotate on your femurs the same amount.

Tim Ferriss 50:14 Yep.

Dr. Shirley Sahrmann 50:14 So one, does your hips not move, and therefore you have to move in your back more because your pelvis isn't rotating, or is it asymmetrical? And then the other thing is that actually, ironically, if your abdominals are really good, instead of sort of rotating off of more of an axis, though it's not perfect, your trunk shifts over because if your trunk shifts over in a twisting motion, it's because your abdominals won't elongate easily.

Tim Ferriss 50:41 Hmm. Fascinating.

Dr. Shirley Sahrmann 50:43 And then which one of these motions causes symptoms? When I see that it's bad, I will correct it. For example, if you had pain side bending, then I'd put my hand above your iliac crest, have you side bend again, and if I've blocked it and you don't have pain, then I know that that motion occurring there is causing your pain.

Tim Ferriss 51:03 The movement of the pelvis or the iliac crest?

Dr. Shirley Sahrmann 51:07 The movement in your back.

Tim Ferriss 51:08 Yeah.

Dr. Shirley Sahrmann 51:09 And the same thing if, if you bend over and there's no pain, but you come back up and you lead with your back rather than your hips, then that causes pain, then I know again, that extending is causing your symptoms.

Tim Ferriss 51:20 Mm-hmm.

Dr. Shirley Sahrmann 51:21 And then if your symptoms, as you've reported, get better when you bend over, again, I know that extension's causing your symptoms.

Tim Ferriss 51:29 Mm-hmm.

Dr. Shirley Sahrmann 51:29 And then I go through little tests in supine to see the length of the hip flexor muscles. I look to see what your symptoms are in supine. If you have symptoms, just like you sort of suggested, if we flex your hips and knees, you ought to be more comfortable than when they're down straight.

Tim Ferriss 51:47 Mm-hmm.

Dr. Shirley Sahrmann 51:48 If I abduct your hips, I know that what's causing it that way. Do you see what I mean?

Tim Ferriss 51:53 Mm-hmm.

Dr. Shirley Sahrmann 51:54 So then I will passively move your hips to see what the range is, make sure it's passive. Then I'll have you do it actively to see if that elicits symptoms, show you how to change it. So I'm going through an exam looking for that movement that shows up consistently. If I stop it or improve it, the symptoms go down. So we do s- in supine, side lying, prone, quadruped, sitting. Watch people walk. Everything that gives them pain. They get in and out of their car, how to roll, how to go up and down stairs. Whatever activities would give them pain, I'll go through them with them.

Tim Ferriss 52:34 Hmm. And is the assessment largely the same for athletes versus non-athletes? It's kind of-

Dr. Shirley Sahrmann 52:40 Yeah, that's a really interesting point because in some ways people have a hard time because these-- I'm looking for little baby things. You know, ironically, there's really good research that's been done by, by Linda VanDillen, and these movements that cause the symptoms occur very early, and they're only a few degrees.

Tim Ferriss 53:02 Mm-hmm.

Dr. Shirley Sahrmann 53:02 And so sometimes with athletes, I've had the issue that, well, these are just baby things, and they don't really matter. But they do matter. [laughs]

Tim Ferriss 53:10 Mm-hmm.

Dr. Shirley Sahrmann 53:10 You, you, you gotta stop that, and then you can build on, on bigger ways. There's a, a therapist by the name of Roby Ohashi, who's put these into-- It's like a movement spectrum. That's not the exact words. I'm blanking on it right now. Where you do isolated exercises, uh, combined exercises, and then more putting them together for your sport, you know, whether it's tennis-

Tim Ferriss 53:38 Mm-hmm

Dr. Shirley Sahrmann 53:39 ... or, or, or whatever. And he's seen a lot of athletes. And that's the whole idea, is that you get somebody to correct the little bitty movements, and then you build on the more complicated, the more demanding movements.

Tim Ferriss 53:53 Mm-hmm.

Tim Ferriss 53:54 Do you have an opinion of-- I've, I've not experienced this personally, but something called DNS. I think it's-

Dr. Shirley Sahrmann 54:01 Yeah

Tim Ferriss 54:02 ... dynamic neuromuscular-

Dr. Shirley Sahrmann 54:03 Neuromuscular stimu- Yeah, I do.

Tim Ferriss 54:05 Because it seems like they build based on some sort of motor skill development chronology from childhood. So you'd do-- You'd start with supine or prone and then move to like one, to crawling or something like that, quadruped and then-

Dr. Shirley Sahrmann 54:20 Yeah

Tim Ferriss 54:20 ... kneeling and so on. Do you have any perspective on this?

Dr. Shirley Sahrmann 54:24 To be perfectly honest, I think you're already grown. So [laughs] I-

Tim Ferriss 54:28 [laughs] Certainly. If my, if my shiny pate is any indication, then yes.

Dr. Shirley Sahrmann 54:34 Yeah. You know, looking at your well-shaved head, I, I'm always reminded of what my father used to say, who was also bald from an early age. And he would always say, "Grass can't grow on a busy street." [laughs]

Tim Ferriss 54:44 [laughs] That's hilarious. I'm definitely gonna use that. Grass cannot grow on a busy street. [laughs]

Dr. Shirley Sahrmann 54:54 I don't think you need to stage it like that. That's why I go through-

Tim Ferriss 54:58 Hmm

Dr. Shirley Sahrmann 54:58 ... the, the whole exam and look at the sort of the finished product that needs some fine-tuning. You know, the, the thing we talked about in the beginning and that- Movement causing pathology and the fact that it's really your everyday activities that cause it in the first place.

Tim Ferriss 55:15 Yeah.

Dr. Shirley Sahrmann 55:15 And so that's why you gotta change the way you're doing basic things. Do you know what I mean?

Tim Ferriss 55:22 I do.

Dr. Shirley Sahrmann 55:23 And look at that because that's what caused the problem. That's what you need to change.

Tim Ferriss 55:28 Mm-hmm. What is, I believe you call it collapso-smasho?

Dr. Shirley Sahrmann 55:33 [laughs] Where did you get... I didn't s- [laughs] didn't put that down.

Tim Ferriss 55:36 [laughs]

Dr. Shirley Sahrmann 55:37 Well, there are two forms here. It relates to this fact that what we talked about already, that the abdominals can get... Well, that the spine suffers from compression type things.

Tim Ferriss 55:50 Mm-hmm.

Dr. Shirley Sahrmann 55:50 And in the older individual without muscles, it's collapso-smasho.

Tim Ferriss 55:55 Mm-hmm.

Dr. Shirley Sahrmann 55:55 In younger individuals like yourself or others who have done a whole lot of abdominal exercises, I call it squeezo-smasho because-

Tim Ferriss 56:02 [laughs]

Dr. Shirley Sahrmann 56:03 [laughs] Because the passive tension from those muscles is adding to the compression. In the older people or people who are hypermobile, then it's, it's kind of collapsing down without enough support. So, you know, it's not good if you don't have enough muscle, and it's not good if you have too much muscle. It's what's in between that's most important.

Tim Ferriss 56:26 So h- how do you find the, the Goldilocks amount of-

Dr. Shirley Sahrmann 56:30 No pain and they look great. [laughs]

Tim Ferriss 56:33 [laughs] All right. S- keep, keep fine-tuning.

Dr. Shirley Sahrmann 56:37 The other thing is, you know, obviously we, we aren't all built the same. I think that's one of the other important things, is looking for structural variations and building, building that into the assessment. That's the part that's tricky.

Tim Ferriss 56:50 Hmm.

Dr. Shirley Sahrmann 56:51 People don't always pick the right parents, and when they find out, it's too late to go back, you know?

Tim Ferriss 56:55 [laughs]

Dr. Shirley Sahrmann 56:56 [laughs]

Tim Ferriss 56:58 All right. So let's talk about perhaps other common pathological patterns. I've read that you've said or written perhaps that most people wear their shoulders too low.

Dr. Shirley Sahrmann 57:11 [laughs]

Tim Ferriss 57:12 Could you speak to that and perhaps also mention what, what corrective measures can be taken? What does it mean for people to wear their shoulders too low?

Dr. Shirley Sahrmann 57:22 It means that they should sit up at a, an angle that is about six degrees or so higher. And often you see when... You don't look so bad, but when people have done a lot of weight training, that's one end of the s- scale. You'll see that their shoulders look really dropped. They look lower.

Tim Ferriss 57:42 Right.

Dr. Shirley Sahrmann 57:42 So that the end of their shoulder isn't sitting up.

Tim Ferriss 57:45 They look like they're sloped downward.

Dr. Shirley Sahrmann 57:47 Yeah. If you know the, the cervical vertebrae between C6 and C7, you should have, that's about the level where your shoulders should be. Your-

Tim Ferriss 57:58 Mm-hmm.

Dr. Shirley Sahrmann 57:59 And so if that's way down or-

Tim Ferriss 58:01 Mm-hmm

Dr. Shirley Sahrmann 58:01 ... you can look at your clavicle and you see that there's not this six-degree angle, but your shoulder-

Tim Ferriss 58:07 Oh, I see

Dr. Shirley Sahrmann 58:07 ... is lower than your, than your-

Tim Ferriss 58:08 So the clavicle should, from inside to outside, have roughly a six-degree-

Dr. Shirley Sahrmann 58:11 Should have a little tilt to it

Tim Ferriss 58:12 ... upward angle

Dr. Shirley Sahrmann 58:13 ... should be upward angle. Right. So it could be too low. And then the other way [laughs] I like to talk about it is just the weight of the world, the husband, the children, you know, the bra straps-

Tim Ferriss 58:25 Mm-hmm

Dr. Shirley Sahrmann 58:25 ... all of that-

Tim Ferriss 58:26 [laughs]

Dr. Shirley Sahrmann 58:26 ... pulling down. And women's shoulder girdles aren't as, aren't as stiff. And, and what, what's important about this is it's not only a factor of what it does to your shoulders. It also does s- a, a number on your neck because-

Tim Ferriss 58:38 Mm-hmm

Dr. Shirley Sahrmann 58:38 ... the muscles that help to hold your shoulder blades up attach to your cervical vertebrae.

