Please enjoy this transcript of my interview with Shirley A. Sahrmann, PT, PhD, Professor Emerita of Physical Therapy at Washington University School of Medicine in St. Louis, Missouri. Shirley 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 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 is a recipient of the Association’s Marion Williams Research Award, the Lucy Blair Service Award, the Kendall Practice Award, and the Inaugural John H.P. Maley Lecturer Award.
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.
Her first book, Diagnosis and Treatment of Movement Impairment Syndromes, has been translated into seven languages. Her second book, Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines, has been equally influential in promoting movement diagnoses.
Transcripts may contain a few typos. With many episodes lasting 2+ hours, it can be difficult to catch minor errors. Enjoy!
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Tim Ferriss: 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 Bowling-Erhard Orthopedic 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, 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 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. 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.
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 boney 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 boney 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, widi, 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 can think of it all— So 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 d’s, which would be pulling it toward the midline. One way that I remember that—abduction is 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 Suzanne Somers thighmaster-type machines at the gym 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’re 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 mention 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. 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 you just think between the shoulder blades for simplicity.
OK, last, and I could say not least, but who knows. These are all kind of equivalent and useful. You have supine vs. 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. OK, 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 there you have it. So if you want a video to go with this, I did record 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 r’s, two s’s—and that will have some helpful graphics and so on overlaid into the video.
OK 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.
***
Tim Ferriss: 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: My pleasure.
Tim Ferriss: 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.
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: Well, I think the one big objective in it — I’ve actually been a physical therapist for over 60 years. During all of that time I’ve been through different eras of changes in physical therapy. Where I’ve sort of gotten to is how movement basically induces pathology.
Part of that, trying to explain that and how it works, is also developing diagnostic categories that direct physical therapy treatment. What this book was about was a first attempt to really put together diagnostic categories that are based on movement and movement as an inducer of musculoskeletal problems.
Also, kind of working on the background of what are the tissue adaptations that contribute to this? It really was an organizational attempt to identify for — the first book covered the back and the shoulder and the hip, so I guess the shoulder is one of the things that he must have been particularly interested in if he’s dealing with pitchers.
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.
I think that putting together this kind of information in a way that could be understood by a whole variety of people — in fact, 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’ve ever found it. That was one of the advantages of being a slow writer. Of course I learned more while all of that was happening, too.
Tim Ferriss: How did that attempt, or maybe not attempt, how did that organizational approach —
Dr. Shirley Sahrmann: No, it was an attempt.
Tim Ferriss: 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: Well, to be perfectly honest with you, Tim, it’s not like this insight has been taken over by even the large majority of the people in my profession. It’s still a bit of a struggle to have people move in this direction for a whole variety of reasons.
Typically, even though I wasn’t there when physical therapy was first started, I wasn’t too far behind. Typically, the role 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.
In fact, I am old enough that I actually saw polio patients. 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. That’s very different than what I’m proposing, or have proposed with this book. I think what’s beginning to be recognized.
I think the other thing that’s so important about all this, I’m sure you are a reflection of this, is in the old days, no one thought lifestyle had anything to do with your health.
Tim Ferriss: Yeah.
Dr. Shirley Sahrmann: I always like to point out this story. My family cooked with so much Crisco I don’t know how my blood flows. If the green beans were too healthy, we had bacon grease to put on them.
I was very fortunate. I worked with a physician for a while who was really leading the way in showing about the role of exercise and nutrition in — he did what that’s really called translational research, showing the cellular changes in animals, and then also running studies in older people.
It was like an amazing insight for me to realize that your lifestyle had something to do with it. I think that’s behind what’s slowly emerging as seeing movement play a different role. I think what I’d like to get across to people, it’s not inevitable what’s going to happen to you, that you can do things via lifestyle to improve what your outcome’s going to be.
Tim Ferriss: I would love to come back to, I believe, and I don’t want to misquote you, but something you said which is, “The treatment of symptoms. So many offices are treating symptoms, perhaps not root causes.”
Dr. Shirley Sahrmann: Yeah.
Tim Ferriss: I have read, and you can’t believe everything you read on the internet, so please correct me if I that’s wrong, but that you’ve —
Dr. Shirley Sahrmann: Is that a new saying?
Tim Ferriss: Yeah.
Dr. Shirley Sahrmann: Wow.
Tim Ferriss: That you’ve described low back pain as not a diagnosis, but a symptom.
Could you just speak to that? Because as someone who currently for the last maybe six to nine months has had a very perplexing constellation of symptoms that I describe as low back pain, this I think will resonate with many people who are listening. Would you mind elaborating on low back pain as a symptom and not a diagnosis?
Dr. Shirley Sahrmann: Well, I mean, just what you’re saying, 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. That is clearly a symptom.
Tim Ferriss: Yeah, right. I am from Long Island, so sometimes I ask the silliest of questions, but got to start with the basics.
Dr. Shirley Sahrmann: Yeah. There you go. Well, the nice part is you can actually get reimbursed for making that big, clever diagnosis. Even without an MD degree. No. Where I would be looking at that problem, and I have an idea of what your problem is —
Tim Ferriss: Wow. Okay. Already.
Dr. Shirley Sahrmann: Well, just because — we can talk about that.
Tim Ferriss: Okay.
Dr. Shirley Sahrmann: I don’t want to sound too glib about it, but so what I would be doing is naming your low back pain by the movement that most consistently causes your symptoms, by changing that movement, reduces or eliminates your symptoms.
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, it’s a disc or a facet joint,” or any of the rest of it.
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. The expertise of a physical therapist needs to be, what is the movement that’s either causing or exacerbating that problem?
Tim Ferriss: I’m curious to — well, maybe we can dive into, you said that you thought you might know what my issue is.
Dr. Shirley Sahrmann: Yeah. That’s because I know you’re a big exerciser.
Tim Ferriss: Yes. Yes, indeed.
Dr. Shirley Sahrmann: I mean, do you want me to just give you a ballpark idea?
Tim Ferriss: I do, absolutely.
Dr. Shirley Sahrmann: Okay. Well, because would you believe that abdominals can get to be too much overdeveloped?
Tim Ferriss: It makes some intuitive sense, but it’s not something you hear many people talk about.
Dr. Shirley Sahrmann: I know, I know, I know. Even within the community of physical therapists, people are really exercising big time. I mean, high-intensity exercise is super popular. I’m all for it because it’ll increase our patient load.
One of the things that happens when your abdominals are overdeveloped, because what happens when muscles hypertrophy, they become stiffer, and muscles are like springs. They have — I mean, I’m using the mechanical word of stiffness.
When the abdominals get to be too much, they increase the compression on your spine. The way you can check me out on this is if you look to see if you take a deep breath, if you go from maximum exhalation to maximum inhalation, you should be able to change the circumference of your rib cage about two and a half to three inches. 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.
Then, if you have any kind of asymmetry, for example, if you put your hands on your iliac crest, and one iliac crest is slightly higher than the other, then basically your spine is in a side bend.
If it’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. Do you see what I mean?
Tim Ferriss: I do, absolutely.
Dr. Shirley Sahrmann: Okay. That’s the ballpark idea. 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: I would love to spend more time on this, selfishly of course, because the reason I am sitting and not standing for this interview is because of this lower back pain, which is actually —
Dr. Shirley Sahrmann: So it’s worse when you’re standing than when you’re sitting?
Tim Ferriss: 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, in my lumbar, so I do have quite a bit of excessive lower back sway or atypical lower back sway, just for people listening.
Dr. Shirley Sahrmann: Now, when you say sway, do you mean an increased curve?
Tim Ferriss: 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 bench or something like that, it also causes this pain.
I have had imaging, but 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 have the other.
Dr. Shirley Sahrmann: Yeah. Right. That’s the whole point.
Tim Ferriss: Yep. Then you have the opposite. I do have some stenosis around L4, L5, but the pain feels to be localized around the SI joint. The relief, if this is helpful, I know we’re getting a little technical for some folks, but 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. He put me on a machine that provided some traction.
Dr. Shirley Sahrmann: There’s traction.
Tim Ferriss: Exactly. 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.” I’ve had quite a bit of relief, but to answer your question, standing, 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. Actually that type of, 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: Yep. Yep.