Tim Ferriss 58:42 Mm-hmm.

Dr. Shirley Sahrmann 58:43 And the really big important thing on trying to address that is using, I think, the muscle that's called the serratus anterior.

Tim Ferriss 58:52 Mm-hmm.

Dr. Shirley Sahrmann 58:52 The serratus anterior attaches to your rib cage, and it can act like a sling. So it attaches to your rib cage and to your shoulder blades. So it's like a sling that can help to hold your shoulder blades up and take some of that load off of your cervical spine as well as put your shoulders in the right position. And having your shoulders sitting at the right position is important for the glenohumeral joint for all of the shoulder joint motions to work without subjecting them to too much injury.

Tim Ferriss 59:25 It seems like perhaps in weight training, I don't know if this contributes to the, the sloped shoulders and maybe the flat or downward angle of the clavicle, but the advice to depress and retract your shoulders is common, right, for any number of exercises. And I recall meeting with Eric and what he has a lot of his athletes do, and this is very individual dependent, so I'm not making a blanket recommendation and I'm not speaking for Eric. But for instance, as r- as he has someone maybe retract on some type of s- of standing pulling motion with, say, some type of cable machine, he'll have them reach forward with the opposing side. And it seems to me that there's less of that kind of fixed depress and retract, retracted position i- in a lot of what he recommends. Is working on the serratus anterior, doing exercises for the serratus anterior enough to correct that downward sloped angle in people who have that as a current state of affairs?

Dr. Shirley Sahrmann 1:00:33 Number one is you have to be sure when people have worked out. Now it d- depends upon, again, what their workout routine is. If they're somebody that hangs and does chin-ups, one of the things can be the latissimus dorsi-

Tim Ferriss 1:00:44 Mm-hmm

Dr. Shirley Sahrmann 1:00:44 ... is this big muscle. And people do lap pull-downs, et cetera, or they do climbing things or hanging things, and that muscle will pull your shoulders down.

Tim Ferriss 1:00:54 Mm-hmm.

Dr. Shirley Sahrmann 1:00:55 So you gotta make sure that that muscle hasn't gotten too short and that you can get your arms up over your head in the first place.

Tim Ferriss 1:01:01 Mm-hmm.

Dr. Shirley Sahrmann 1:01:02 Number two is what you really wanna do is use the upper trapezius. And the exercises where you're down here is using The rhomboids and the middle trapezius

Tim Ferriss 1:01:16 And just for people who are listening, this is like a, a rowing motion?

Dr. Shirley Sahrmann 1:01:19 Yeah. Anything where your arms are below your shoulders or at the level of your shoulders, you're using muscles. They pull your shoulder blades together.

Tim Ferriss 1:01:29 Mm-hmm.

Dr. Shirley Sahrmann 1:01:29 But particularly the rhomboids downwardly rotate. So it's gonna make it more difficult to get your scapula to upwardly rotate and to get the upper trapezius to work.

Tim Ferriss 1:01:40 Mm-hmm.

Dr. Shirley Sahrmann 1:01:41 So one of the things that is probably more effective is actually, I like to start people off-- And I think that's the other thing that when I look at what recommendations there are on the internet, they never show people where to start. It's like, "Do this exercise." Well, not everybody's ready to do that exercise. They've gotta get ready to do it-

Tim Ferriss 1:02:02 Right

Dr. Shirley Sahrmann 1:02:02 ... the way that's recommended. But if you can face the wall and slide your arms up the wall, and then once your arms get to shoulder height, particularly when they're lower, then you shrug a little bit to get them up. And then you try to lift them off while holding your shoulders up.

Tim Ferriss 1:02:22 How far are you standing from the wall?

Dr. Shirley Sahrmann 1:02:24 Oh, you're right up. You're right up there facing it.

Tim Ferriss 1:02:27 Oh, got it. Okay, got it.

Dr. Shirley Sahrmann 1:02:28 Right up there facing. Your elbows are flexed. You're sliding the little finger side of your hands up there-

Tim Ferriss 1:02:32 Mm-hmm

Dr. Shirley Sahrmann 1:02:33 ... to get it. And then if you just let your shoulders drop, you've gained nothing.

Tim Ferriss 1:02:38 Mm-hmm.

Dr. Shirley Sahrmann 1:02:38 But you've got to also hold them up as you lower your arms.

Tim Ferriss 1:02:43 Keeping your shoulders up as you do this exercise.

Dr. Shirley Sahrmann 1:02:45 Right. Keep them up. Get them up to where they should be worn, not-

Tim Ferriss 1:02:49 Mm-hmm

Dr. Shirley Sahrmann 1:02:49 ... closer to your ears than your iliac crest.

Tim Ferriss 1:02:52 Mm-hmm. So you're looking to keep the shoulders in that, in the position where the-

Dr. Shirley Sahrmann 1:02:58 Where you wanna wear them

Tim Ferriss 1:02:58 ... clavicle is angling up. Yeah. Slightly.

Dr. Shirley Sahrmann 1:03:01 Yeah.

Tim Ferriss 1:03:01 Mm-hmm.

Dr. Shirley Sahrmann 1:03:02 The other thing is it, it just makes such common sense. You can't spend the rest of the day ha- have them hanging down either.

Tim Ferriss 1:03:08 Right.

Dr. Shirley Sahrmann 1:03:08 So you should have a chair that has armrests on it so that they're up when you're-- you got your armrests up.

Tim Ferriss 1:03:14 Hmm.

Dr. Shirley Sahrmann 1:03:14 If you have to stand a lot, you can put them on your hips. If one shoulder in particular is problematic, you can support it with the other hand.

Tim Ferriss 1:03:21 Mm-hmm.

Dr. Shirley Sahrmann 1:03:22 I mean, so again, exercises will mean nothing if you don't follow through. If you're doing even 20 minutes of exercise but you're spending 12 hours with your shoulders hanging down, it ain't gonna work. [laughs]

Tim Ferriss 1:03:37 [laughs] What is your position on, and I know there are many different types, but stretching? This can be a controversial, sometimes polarizing topic. But could you elaborate on how various forms of stretching should or shouldn't be used in healthy and rehabilitating populations?

Dr. Shirley Sahrmann 1:03:58 Number one is really understanding what you're meaning by, by stretching. One-

Tim Ferriss 1:04:02 Mm-hmm

Dr. Shirley Sahrmann 1:04:03 ... I've talked about this as, as we've gone on through this, but I keep using the term stiffness because I feel like I was sort of misled during my early days as a physical therapist when I didn't use my own sense of looking carefully.

Tim Ferriss 1:04:21 Mm-hmm.

Dr. Shirley Sahrmann 1:04:21 Because we were told that certain movements occurred because a muscle was too short and it needed to be stretched. I'll give you an example. Well, the, the example we talked about already. If you're on your back and you slide your legs down and your pelvis tilts forward, your hip flexors are too short. Well, actually, what it is is the struggle between the tension from your abdominals and the tension from your hip flexors.

Tim Ferriss 1:04:48 Mm-hmm.

Dr. Shirley Sahrmann 1:04:49 So stretching your hip flexors is not gonna fix the lack of tension in your abdominals.

Tim Ferriss 1:04:55 Hmm.

Dr. Shirley Sahrmann 1:04:56 And so what I find is that most often there aren't muscles that are short. There's a relative stiffness problem.

Tim Ferriss 1:05:02 Mm-hmm.

Dr. Shirley Sahrmann 1:05:03 So improving the stiffness of your abdominals will elongate your hip flexors.

Tim Ferriss 1:05:10 Hmm.

Dr. Shirley Sahrmann 1:05:11 Do you see what I mean?

Tim Ferriss 1:05:12 Yeah. It's a relationship, not just an isolated muscle that you need to stretch.

Dr. Shirley Sahrmann 1:05:17 Right. And that it isn't the length of the hip flexors that's the problem. It's the-

Tim Ferriss 1:05:22 Mm-hmm

Dr. Shirley Sahrmann 1:05:22 ... passive tension from those, those muscles.

Tim Ferriss 1:05:24 Mm-hmm.

Dr. Shirley Sahrmann 1:05:25 Because when you're sliding your leg down, that muscle isn't that active anyway.

Tim Ferriss 1:05:31 Mm-hmm.

Dr. Shirley Sahrmann 1:05:32 And if it's related to the length of the muscle, it shouldn't occur until you get to the end of that muscle length.

Tim Ferriss 1:05:37 Right.

Dr. Shirley Sahrmann 1:05:38 And that's not when the tilting occurs. So there's all these things that just don't make sense. So-

Tim Ferriss 1:05:43 Hmm

Dr. Shirley Sahrmann 1:05:43 ... what I found through these numerous years of experience I've had is that there's many more problems with relative stiffness than there is with muscles really being short.

Tim Ferriss 1:05:55 Hmm.

Dr. Shirley Sahrmann 1:05:55 Now, if it's really short, then you also need to find out what's making it short because it doesn't just like, "Oh, I think I'll go short today." [laughs]

Tim Ferriss 1:06:06 Right.

Dr. Shirley Sahrmann 1:06:06 It's a matter of what is your activity? For example, when I'm teaching courses, I have a great picture of a, of a young man who has big curve, like you're talking about, an increased lumbar curve. Clearly, his hip flexors are short, and he's a cyclist. Well, you usually don't see that kind of alignment in a cyclist. You usually see a, a flatter back.

Tim Ferriss 1:06:26 Hmm.

Dr. Shirley Sahrmann 1:06:27 But if I didn't let him use toe clips, he couldn't move the pedals around. So he moved the pedals by flexing rather than pushing.

Tim Ferriss 1:06:37 Hmm.

Dr. Shirley Sahrmann 1:06:38 So that's why his hip flexors were short. So it wouldn't matter how much you stretched him if every time he went out to ride the bicycle, he's using his hip flexors all over again in a shortened position.

Tim Ferriss 1:06:50 Got it. So he's basically in that rear half of the rotation of the pedal. He's pulling with his hip flexors.

Dr. Shirley Sahrmann 1:06:56 Right. Instead of more pushing than just the, the lifting.

Tim Ferriss 1:07:01 Mm-hmm.

Dr. Shirley Sahrmann 1:07:01 So what is it that people are doing that's causing that muscle to get short?

Tim Ferriss 1:07:06 Hmm.

Dr. Shirley Sahrmann 1:07:08 You know, other examples, and, and again, I find it so interesting about what intensive weight training's doing because if you're lifting, I- [laughs] I've actually examined young women who are lifting twice their body weight. Well, you know, how many muscles do you use if you were lifting twice your body weight in a deadlift?

Tim Ferriss 1:07:25 Mm-hmm.

Dr. Shirley Sahrmann 1:07:25 Like, every little muscle you've got in your body. Well, what happens is you en- end up training all of those muscles to come on. [laughs]

Tim Ferriss 1:07:32 Mm-hmm.

Dr. Shirley Sahrmann 1:07:33 And they don't just go off, so they walk stiff-legged because there's too much activation of these muscles.

Tim Ferriss 1:07:40 Hmm.

Dr. Shirley Sahrmann 1:07:40 And so they can't stand and have muscles relaxed, 'cause everything comes on. It, it doesn't say, "I'll only come on when I'm weight training." [laughs] You've trained them to come on.

Tim Ferriss 1:07:51 Hmm.

Dr. Shirley Sahrmann 1:07:51 And now you've got much more output for a given muscle [laughs] than, than you would otherwise.

Tim Ferriss 1:07:58 Mm-hmm.

Dr. Shirley Sahrmann 1:07:58 So it's, it's too much, so you've gotta learn also how to not activate them as much as you're learning how to activate them. I'm, I'm not against any of this.

Tim Ferriss 1:08:07 Mm.

Dr. Shirley Sahrmann 1:08:07 It's just that you need to know what all the additional factors are that take place with this training. So it's a long answer to the question about stretching, but m- my big point is you've gotta figure out what's making it short. That if you need constant stretching, you've got a problem with what's active, what's making it short that has to be addressed.

Tim Ferriss 1:08:29 So I've been advised, and it seems to help a bit, but to do a fair amount of, say, [smacks lip] hip bridging or glute activation alternated with, say, hip flexor stretches. And if I have, in addition to that, the stiffness in the abdominal muscles contributing to this low back presentation, right, these symptoms I'm experiencing, could you just remind me of, of how I would then work on that abdominal stiffness? I could do, I could do the overhead breathing and the side bend.

Dr. Shirley Sahrmann 1:09:05 No, no, no. That, that's for th- that stiffness. But again, what you're telling me, and again, I haven't seen you standing, but-

Tim Ferriss 1:09:12 I could stand. We're also on video.

Dr. Shirley Sahrmann 1:09:14 Okay.

Tim Ferriss 1:09:14 Would you like me to stand?

Dr. Shirley Sahrmann 1:09:15 Please, please.

Tim Ferriss 1:09:17 Okay. And I can tilt the camera as needed.

Dr. Shirley Sahrmann 1:09:19 Okay. Yeah, pull up the shirt so I can see. Now turn sideways for me. Oh.

Tim Ferriss 1:09:27 [laughs] Oh, boy.

Dr. Shirley Sahrmann 1:09:29 No, no, no. I mean, I don't know what you're talking about your tummy sticking out.

Tim Ferriss 1:09:34 Oh. Well, yeah, I mean, like, if I wanna look kind of in my second trimester, I can do the-

Dr. Shirley Sahrmann 1:09:39 Which one's the real you?

Tim Ferriss 1:09:41 This is probably the real me. This is the real me. This is, this is how I would stand. If I were standing at an event, I would probably try to tuck my hips a bit to take pressure off the back.

Dr. Shirley Sahrmann 1:09:50 Yeah. But you see, you don't have an increased lumbar curve. You've got an increased thoracic curve.

Tim Ferriss 1:09:55 Like the kyphosis on the back ty- Yeah.

Dr. Shirley Sahrmann 1:09:58 Yeah. Yeah, right up there. And part of that kyphosis comes from your rectus abdominis pulling down on your thoracic spine.

Tim Ferriss 1:10:06 Interesting. Right here?

Dr. Shirley Sahrmann 1:10:08 Yeah. And see, when you lean back like that, then the rectus and the, and the other abdominals become your anti-gravity muscles, so they're constantly being used.

Tim Ferriss 1:10:17 Meaning that I lean back and then these are pulling me forward?

Dr. Shirley Sahrmann 1:10:21 Yeah. You lean back to get away from those, but you need to-- The rectus needs to be a little bit longer.

Tim Ferriss 1:10:27 Okay. This needs to be a bit longer.

Dr. Shirley Sahrmann 1:10:30 And the best way for you to do that is to, to do the quadruped thing and then let your thoracic spine go down.

Tim Ferriss 1:10:36 So that would be almost like the cat of the cat cow, I guess, sort of. As I'm on my hands and knees-

Dr. Shirley Sahrmann 1:10:41 All you need to do is think about letting your chest go towards the floor, and, like, you feel the load on your shoulder blades.

Tim Ferriss 1:10:48 Mm-hmm.

Dr. Shirley Sahrmann 1:10:48 Okay.

Tim Ferriss 1:10:48 Okay.

Dr. Shirley Sahrmann 1:10:49 Now let me watch you just easily, like you're gonna contract your tummy to pull it in. Yeah. See, you do sway back. Okay, stop. You did lean back. That's it. That's better. That's better. Now, do you have any symptoms like that at all?

Tim Ferriss 1:11:06 No.

Dr. Shirley Sahrmann 1:11:06 No.

Tim Ferriss 1:11:06 There's a little bit of tightness here, but it actually-- it doesn't bother me right now.

Dr. Shirley Sahrmann 1:11:11 Yeah, okay. And it looks like your hips are fairly straight, so go ahead and turn. Put your back to me for a minute. And put your hands on your iliac crest. Now, with your hands like that, they don't look so bad to me.

Tim Ferriss 1:11:26 Okay.

Dr. Shirley Sahrmann 1:11:27 Let's do what we talked about before. Put your feet apart and let's just see what happens, if that changes your symptoms at all. Is it better?

Tim Ferriss 1:11:36 Yeah. It's better. This would help if I were, say, recording a podcast. What would help even more is if I put my one leg up on something, if I stepped on something.

Dr. Shirley Sahrmann 1:11:47 Does it matter which leg?

Tim Ferriss 1:11:49 Right leg, because-

Dr. Shirley Sahrmann 1:11:50 Right leg. Yeah, that-

Tim Ferriss 1:11:51 Where I, where I feel most of the pain, it sort of localizes around this bony process.

Dr. Shirley Sahrmann 1:11:55 Right. Right. Yeah. So that is gonna be the, the tensor on that side. Now let me do one more thing. Just bend over and come back up.

Tim Ferriss 1:12:02 From the side like this?

Dr. Shirley Sahrmann 1:12:03 Yeah. Well. Yeah. See, now you need to, to work a bit on how you come back up from forward bending. And don't worry about going over that far.

Tim Ferriss 1:12:20 Okay.

Dr. Shirley Sahrmann 1:12:21 You need to come up with your hips and less back. As you finish off your back, you sway back and do too much back extension.

Tim Ferriss 1:12:30 Oh, when I get to the top, you're saying?

Dr. Shirley Sahrmann 1:12:31 Yeah, about the last 30, 40%.

Tim Ferriss 1:12:33 So, so hinge more at the hip? Is that what you mean?

Dr. Shirley Sahrmann 1:12:37 Just think about going over and coming back up by making your hips extend.

Tim Ferriss 1:12:43 Okay.

Dr. Shirley Sahrmann 1:12:44 Hold it there. Now hips. Just come back up with hips. Hips, hips, hips, hips. Yeah.

Tim Ferriss 1:12:50 Yeah.

Dr. Shirley Sahrmann 1:12:50 That was better.

Tim Ferriss 1:12:51 More like that. So sort of-

Dr. Shirley Sahrmann 1:12:54 Yeah, and try not to let your back sway back. You, you use the momentum of your upper back coming back to finish up.

Tim Ferriss 1:13:01 I see. I get a little extension.

Dr. Shirley Sahrmann 1:13:02 You get a little extension, and that's not good.

Tim Ferriss 1:13:04 Overextension.

Dr. Shirley Sahrmann 1:13:05 Right. Right, right.

Tim Ferriss 1:13:06 Got it. Anything else that I can-- Yeah, I mean, I can do more certainly. This is helpful.

Dr. Shirley Sahrmann 1:13:12 If you can easily practice, you've got those The lower abdominals are the external obliques. They're the ones that tilt your pelvis. And if you just easily practice tightening those, but don't work hard at it so that you sway back

Tim Ferriss 1:13:27 So this is the external obliques, and then what was the other musculature you mentioned?

Dr. Shirley Sahrmann 1:13:32 I'm saying don't sway back. Just easily try to tighten them so you get a little bit of a pelvic... Yeah, plenty. Now, are you good that way?

Tim Ferriss 1:13:41 Yeah, I'm good.