Tim Ferriss: Those are a few of the things.
Dr. Shirley Sahrmann: Have you put your hands on your pelvis to see when you’re walking if it rotates?
Tim Ferriss: I have not. I would love to know how to do that properly.
Dr. Shirley Sahrmann: Well, I mean, it’s not rocket science. You know where your pelvis, you know where your hands are.
Tim Ferriss: Yeah.
Dr. Shirley Sahrmann: Just because very often when your hip flexors are not even just not short, just stiff, stiffer than your back as you walk, it rotates your pelvis. That’s where you’re going to be getting your symptoms from.
Evidently when you go fast enough, you’re not staying static and you’re causing enough equal movement. 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: I can, yeah. It seems as though I can.
Dr. Shirley Sahrmann: Does that decrease your symptoms?
Tim Ferriss: It does decrease my symptoms.
Dr. Shirley Sahrmann: Right.
Tim Ferriss: 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: Yeah.
Tim Ferriss: 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 standing straight up that, and with compression, that shows that type of intolerance. I get that pain kind of directly on the lower spine.
Dr. Shirley Sahrmann: The other thing to try, Tim, is when you stand up, put your feet apart. Separate them out and see if that changes your symptoms.
Tim Ferriss: And what is that doing?
Dr. Shirley Sahrmann: Well, number one is this little thing I referred to before. If one iliac crest is higher than another, and it’s a test for what we call relative stiffness. If you are — one of the big hip flexor that’s problematic is called the tensor fasciae latae.
Tim Ferriss: Yes.
Dr. Shirley Sahrmann: It’s an abductor. If you put your feet apart, so your hips are abducted, it takes the stretch off of that band. Any kind of asymmetry that you would have, particularly with the transition vertebrae, would be playing into the symptoms. Do you see what I mean?
Tim Ferriss: I do.
Dr. Shirley Sahrmann: You could find out, yeah, and then if you put them together and your symptoms increased, then you would know that that’s what’s playing a role, doing this.
Tim Ferriss: Yeah. I’ll add a few more things just because this is a rare opportunity to get to talk with you about this. My TFL is very — tends to be very tight and sensitive.
Dr. Shirley Sahrmann: That’s right. Yeah.
Tim Ferriss: The piriformis muscle is also very tight. A piece of this that may be helpful as far as, may or may not be helpful, but what gives my back also some release is working on the, very specifically, the iliacus and then some of the adductors on the inside of the thigh.
Dr. Shirley Sahrmann: Yeah. [inaudible]. Tell me what that means.
Tim Ferriss: Well, having someone really dig into the abdomen to have me, say, extend the leg almost.
Dr. Shirley Sahrmann: Okay. It’s not you working on it. Somebody else is working on it.
Tim Ferriss: No, it’s somebody else working on it. Then, it’s not very pleasant for people who are listening. Then some of my adductors, I don’t know if it’s magnus, longus, or whatever, but also very tight and seemingly potentially weak.
To come back to the height, maybe the asymmetry of the iliac crest, my right side seems to get hiked up a lot.
Dr. Shirley Sahrmann: Yeah.
Tim Ferriss: 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, but —
Dr. Shirley Sahrmann: See, that’s what I mean. You’ve just confirmed — one of my thoughts is that if your right iliac crest is higher than your left — but then I would also bet that your right TFL is stiffer than your left. If that’s playing a role, then when you put your feet apart, your iliac crest should level out and that should help with your symptoms.
Tim Ferriss: Yep. Historically when I’ve been recording podcasts, I basically end up in that really wide stance. I think I’m — now, is that — I mean, that’s useful for maybe temporarily relieving the symptoms if I’m recording a podcast. In terms of corrective measures, let’s just say using your —
Dr. Shirley Sahrmann: Have you ever tried anything where you’re in the quadruped position?
Tim Ferriss: 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: Well, because part of what happens when one iliac crest stays higher than another, and I’m not — to be perfectly honest with you, I haven’t quite figured it all out yet, but there’s some adaptation of the other hip muscles. I’ve just found that if you do this in quadruped, you just rock back, often it will improve the asymmetry that you have.