Dr. Shirley Sahrmann 1:13:42 Yeah.

Tim Ferriss 1:13:43 And this would be in a standing position when I would have just a little bit of tension in the external obliques.

Dr. Shirley Sahrmann 1:13:47 If you do that as much as you can, because, you see, it eliminates your symptoms. That's all you need to do.

Tim Ferriss 1:13:54 Yeah.

Dr. Shirley Sahrmann 1:13:54 And then work on that little increased thoracic kyphosis.

Tim Ferriss 1:13:58 Or I'm, I guess, reducing this kyphosis by lengthening.

Dr. Shirley Sahrmann 1:14:02 Yeah, if you decrease that, then you won't sway back so much.

Tim Ferriss 1:14:05 I got it.

Dr. Shirley Sahrmann 1:14:06 And if your rectus abdominis elongates better, you won't have that tendency for a thoracic kyphosis.

Tim Ferriss 1:14:12 And to extend, then elongate the rectus abdominis. For people listening, this is like the six-packs, right? The stuff running down the, the front of the abdominal-

Dr. Shirley Sahrmann 1:14:22 I'm having a hard time hearing you, Tim.

Tim Ferriss 1:14:23 Oh, sorry. I forgot about the microphone over here. [laughs] That to elongate the rectus abdominis, I could get in that quadruped position-

Dr. Shirley Sahrmann 1:14:35 Right

Tim Ferriss 1:14:35 ... and basically drop my chest to the floor as I'm pushing my hips backwards.

Dr. Shirley Sahrmann 1:14:40 Just in that position, just let it go down.

Tim Ferriss 1:14:42 Mm-hmm.

Dr. Shirley Sahrmann 1:14:45 It's amazing how much you can improve your alignment, and it looks like you, you could change pretty readily.

Tim Ferriss 1:14:51 Okay, great.

Dr. Shirley Sahrmann 1:14:52 And the big thing, so y- we started off because you were doing the, the, the bridging exercise. I, I wouldn't be tempted to do that.

Tim Ferriss 1:15:00 Okay.

Dr. Shirley Sahrmann 1:15:01 One, you'll do a much better loading of your gluteal muscles by that bending over and coming back up with your hip extensors.

Tim Ferriss 1:15:09 Yep.

Dr. Shirley Sahrmann 1:15:09 And if you tighten it there, there's also a tendency for the glutes to actually posteriorly tilt the pelvis but the spine doesn't go along for the ride.

Tim Ferriss 1:15:19 Hmm. Could you say more about that, please?

Dr. Shirley Sahrmann 1:15:21 [laughs]

Tim Ferriss 1:15:22 [laughs]

Dr. Shirley Sahrmann 1:15:23 Well, it's kind of like this is one of my guilt trips because many years ago I was working to get the point across. I'll tell you my little story.

Tim Ferriss 1:15:32 Yes, please.

Dr. Shirley Sahrmann 1:15:33 I was working with this older woman. I thought old, who's my age now. [laughs]

Tim Ferriss 1:15:39 [laughs]

Dr. Shirley Sahrmann 1:15:39 And so she, she did have spinal stenosis, and I was working on sit to stand so she didn't have any symptoms. And I had her try to tighten her abdominals, and she was doing pretty good, and then I said, "Okay, now let's tighten your gluteal muscles as you get up." Well, she did that, and she got pain shooting down her legs.

Tim Ferriss 1:16:00 Hmm.

Dr. Shirley Sahrmann 1:16:00 And, and the reason being that your gluteal muscles, as you know, attach to the pelvis, so if they posteriorly tilt the pelvis but if the spine doesn't wanna go along for the ride-

Tim Ferriss 1:16:13 Mm-hmm

Dr. Shirley Sahrmann 1:16:13 ... it stays there and you get a translation motion between where the pelvis is moving and the vertebrae are not moving.

Tim Ferriss 1:16:20 Right. The gluteal muscles are basically pulling the pelvis-

Dr. Shirley Sahrmann 1:16:24 Right

Tim Ferriss 1:16:24 ... out from under the spine, in a sense.

Dr. Shirley Sahrmann 1:16:26 Exactly. Exactly. Not a good idea. Now, if your-

Tim Ferriss 1:16:30 Not a good idea

Dr. Shirley Sahrmann 1:16:30 ... spine, if your spine moves easily, then that's all right. And, and you can get the same effect if, if you would put your hand where your spine is and tighten your glutes, you'll see your spine doesn't move.

Tim Ferriss 1:16:42 Mm-hmm.

Dr. Shirley Sahrmann 1:16:43 Do you see what I mean?

Tim Ferriss 1:16:44 Right.

Dr. Shirley Sahrmann 1:16:44 If it wants to go along for the ride, it'll go along for the ride, but the problem is those people where it doesn't wanna go along for the ride, and you're gonna be one of them.

Tim Ferriss 1:16:53 Hmm. So in, in what ways do I need to be careful th- then? If-

Dr. Shirley Sahrmann 1:16:56 I mean, I just don't think that's a good, a good exercise for you.

Tim Ferriss 1:17:00 Got it. The bridging.

Dr. Shirley Sahrmann 1:17:01 The bridging, yeah.

Tim Ferriss 1:17:03 Yeah. I, I feel, especially if, if I do bridging single leg, but even, even double legged, I, I remember I... It's been recommended to me by a number of PTs and I'm, and I've told them all like, "Guys, this really bothers my back."

Dr. Shirley Sahrmann 1:17:15 Yeah, yeah, and it's arching your back. It's not a good plan.

Tim Ferriss 1:17:18 Yeah, okay. I'll skip those. [laughs]

Dr. Shirley Sahrmann 1:17:20 I would skip those. When do you have time to do all this? [laughs]

Tim Ferriss 1:17:23 [laughs] I don't. I don't. That's honestly, Shirley, been one of the compounding factors that has been so frustrating is not only am I getting very often entirely different diagnoses, but I also get 37 different programs, and there's just no way that I can fit them in, and many are probably conflicting also.

Dr. Shirley Sahrmann 1:17:44 Right. Yeah, yeah, yeah, yeah, yeah.

Tim Ferriss 1:17:46 And I've found the movement focused approach to make a lot of at least intuitive sense to me. If, if our entire conscious experience of reality is modeled on a brain that is evolved to move us through space, [laughs] it just seems to make sense that that is the variable to pay a lot of attention to because it's not just a variable but a system of systems, as you put it.

Dr. Shirley Sahrmann 1:18:10 Yes.

Tim Ferriss 1:18:10 Much like the immune system. So it, it makes a whole lot of sense. Now, you, you just mentioned older woman, but she's now my age. Would, uh, [laughs]

Dr. Shirley Sahrmann 1:18:17 [laughs]

Tim Ferriss 1:18:18 Would you mind sharing your age, but also your own self-care, I suppose, routine? What do you do to keep as sharp and as in shape as, as you are? I would, I would love to know more about that.

Dr. Shirley Sahrmann 1:18:33 Well, I, yeah, next month I'll be 86 years old.

Tim Ferriss 1:18:36 It's incredible. It's just amazing. I would never guess in a million years.

Dr. Shirley Sahrmann 1:18:41 I'm so lucky. I'm so fortunate, too, because I don't mind saying both of my parents had dementia.

Tim Ferriss 1:18:47 Hmm.

Dr. Shirley Sahrmann 1:18:48 I've now exceeded their ages both in life and in dementia.

Tim Ferriss 1:18:53 Hmm.

Dr. Shirley Sahrmann 1:18:53 Right now I don't know that I have any.

Tim Ferriss 1:18:55 I would not think you have any. Very, very sure.

Dr. Shirley Sahrmann 1:18:59 Well, so far so good.

Tim Ferriss 1:19:00 So far so good.

Dr. Shirley Sahrmann 1:19:01 As I told you that, number one, choosing to be a physical therapist and, and also I was very fortunate because growing up I refused to grow up and I played sports.

Tim Ferriss 1:19:11 Mm-hmm.

Dr. Shirley Sahrmann 1:19:12 And in, in my day [laughs] it's when are you gonna grow up and stop all that stuff? And-

Tim Ferriss 1:19:16 Mm-hmm

Dr. Shirley Sahrmann 1:19:17 ... that was very good. We also didn't have air conditioning, and we only had one car. [laughs]

Tim Ferriss 1:19:21 Hmm.

Dr. Shirley Sahrmann 1:19:21 So instead of Paying more for a bicycle than a car. [laughs] I had to ride a big old bicycle and ride it everywhere.

Tim Ferriss 1:19:29 Mm.

Dr. Shirley Sahrmann 1:19:30 So I happily laid down enough bone and enough muscle in my early years, and then the physician that I encountered, who was part of the Department of Medicine at Washington University in St. Louis, his name was John Holloszy, he started bringing in the lifestyle issues.

Tim Ferriss 1:19:48 Mm-hmm.

Dr. Shirley Sahrmann 1:19:49 And as a physical therapist, even though I got a PhD in neurobiology 'cause I wanted to solve the motor control problems of the stroke patient, I stayed very physically active. I started really running and doing things when I started my PhD studies, and after encountering this physician. And, and learned a bit about nutrition, breaking all the family tendencies. [laughs]

Tim Ferriss 1:20:17 [laughs]

Dr. Shirley Sahrmann 1:20:18 And then again, learning about musculoskeletal problems even though I was really interested in working with neurological patients, people with spinal cord injury, head injury, stroke. I'd always had this tendency to look at how people moved and I t- always tried to figure out why they were moving the way they were moving, et cetera, and got involved with musculoskeletal patients, and they started getting better [laughs] so I had to figure that out.

Tim Ferriss 1:20:47 Hmm.

Dr. Shirley Sahrmann 1:20:47 And then I applied my own ideas to, to myself. In fact, there... I don't know how folksy you wanna get, but there are really some funny stories connected with that.

Tim Ferriss 1:20:59 Oh, let's do it. Oh, yeah, no, we love funny stories around here.

Dr. Shirley Sahrmann 1:21:02 And it really related to doing this quadruped little exercise because... So one, one sort of funny story was I was really poor g- going through getting my PhD 'cause I didn't have any income and was living off of a m- m- a minimum amount of money. And so I, I didn't get to buy new clothes very often, and I had a pair of slacks that I was wearing for a long time, and a friend actually took me out to play golf and o- and it, it was an older woman at that time, and we're out playing golf, and she says, "You know, Shirley, you've got your pants on backwards." And I said, "You know, I'm working on my PhD. I think I ought to be able to know how to put my pants on." [laughs]

Tim Ferriss 1:21:44 [laughs]

Dr. Shirley Sahrmann 1:21:45 And so we started looking at the darts, and sure enough, I had them on backwards. Well-

Tim Ferriss 1:21:49 [laughs]

Dr. Shirley Sahrmann 1:21:49 ... before [laughs] , before my alignment was such that they looked all right, but now that I was doing this quadruped exercise, they didn't look all right. They w- they were looking funny because I had changed the curves in my back and my buttocks. And so that's why she caught the idea that I wasn't wearing my pants right.

Tim Ferriss 1:22:09 Hmm. Which quadruped movements were these?

Dr. Shirley Sahrmann 1:22:12 It's just the idea of being in quadruped and, and just letting your back go down and then rocking back.

Tim Ferriss 1:22:19 Mm-hmm.

Dr. Shirley Sahrmann 1:22:21 I tended to sit, ride the bicycle. I was a, a catcher for three different softball teams. So I was really in a posterior tilt with a really flat back.

Tim Ferriss 1:22:32 Got it.

Dr. Shirley Sahrmann 1:22:32 And I had never really gone the other way.

Tim Ferriss 1:22:36 And just for people who are listening, if you don't know, just to, to imagine, if you imagine the, the, sort of the, the pelvis as a bowl of soup, posterior tilt, you're kind of pouring soup out the back of your [laughs] pelvis.

Dr. Shirley Sahrmann 1:22:47 [laughs]

Tim Ferriss 1:22:48 Just for people.

Dr. Shirley Sahrmann 1:22:48 Holding it in the middle. [laughs]

Tim Ferriss 1:22:49 Yeah, yeah. Right. Yeah. Got it. Okay.

Dr. Shirley Sahrmann 1:22:52 And so your back, your whole back goes kind of flat then.

Tim Ferriss 1:22:54 And when you're pushing your hips back, you're facilitating more of a natural curve in the lower back.

Dr. Shirley Sahrmann 1:22:59 Well, I was, yeah, getting my hips to bend and, yeah, letting my back go down, so I was getting more of a curve.

Tim Ferriss 1:23:04 Mm-hmm.

Dr. Shirley Sahrmann 1:23:05 And I think also decreasing a bit of a tendency towards a thoracic kyphosis.

Tim Ferriss 1:23:09 Mm-hmm.

Dr. Shirley Sahrmann 1:23:10 The other thing that was really an interesting, I, I used to bowl, you know, like with a bowling ball.

Tim Ferriss 1:23:16 Yeah.

Dr. Shirley Sahrmann 1:23:16 And while I was in my PhD program, which took me six years, I didn't have any money to bowl. And so when I went and got my bowling ball out again, I had to change the finger grips because I had stretched my finger flexors out. And so the, the finger grips no longer fit me because my fingers were, were longer.

Tim Ferriss 1:23:36 Can you explain that? So your, your-

Dr. Shirley Sahrmann 1:23:38 [laughs]

Tim Ferriss 1:23:38 ... grips had been molded to fingers that were...

Dr. Shirley Sahrmann 1:23:41 Well, my fingers were always flexed from everything I did.

Tim Ferriss 1:23:44 Right.

Dr. Shirley Sahrmann 1:23:44 And I never really thought about stretching them out. And so when you're in quadruped, you end up stretching those all out.

Tim Ferriss 1:23:52 Right. Okay. I see. Right. Instead of... So for people who are listening, because we're making movements with their hands and gestures with the hands-

Dr. Shirley Sahrmann 1:23:59 Oh, you can't see?

Tim Ferriss 1:24:00 We're gonna make the video available as well, but some people will only hear audio. So instead of being in sort of that keyboard, you know, hawk talon position, when you're in quadruped, right, as if you were doing a, a pushup, but not in that pushup position, if your hands are flat on the floor, then you're gonna be stretching those flexors.

Dr. Shirley Sahrmann 1:24:18 Stretching across the wrist and across the fingers, yeah.

Tim Ferriss 1:24:21 Got it. So you had to change your bowling ball. That's wild.

Dr. Shirley Sahrmann 1:24:24 Yeah. And then the other thing is I had always worn my shoes off so that they were going off to the side, and after I did this, you know, few years of this quadruped rocking, I didn't walk in the same way and I didn't have my, shoes weren't worn off to the side from just walking.

Tim Ferriss 1:24:41 Oh, interesting. So worn off to the side, you mean the shoes on the inside were worn or on the-

Dr. Shirley Sahrmann 1:24:47 Yeah, the, like the outside of the right and the inside of the left. So there were all these little changes that took place just from-

Tim Ferriss 1:24:54 Mm-hmm

Dr. Shirley Sahrmann 1:24:55 ... improving my alignment partly with that. So to go on to answer your full question, so what do I do these days? Guess what? I still do quadruped. I don't go all the way back and sit on my heels. I, and I also want to tell you about one thing people need to know about th- that exercise. And then I do a modified pushups, modified pushups.

Tim Ferriss 1:25:19 Mm-hmm.

Dr. Shirley Sahrmann 1:25:19 In prone, and I think that if you could do this carefully it'd be good, is in prone I, I flex my knee so that my leg, as much as possible, is falling Falling on my thigh

Tim Ferriss 1:25:33 Mm-hmm. So is this similar to what you were describing? You're laying down on your chest-

Dr. Shirley Sahrmann 1:25:39 Yeah, I'm laying down, face down, bend my knee, and I try to get my leg to fall back on my thigh because I don't wanna hold it bent at 90. In other words, if you flex, if you bend your knee, y- you can go to 90 degrees. If you go more than 90 degrees, your leg is falling on your thigh.

Tim Ferriss 1:25:58 I see. Right, your lower leg is sort of falling onto your hamstring.

Dr. Shirley Sahrmann 1:26:02 Yes. That's your thigh. Yeah.

Tim Ferriss 1:26:04 Got it. Okay.

Dr. Shirley Sahrmann 1:26:05 In that position, then I lift my thigh off of the floor. I do hip extension, but not high. There's only 10 degrees of motion.

Tim Ferriss 1:26:15 Mm-hmm.

Dr. Shirley Sahrmann 1:26:15 But it's a way to stretch. It's a way to use your gluteal muscle.

Tim Ferriss 1:26:19 Mm-hmm.

Dr. Shirley Sahrmann 1:26:20 Because you can't-- If you use your hamstring, you'll get a cramp.

Tim Ferriss 1:26:23 Yeah.

Dr. Shirley Sahrmann 1:26:24 You'll get a bad cramp in your hamstring.

Tim Ferriss 1:26:26 Mm-hmm.

Dr. Shirley Sahrmann 1:26:27 So just a little bit of hip extension to use my gluteal muscle.

Tim Ferriss 1:26:32 How many repetitions are you doing on each side, or what is-

Dr. Shirley Sahrmann 1:26:35 I just do 10 repetitions on one side and then 10 repetitions on the other.

Tim Ferriss 1:26:40 And you're doing roughly 10 repetitions of the quadruped rocking as well?

Dr. Shirley Sahrmann 1:26:45 Yep.

Tim Ferriss 1:26:45 I'm not sure if that's the right term or not.

Dr. Shirley Sahrmann 1:26:46 Yep, and 15 push-ups. Fifteen modified push-ups. Modified is your knees are bent. I don't go to my toes.

Tim Ferriss 1:26:52 Got it. Okay.

Dr. Shirley Sahrmann 1:26:54 And then still in the prone position, knees flexed to 90 degrees, and then I do hip rotation.

Tim Ferriss 1:27:01 Mm-hmm.

Dr. Shirley Sahrmann 1:27:02 You know, in both directions. Letting my-

Tim Ferriss 1:27:05 Mm-hmm

Dr. Shirley Sahrmann 1:27:05 ... lower leg come in and then go out. Come in and go out.

Tim Ferriss 1:27:10 Right. So just if I can translate, and please correct me if I'm getting this wrong, but you're bending one l-- you're laying on your, on your chest, one leg bent to 90 degrees, and basically windshield wiper with that lower leg on each side.

Dr. Shirley Sahrmann 1:27:24 Yeah, but I do both at the same time.

Tim Ferriss 1:27:26 Oh, you do both at the same time. Okay. I see.

Dr. Shirley Sahrmann 1:27:27 Yeah, so they're not quite, you know, one's maybe 80, the other maybe 70. Just because it doesn't take all that long.

Tim Ferriss 1:27:36 Yeah, right.

Dr. Shirley Sahrmann 1:27:37 And then with my knees extended straight, with my lower extremity straight, I alternate doing hip extension, but I think about using my gluteal muscle.

Tim Ferriss 1:27:48 Mm-hmm.

Dr. Shirley Sahrmann 1:27:48 I think about activating my gluteus maximus.

Tim Ferriss 1:27:51 Mm-hmm.

Dr. Shirley Sahrmann 1:27:52 And again, only about 10 degrees of hip extension.

Tim Ferriss 1:27:54 Mm-hmm. Okay.