Tim Ferriss: Basically being on hands and knees? So, your knees —
Dr. Shirley Sahrmann: Hands and knees, right. Let your hips drop to about 90 degrees. You don’t have to go back all the way. You just need to go back a little bit. Go back by easily pushing with your hands, because otherwise if you activate your hip flexors, it could pull it, contribute to your problems.
Tim Ferriss: Right. Okay.
Dr. Shirley Sahrmann: Then, can you tolerate prone face down?
Tim Ferriss: I can, yeah. Yeah, I can tolerate prone.
Dr. Shirley Sahrmann: And then you need to just do — just flex your knee, and then you need to laterally rotate your hips. You’re letting your knee flex to 90 degrees and then let your foot go in towards the other leg. That’s lateral rotation.
Tim Ferriss: Yep.
Dr. Shirley Sahrmann: That kind of motion will help to elongate the TFL. ITB.
Tim Ferriss: Interesting. And you’re doing that leg by leg? The [inaudible].
Dr. Shirley Sahrmann: Oh, yeah. One leg at a time.
Tim Ferriss: One leg at a time. Okay.
Dr. Shirley Sahrmann: Do everything bilaterally, yeah.
Tim Ferriss: Okay. Very interesting.
Dr. Shirley Sahrmann: You can try those things. Let me know.
Tim Ferriss: Great. I will. I will do both of those. If we zoom out just for a moment — 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: It basically is putting a formal name — in 2013, the American Physical Therapy Association adopted the movement system as its identity. 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 the movement system.
It’s not like the traditional anatomically defined systems, like the cardiovascular system or the musculoskeletal system or the nervous system. It’s a system of systems, but that’s just like, in my mind, the immune system, which nothing is more important in medicine these days than the immune system. It’s a system of systems. It uses many of the different organs in its function. Metabolic system is the same way.
When you think of it as running from subcellular all the way up to how do you move in your environment, movement is critical. The movement stops, everything stops.
Tim Ferriss: Yeah.
Dr. Shirley Sahrmann: I think we take — in some ways, to me, it’s like a parallel to the nutrition system because we take for granted doing it. Yet, there’s right ways and there are wrong ways.
The whole idea of this is to realize that their movement does involve a system. 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.
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 kinds of things because for lack of movement.
How important it is to move, this is related to the lifestyle issue and doing it right. One of the things I always loved doing with patients was saying, “So, who taught you to walk?” They say “Nobody.” I say, “That’s the problem.” Just because you’re doing it doesn’t mean you’re doing it right. You’re just doing it.
Tim Ferriss: Yeah. Yeah.
Dr. Shirley Sahrmann: Just like you, if you’re walking and you’re getting lumbopelvic rotation, that’s playing into your problem.
Tim Ferriss: Right. Also, if I don’t have, which I don’t think I do — this is one pattern of diagnosis with me that I think is accurate, that I don’t have much terminal hip extension, so when I walk, I’m using my lower back to fake hip extension.
Dr. Shirley Sahrmann: That’s what I’m telling you. Exactly.
Tim Ferriss: Yeah. Okay.
Dr. Shirley Sahrmann: See, that’s what I’m saying. You really can’t do that. I mean, there’s no way you won’t keep injuring your back if you keep walking like that.
Tim Ferriss: Yeah. How do you re-pattern or help people to adopt so that they can use it subconsciously, new motor patterns or new movement patterns? Because I’ve been doing this for God knows how many decades.
Dr. Shirley Sahrmann: Well, not that many. You don’t look that old.
Tim Ferriss: Thank you. Thank you. I appreciate that. My new best friend. How do you help patients to get to that point where they’ve changed something as fundamental as how they walk?
Dr. Shirley Sahrmann: Well, in my mind it’s twofold. In one, we know 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 attention and it takes specificity.
One is, just like we’re talking about with you, what are the most important kinds of exercises? What are the issues that are an impediment to doing it the way you should do it? What are specific exercises that can help you and minimize those?
Then, what’s really important is showing you in your everyday activities what you should do. For example, if you already know that your hip flexors, you’re calling it the iliacus, is problematic then even when you’re sitting, making sure you’re not pulling with your hip flexors to stay forward when you’re sitting.