Dr. Shirley Sahrmann 1:27:56 And then in that same position, I do hip abduction.

Tim Ferriss 1:28:00 Mm-hmm.

Dr. Shirley Sahrmann 1:28:00 In other words, one leg out to the side 10 times 'cause you use, you use your gluteus medius and that better if you're working against gravity and extension than you do when you're supine.

Tim Ferriss 1:28:14 Okay.

Dr. Shirley Sahrmann 1:28:14 Supine, you tend to recruit the tensor too much.

Tim Ferriss 1:28:18 Oh, I see. Mm-hmm. Got it. And is there anything that, that follows that abductor work?

Dr. Shirley Sahrmann 1:28:28 Then I go supine. I turn over.

Tim Ferriss 1:28:30 Mm-hmm.

Dr. Shirley Sahrmann 1:28:30 And I think this is really... You know, I'm pretty good about not having a, a kyphosis, but I have to adduct-- in supine, I adduct, pull my shoulder blades together and slide my arms up over my head.

Tim Ferriss 1:28:48 Mm-hmm.

Dr. Shirley Sahrmann 1:28:48 So that my arms are all the way up over my head as much as I can. And I'm on a hard floor.

Tim Ferriss 1:28:54 Mm-hmm.

Dr. Shirley Sahrmann 1:28:55 And I'm starting with my hips and knees bent, arms up overhead, and then slide one leg down, slide the other leg down.

Tim Ferriss 1:29:02 Mm-hmm.

Dr. Shirley Sahrmann 1:29:02 And believe me, for an older person who's got a tendency towards collapso-smasho [laughs] just getting yourself as stretched out as possible is so important.

Tim Ferriss 1:29:15 Mm. Yeah.

Dr. Shirley Sahrmann 1:29:16 I mean, really.

Tim Ferriss 1:29:17 Sounds like for me with my kyphosis, that would also be important.

Dr. Shirley Sahrmann 1:29:21 Yeah. The biggest worry is gonna be with the older person, that if you have a kyphosis, you're not gonna be able to get your arms on the floor all the way up over your head.

Tim Ferriss 1:29:33 Mm-hmm.

Dr. Shirley Sahrmann 1:29:34 You don't want any pain on top of your shoulder 'cause that's not gonna be a good plan.

Tim Ferriss 1:29:38 Mm-hmm.

Dr. Shirley Sahrmann 1:29:39 So they may need to have a pillow up there when they're first starting to, so their arms don't go all the way back 'cause you wanna avoid any kind of pain on top of your shoulder.

Tim Ferriss 1:29:51 Mm-hmm.

Dr. Shirley Sahrmann 1:29:52 But happily, I know how to do it, and I can do it.

Tim Ferriss 1:29:54 Mm-hmm.

Dr. Shirley Sahrmann 1:29:55 And then I do active, actively hip and knee flex, you know, bring one knee towards my chest, put it down, and the other one. And 10 times with each leg. And then with one foot on the floor, I do a s- straight leg raise. But I don't, like, tighten all my leg, my thigh muscles so that my knee is perfectly straight, and I turn it out a little bit so that I don't use the tensor.

Tim Ferriss 1:30:24 Hmm.

Dr. Shirley Sahrmann 1:30:24 I wanna-- That-- If I rotate it out, you'll use the psoas more, and I think about tightening my abdominals.

Tim Ferriss 1:30:32 Okay.

Dr. Shirley Sahrmann 1:30:33 Because I have had a, a significant problem, and I, I don't wanna put too much stress on my lumbar spine from the iliopsoas. I wanna use it-

Tim Ferriss 1:30:44 Mm-hmm

Dr. Shirley Sahrmann 1:30:44 ... but I wanna protect my back. That's why I have one foot on the floor.

Tim Ferriss 1:30:49 I see. That's why you're doing one leg at a time.

Dr. Shirley Sahrmann 1:30:51 Well, yeah, it's certainly one leg at a time.

Tim Ferriss 1:30:53 So could you just reiterate, given the last lumbar issue, why you would want to engage the psoas instead of the TFL in this case?

Dr. Shirley Sahrmann 1:31:04 It's a good muscle to use. I need to be able to flex my hip. But-

Tim Ferriss 1:31:07 Mm

Dr. Shirley Sahrmann 1:31:08 ... the tensor, it has a real low threshold for activation. I mean, interestingly enough-

Tim Ferriss 1:31:14 I see

Dr. Shirley Sahrmann 1:31:14 ... if you would scratch the bottom of your foot, the first muscle to go off will be your tensor fasciae latae.

Tim Ferriss 1:31:19 No kidding.

Dr. Shirley Sahrmann 1:31:20 Yeah. [laughs]

Tim Ferriss 1:31:20 Wild.

Dr. Shirley Sahrmann 1:31:21 In fact, I think it's so interesting because I've tried to contact the World Health Organization because all over the world the tensor is run amok, but they, they don't listen to me.

Tim Ferriss 1:31:30 [laughs] They're not returning the calls.

Dr. Shirley Sahrmann 1:31:32 No, I know. And, and it's this little-

Tim Ferriss 1:31:34 [laughs]

Dr. Shirley Sahrmann 1:31:34 ... bitty, wimpy muscle, and you say, "How can it cause so much trouble?" But it sure does. You know, it plays a role in what happens to the knee. It plays a role in what happens to the back and the hip. I mean- It's an evil thing. But [laughs]

Tim Ferriss 1:31:49 [laughs] Oh, yeah

Dr. Shirley Sahrmann 1:31:52 Anyway, you know, an interesting thing, one of my colleagues was doing a study, and we actually had a student that did not have a tensor fasciae latae.

Tim Ferriss 1:32:00 No kidding.

Dr. Shirley Sahrmann 1:32:01 Yeah. We didn't throw her out of school or anything, uh, but [laughs]

Tim Ferriss 1:32:05 [laughs]

Dr. Shirley Sahrmann 1:32:06 But anyway, I, I couldn't wait to do all the tests that we do to look for the length of the tensor, and she was a, a, you know, a fair athlete. So it wasn't like it, it had been sitting not doing anything if it was there. And I did all the tests, and they were negative, which was kind of supportive to me that indeed the tensor does do things that aren't so kind to the rest of the body.

Tim Ferriss 1:32:30 Hmm.

Dr. Shirley Sahrmann 1:32:30 So anyway, all that to say that's why when I do the straight leg raise, I try to laterally rotate my hip, 'cause I'd rather use the psoas than I would-

Tim Ferriss 1:32:40 The TFL

Dr. Shirley Sahrmann 1:32:41 ... and it's not causing me any problems. Clearly, if I thought I was injuring myself, I would not, would not do that.

Tim Ferriss 1:32:48 Yeah.

Dr. Shirley Sahrmann 1:32:48 And then I do one other thing with one leg straight and the other foot on the floor so that my knee is bent, my foot's on the floor. I let my leg go out to the side, and that's my way of trying to work on controlling rotation with the trunk.

Tim Ferriss 1:33:02 Mm-hmm.

Dr. Shirley Sahrmann 1:33:03 If my leg goes out to the side, it wants to rotate your pelvis, but contracting your abdominals prevents that rotation.

Tim Ferriss 1:33:10 Mm-hmm.

Dr. Shirley Sahrmann 1:33:10 So that's another way I'm trying to work my abdominals. And then, and then I stand up. And, you know, I'm so proud of myself because I can get up from the floor without any difficulty, and-

Tim Ferriss 1:33:23 Mm-hmm

Dr. Shirley Sahrmann 1:33:24 ... and many people at my age or many years younger than that can't do that.

Tim Ferriss 1:33:27 Mm-hmm.

Dr. Shirley Sahrmann 1:33:28 And put my back to the wall, and then do what I was telling you to do, arms up overhead, and do, do the little side bend thing.

Tim Ferriss 1:33:37 And you do this every day?

Dr. Shirley Sahrmann 1:33:39 I do. And then I walk three to four miles a day.

Tim Ferriss 1:33:43 Amazing.

Dr. Shirley Sahrmann 1:33:44 And sometimes ride a stationary bike.

Tim Ferriss 1:33:47 Well, these are things I'm paying more and more attention to. I'm, I'm so impressed. [laughs]

Dr. Shirley Sahrmann 1:33:53 But let me tell you one thing now, Tim, that the quadruped, as much as I love it, and I think it's important whether you have a shoulder problem, a cervical problem, et cetera, is that one of the things that's a problem though, and it can be for several reasons, but again, the tensor is one of them, if you rock back and your hip medially rotates. In other words, I found this in some patients that as you rock back, your hip should just flex.

Tim Ferriss 1:34:21 Mm-hmm.

Dr. Shirley Sahrmann 1:34:21 But if you are monitoring the femur, you can sometimes see that it medially rotates.

Tim Ferriss 1:34:29 Right.

Dr. Shirley Sahrmann 1:34:29 That is really bad.

Tim Ferriss 1:34:31 Hmm.

Dr. Shirley Sahrmann 1:34:31 And the reason why it's really bad is because it's rotating in your knee joint too, and that's a good way to set yourself up for an ACL tear, anterior cruciate ligament.

Tim Ferriss 1:34:40 Ooh.

Dr. Shirley Sahrmann 1:34:41 Yeah. Yeah, yeah, yeah. And I think people should be monitoring that. Anybody that's doing that. One of the things that helps is if you slightly laterally rotate your hips.

Tim Ferriss 1:34:52 Mm-hmm.

Dr. Shirley Sahrmann 1:34:52 You know, many people, particularly men, come with what we call femoral retroversion. Do you know what that is?

Tim Ferriss 1:34:59 I don't. Mm-mm.

Dr. Shirley Sahrmann 1:35:00 Okay. Well, you probably have it.

Tim Ferriss 1:35:01 [laughs]

Dr. Shirley Sahrmann 1:35:02 Femoral retroversion, it's a structural variation. And so the femur, as you know, has a head and neck on it. It's angled.

Tim Ferriss 1:35:13 Mm-hmm.

Dr. Shirley Sahrmann 1:35:13 Well, it's also rotated on the shaft.

Tim Ferriss 1:35:16 Right.

Dr. Shirley Sahrmann 1:35:16 And if it's in the ideal world, the average, not the normal, the average is that that rotation is 15 degrees.

Tim Ferriss 1:35:27 Mm-hmm.

Dr. Shirley Sahrmann 1:35:28 So the head and neck of the femur are pointing 15 degrees forward.

Tim Ferriss 1:35:32 Mm-hmm.

Dr. Shirley Sahrmann 1:35:33 Now, many men, it's not rotated. So what it means is that when you're doing your hip rotation, you go out a long ways, but you don't go in.

Tim Ferriss 1:35:42 That's true for me, for sure.

Dr. Shirley Sahrmann 1:35:44 Yeah.

Tim Ferriss 1:35:44 My internal rotation is terrible compared to my external rotation.

Dr. Shirley Sahrmann 1:35:47 But that's because you came that way, and it should never change.

Tim Ferriss 1:35:50 [laughs]

Dr. Shirley Sahrmann 1:35:51 No, I mean it. And so you-

Tim Ferriss 1:35:53 Yeah

Dr. Shirley Sahrmann 1:35:53 ... and men need to know that. And so, in fact, that's a problem because if your tensor is really developed, you could be sitting in hip medial rotation when you shouldn't be.

Tim Ferriss 1:36:03 Hmm.

Dr. Shirley Sahrmann 1:36:03 And if your glutes are really good, that'll also medially rotate your hip when you're sitting.

Tim Ferriss 1:36:08 Hmm.

Dr. Shirley Sahrmann 1:36:08 That's a problem.

Tim Ferriss 1:36:09 Okay. Yeah.

Dr. Shirley Sahrmann 1:36:10 Okay. So one of the ways to, if you're trying to do the quadruped thing, is to turn your hip out a little bit when you're in the quadruped position. So your feet would come together a little bit closer.

Tim Ferriss 1:36:24 Right. More of like a wrestling partier position.

Dr. Shirley Sahrmann 1:36:27 Yeah. I don't know. I never wrestled.

Tim Ferriss 1:36:28 Oh, yeah. [laughs] Yeah. [laughs] That I can, I can pick up the slack on, on explaining that then. So from-

Dr. Shirley Sahrmann 1:36:34 Not with a referee anyway.

Tim Ferriss 1:36:35 [laughs] Okay.

Dr. Shirley Sahrmann 1:36:39 Anyway.

Tim Ferriss 1:36:39 Right, right. So from the feet to the knees, it would just be making a very, very, very slight V shape. It's not a V shape, but the, the lines would converge, in other words, right?

Dr. Shirley Sahrmann 1:36:50 Your feet would be a little bit closer together.

Tim Ferriss 1:36:52 Exactly. Mm-hmm. [laughs] You're funny. [laughs]

Dr. Shirley Sahrmann 1:36:58 [laughs]

Tim Ferriss 1:36:59 All right. So that makes a lot of sense to me, and I'm certainly comfortable with that. What, what would it mean or how would you read the movement pattern that I have of sitting and having my legs sort of splay open? That's also something-

Dr. Shirley Sahrmann 1:37:12 Really good

Tim Ferriss 1:37:12 ... that alleviates my low back symptoms.

Dr. Shirley Sahrmann 1:37:15 Yeah.

Tim Ferriss 1:37:15 If I'm sitting in a chair, oftentimes I'll take my shoes off and fold them up on top of the chair. Restaurants hate this, by the way, so I do get chastised occasionally. But, but it alleviates some of my lower back issues.

Dr. Shirley Sahrmann 1:37:28 Yeah. You're getting it fore and aft because you're probably in this, this one of the syndromes I have of the hip, that I've described of the hip because if your tensor is really developed, it's gonna be holding your femur in medial rotation when you're standing, 'cause it's pulled taut then.

Tim Ferriss 1:37:45 Mm-hmm.

Dr. Shirley Sahrmann 1:37:45 If your gluteals are really well developed- When your hip's flexed to 90 degrees, they become medial rotators too.

Tim Ferriss 1:37:52 Mm.

Dr. Shirley Sahrmann 1:37:53 So they're trying to hold your hip in medial rotation, and you're probably getting that twist on your back then.

Tim Ferriss 1:37:58 Mm.

Dr. Shirley Sahrmann 1:37:59 Do you see what I mean?

Tim Ferriss 1:38:01 Yeah.

Dr. Shirley Sahrmann 1:38:01 So when you laterally rotate your hips, then you're taking that pull off of them.

Tim Ferriss 1:38:07 Taking the pressure off of it, yeah.

Dr. Shirley Sahrmann 1:38:09 Yeah. You're not getting that extra pull on your pelvis from those gluteal muscles being pulled so tight. And that's where you should be.

Tim Ferriss 1:38:16 Mm.

Dr. Shirley Sahrmann 1:38:16 That's your, your normal thing because you have femoral retroversion.

Tim Ferriss 1:38:21 Mm.

Dr. Shirley Sahrmann 1:38:22 See, that's one of the things that's bad is because, you know, like when people go in and they're taught deadlifts and they say, "Well, make your feet point straight ahead," well, many men in particular shouldn't have their feet pointing straight ahead because they have this femoral retroversion.

Tim Ferriss 1:38:37 Mm-hmm.

Dr. Shirley Sahrmann 1:38:37 And also when they do things that rotate, like play golf, their feet should be turned out because if they're straight ahead, they're in, at the end of their medial rotation range.

Tim Ferriss 1:38:47 Yeah.

Dr. Shirley Sahrmann 1:38:47 Do you see what I mean?

Tim Ferriss 1:38:48 Yeah, that makes sense.

Dr. Shirley Sahrmann 1:38:48 So then it'll be the knee or the back or the hips that are gonna go.

Tim Ferriss 1:38:52 Mm. Makes a lot of sense.

Dr. Shirley Sahrmann 1:38:54 Yeah. It's also interesting.

Tim Ferriss 1:38:56 Yeah. Super fascinating.

Dr. Shirley Sahrmann 1:38:58 Yeah. It's like the backbone's attached to the pelvic bone. You know, and, and I think to me, that's what's so valuable about being a physical therapist or looking at people because I can't, like an orthopedic surgeon, just look at the knee or I can't just look at the hip-

Tim Ferriss 1:39:12 Mm-hmm

Dr. Shirley Sahrmann 1:39:12 ... because it's the result of all of these interactions of the body. That's what's so important.

Tim Ferriss 1:39:18 Mm-hmm.

Tim Ferriss 1:39:20 And in a case like mine where I, if you look at family photos, right, especially on my mom's side, the feet point way out. I mean, all, a lot of the guys-

Dr. Shirley Sahrmann 1:39:27 Oh

Tim Ferriss 1:39:27 ... stand like ducks. Now, at the same time, I've been told, and I agree with this, that if, if one were to watch me walk, I have, probably because I have at times the, the feet pointing out, very little sort of glute hamstring assisted hip extension. So I tend to bend at that lower back. Maybe I'm misdiagnosing things, but how would you sort of make sense of that? Would it be bad for me to try to point my feet a little more straight ahead so that I get better hip extension using the gluteal muscles in the hamstrings versus the lower back? Or is that gonna be setting me up for knee problems?

Dr. Shirley Sahrmann 1:40:09 Usually if you're not using your gluteal muscles and that, it's because you're, you're swayed back.

Tim Ferriss 1:40:15 Mm-hmm.

Dr. Shirley Sahrmann 1:40:17 If you're swayed back, your line of gravity's behind your hip joint.

Tim Ferriss 1:40:20 Right.

Dr. Shirley Sahrmann 1:40:20 And if your line of gravity's behind your hip joint, you don't need your gluteals or those other muscles. So-

Tim Ferriss 1:40:27 Mm-hmm

Dr. Shirley Sahrmann 1:40:27 ... if, if you reduce that kyphosis and get rid of the... Which isn't bad, it's, it's just not helpful for what your condition is.

Tim Ferriss 1:40:35 Yeah.

Dr. Shirley Sahrmann 1:40:36 And then you go forward. And then the other thing is if you also push off, in other words, when you're walking-

Tim Ferriss 1:40:43 Mm-hmm

Dr. Shirley Sahrmann 1:40:45 ... and this could be another way in which you're, you're reinforcing what your tensor's doing. If you tend-

Tim Ferriss 1:40:49 Mm

Dr. Shirley Sahrmann 1:40:50 ... to walk by pulling your leg through rather than pushing with your feet and letting it swing through.

Tim Ferriss 1:40:56 Right.

Dr. Shirley Sahrmann 1:40:57 And if you push with your feet, you'll activate the extensors more. So the two things-

Tim Ferriss 1:41:02 Mm

Dr. Shirley Sahrmann 1:41:02 ... the things that may be contributing to, and I'm not saying this is for sure because I'm obviously not analyzing you, but let's say if we paint a scenario that you're swayed back with a kyphosis, your line of gravity's behind your hip joint. I, I always call it then the gluteals are, do not have good definition. I call it missing for lack of action. [laughs]

Tim Ferriss 1:41:24 [laughs]

Dr. Shirley Sahrmann 1:41:24 And so then, then you pull your legs forward with your hip flexors. You're just reinforcing the overuse of the, of the tensor. But if you decrease your kyphosis so your line of gravity's a little more running through your hip rather than way behind it-

Tim Ferriss 1:41:42 Mm-hmm

Dr. Shirley Sahrmann 1:41:42 ... and you roll over your feet and you push with your feet. Do, do you know what I'm saying?

Tim Ferriss 1:41:47 I do.

Dr. Shirley Sahrmann 1:41:48 So you roll over so that you're pushing with the ball of your foot and your leg swings out, you'll, you'll use your gluteals more.

Tim Ferriss 1:41:54 Yeah. Makes perfect sense.

Dr. Shirley Sahrmann 1:41:55 Just pushing instead of pulling. You wanna chase your center of gravity, not pull it.

Tim Ferriss 1:42:00 Mm-hmm.

Tim Ferriss 1:42:01 Yeah, this kyphosis has been, been with me since I was a little kid, and it's, it's, I've tried foam rolling, manual release, strengthening the mid back and, but I have not worked on elongating the rectus abdominis.

Dr. Shirley Sahrmann 1:42:16 You know, there's a condition called Scheuermann's disease, which isn't really a disease.

Tim Ferriss 1:42:20 Mm-hmm.

Dr. Shirley Sahrmann 1:42:21 But it, it, if you had it, particularly it happens in your teenage years where you get a-

Tim Ferriss 1:42:26 Mm-hmm.

Dr. Shirley Sahrmann 1:42:27 You've heard of it?

Tim Ferriss 1:42:29 No, I haven't heard of Scheuermann's disease, but I, ever since I, I would say since I've been like 12, 13, I've had this kyphosis lordosis combo.

Dr. Shirley Sahrmann 1:42:36 Well, then you probably got Scheuermann's disease.

Tim Ferriss 1:42:38 Oh, okay. I'll have to look it up.

Dr. Shirley Sahrmann 1:42:40 It's S-C-H-E-U-E-R-M-A-N-N.

Tim Ferriss 1:42:45 Okay.

Dr. Shirley Sahrmann 1:42:46 And it's kind of a idiopathic compression fracture of the thoracic spine.

Tim Ferriss 1:42:50 Oof.

Dr. Shirley Sahrmann 1:42:50 It means you won't get rid of it.

Tim Ferriss 1:42:52 [laughs] Oh, man.

Dr. Shirley Sahrmann 1:42:54 Yeah.

Tim Ferriss 1:42:54 Okay. Well-

Dr. Shirley Sahrmann 1:42:55 But I think if you, if you just don't sway back more. You know what I mean?

Tim Ferriss 1:43:00 Uh-huh.

Dr. Shirley Sahrmann 1:43:01 And just stay forward a little bit if you can make peace with that.

Tim Ferriss 1:43:04 Well, I can try to work on the elongating of the-

Dr. Shirley Sahrmann 1:43:08 Well, it's, it's not gonna change. The big thing is don't let it get worse.

Tim Ferriss 1:43:13 Right.

Dr. Shirley Sahrmann 1:43:13 If that's what you have. I'm not saying that's what you have, but I'm saying-

Tim Ferriss 1:43:16 Right. It's possible.

Dr. Shirley Sahrmann 1:43:18 Yeah, because it happens around the teenage years.

Tim Ferriss 1:43:21 Hmm. So what would be the keys to not letting it get worse, would you say?

Dr. Shirley Sahrmann 1:43:26 Don't have it increase. I mean-

Tim Ferriss 1:43:27 [laughs]

Dr. Shirley Sahrmann 1:43:28 ... you can still do the same things, Tim, but-

Tim Ferriss 1:43:31 Yeah

Dr. Shirley Sahrmann 1:43:31 ... just don't say, "I will be absolutely perfect. I have to settle for kind of perfect instead of absolute perfect."

Tim Ferriss 1:43:37 Yeah. [laughs] That's probably a good-

Dr. Shirley Sahrmann 1:43:39 [laughs]

Tim Ferriss 1:43:39 ... MO for most of my life, I would say.

Dr. Shirley Sahrmann 1:43:41 [laughs]

Tim Ferriss 1:43:43 [laughs] All right.

Dr. Shirley Sahrmann 1:43:44 Well, most of us don't get that close. There we go.

Tim Ferriss 1:43:47 [laughs] I'm probably further away than I would like to admit.

Dr. Shirley Sahrmann 1:43:50 [laughs]

Tim Ferriss 1:43:51 So Shirley, this has been such a great conversation. We've covered so much. I've taken copious, copious notes. And certainly people can find your books, The Diagnosis and Treatment of Movement Impairment Syndromes, which has been translated into seven languages, as well as your second book, Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines, has been very influential in promoting movement diagnoses. Is there anything else you would like to mention? Anything else we should talk about? Anything you would like to draw attention to with my audience? Anything at all that you think is, is worth saying or discussing before we begin to wind to a close?

Dr. Shirley Sahrmann 1:44:32 Well, it's probably just a little repeat of all the things we've been talking about. It, it's been-

Tim Ferriss 1:44:37 Mm-hmm

Dr. Shirley Sahrmann 1:44:37 ... really great and generous of you to [laughs] allow me to discuss your, your issues. But-

Tim Ferriss 1:44:43 [laughs]

Dr. Shirley Sahrmann 1:44:43 ... you know, what's really nice is here you are, somebody that's worked so hard to address all of these things with all the discipline that most people don't have, and-

Tim Ferriss 1:44:52 Mm

Dr. Shirley Sahrmann 1:44:52 ... and it's still hard to get a straightforward story about what's going on and how best to suit, suit you.

Tim Ferriss 1:44:58 Mm.

Dr. Shirley Sahrmann 1:44:58 And that's what worries me a lot is, number one is I look on the internet for exercises and, and most of them people can't do, and they're not taking into account the variations in how people are. I mean, here you've been through-

Tim Ferriss 1:45:11 Mm-hmm

Dr. Shirley Sahrmann 1:45:11 ... all this exam, and nobody said you have femoral retroversion, which-

Tim Ferriss 1:45:14 Right

Dr. Shirley Sahrmann 1:45:15 ... you need to know. Because you came that way, you need to stay that way.

Tim Ferriss 1:45:19 Mm-hmm.

Dr. Shirley Sahrmann 1:45:20 So I would like to see that there's more respect for how difficult exercise is. It's, it's not like, "Here's the way everybody should go out and do this one thing, and then they'll all will be well."

Tim Ferriss 1:45:34 Mm-hmm.

Dr. Shirley Sahrmann 1:45:35 I'd like to see this recognition of that movement is, is complicated as anything else that the body does, that there is a movement system, a physiological thing, and that we should have diagnostic categories so that people, when they're consulting a physical therapist, get a diagnosis just like when they go to any doctor. I mean, that's to me why you go to a doctor is to get a diagnosis-

Tim Ferriss 1:45:58 Mm-hmm

Dr. Shirley Sahrmann 1:45:58 ... or find out what condition you're, you're working on. And I think that would do a lot to help reducing all this variability in, in treatment.

Tim Ferriss 1:46:08 Mm-hmm.

Dr. Shirley Sahrmann 1:46:09 And I think helping people to understand how it's the way they do their everyday activities that causes the problem, and that those can be changed with, with good direction. You know, I, I can't help but say this, too. I, I help a, a, a good friend who's actually on a dementia floor. I go to help feed her twice a day.

Tim Ferriss 1:46:30 Mm.

Dr. Shirley Sahrmann 1:46:30 And I look at all the other people, older people that are in assisted living, and the majority of them are there because they have physical disabilities.

Tim Ferriss 1:46:39 Mm.

Dr. Shirley Sahrmann 1:46:40 I'm older than most of them.

Tim Ferriss 1:46:42 Yeah.

Dr. Shirley Sahrmann 1:46:43 A- and I think if people had a chance to, to address these things early on and with the discipline like you show and good direction, w- we could cut down on and, and improve the quality of life. I know you've interviewed Dr. Attia.

Tim Ferriss 1:46:59 Mm-hmm.

Dr. Shirley Sahrmann 1:46:59 And, you know, much of what he says, you know, m- medicine 3.0 or something. And if we did that-

Tim Ferriss 1:47:06 Mm-hmm

Dr. Shirley Sahrmann 1:47:06 ... with more care on exercise and knowing how to do everyday activities and not just take them for granted, I think people could have longer, fuller lives and be as fortunate as I am.

Tim Ferriss 1:47:20 Agreed. Agreed, agreed. What a great conversation. I've, I've learned so much, and I've taken so many notes. I have a lot to dig into. It's g- also given me some renewed optimism in terms of exercises that I can work with, movements, I should say, that I can experiment with.

Dr. Shirley Sahrmann 1:47:41 I hope you'll get back to me if I can help further.

Tim Ferriss 1:47:45 I will.

Dr. Shirley Sahrmann 1:47:45 If you find out that these things are going along, I would be more than happy to-

Tim Ferriss 1:47:50 Thank you

Dr. Shirley Sahrmann 1:47:51 ... do this a little more formally.

Tim Ferriss 1:47:53 Yeah, I-- absolutely. I really appreciate it.

Dr. Shirley Sahrmann 1:47:55 We can do it on Zoom. I mean, we can do it on this.

Tim Ferriss 1:47:58 Yeah. That I would, I would very much like to do that, so thank you for the very kind offer. And thank you for so kindly taking the time to h- have this conversation. I think it'll be really helpful to people.

Dr. Shirley Sahrmann 1:48:09 As my dear friend Michael said, you are tremendous. I'm-- I've really enjoyed talking to you, and you do have a sense of enthusiasm on how to ask the right questions to make it fun for both of us.

Tim Ferriss 1:48:21 Thank you so much. And for everybody listening, we will link in the show notes to everything we discussed as usual at tim.blog/podcast. And until next time, be just a bit kinder than is necessary, not only to others, also to yourself. And as always, thanks for tuning in.