Tim Ferriss: Yeah, I’m probably doing that right now.
Dr. Shirley Sahrmann: I know. I’ve been watching you. It’s how you even roll over or get out of bed. We go through every one of these things teaching you in your everyday activities so that it does become automatic, but it obviously takes participation on the patient’s or the subject’s part as well to learn it.
Then, it’s going to take time. 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 going to move differently. I think that’s been part of what’s been picked up 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: You mentioned the psoas. 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: Oh, really?
Tim Ferriss: 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 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 iliac, is 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 back pain, is that something that you still feel is something people pay too little attention to?
Dr. Shirley Sahrmann: Oh, yeah. I mean, I don’t think it’s always the cause, but it can certainly be an exacerbator, because the psoas attaches to the lumbar vertebrae, and it also attaches to the intervertebral disc. So it’s a muscle that’s constantly pulling on your back and pulling it in sort of a translation motion. Iliac is attached to your pelvis, so it is not directly acting on the vertebrae the same way the psoas is. So in fact, people that truly have a herniated disc and they’re in that acute phase, I try to have them do nothing with their iliopsoas. If they want to lift their leg up, use your hand to lift your leg up 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 want to rock back, you will probably use the psoas to do it. And that’s why I suggested to you to push with your hands 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: Yeah. 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 with respect to helping them to identify common patterns or positions that contribute to that overactivity?
Dr. Shirley Sahrmann: Well, in some ways I would be looking more specifically at which particular movements do it and then try to identify. For example, it would be hard for me to believe this, but if your hip flexors — and it makes a difference. The tensor fascia latae is a hip flexor, but it has a rotational component that’s much stronger than the psoas does. The psoas has more anterior pull. The tensor fascia latae is going to 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 percent of the people with back pain, it’s because their hip’s not moving optimally. And you said it yourself: “My hip is not moving and then 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. So usually with younger people, if I’m going to generalize about back pain, it’s related to their spine flexing. Because when you’re younger, you’re more flexible.
And I think 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 femoroacetabular impingement, hips aren’t flexing as much. There’s structural changes going on. So if your hip only flexes 90 degrees, then you want to bend over, you’re going to do it much more in your back because your hip’s not doing it. So I want to 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 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. And that’s what you have to know.
Tim Ferriss: Now, you were asking about my breathing and the deep breath. When I met with Eric, and I could be totally screwing up this terminology, so you may need to rein me in, but had me take off my shirt. And 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 rib cage. I’m a belly breather. And I’ve had a number of people note that it’s likely when I breathe, I kind of rotate my entire rib cage backwards, which also causes that excessive —
Dr. Shirley Sahrmann: [inaudible].
Tim Ferriss: Exactly. That excessive hinging at the lumbar. What do you do with somebody who’s got this type of predicament or pattern?
Dr. Shirley Sahrmann: Well, usually, as I was saying before, if your rib cage doesn’t expand, then it’s often because your abdominals are too taut.
Tim Ferriss: I see.
Dr. Shirley Sahrmann: And so one of the ways is to elongate them, so arms up over your head and take in a deep breath, 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 bucket handle.
Tim Ferriss: I’d love for you to elaborate on that. Yeah.
Dr. Shirley Sahrmann: Okay. Well, pump handle means the front of your chest, your sternum, is going up like a pump, and bucket handle is like the sides expand. And so with arms up overhead, you want to really think about now lifting your chest as well as pushing your rib cage out.
Tim Ferriss: Laterally, you mean?
Dr. Shirley Sahrmann: Yeah. Laterally, like it’s all going up. And then — yep, yep. Can you do that? Can you take —
Tim Ferriss: Yeah, it’s sad. Yeah, I don’t have much. It doesn’t do much.
Dr. Shirley Sahrmann: Yeah, I know, but that —
Tim Ferriss: As it stands right now, yeah.
Dr. Shirley Sahrmann: That’s what you need to do. And then here’s the other thing that if you stand with your back against the wall, and then you try to do a side bend, but, but, but, you want to 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: Mm-hmm. Yeah, that’ll be —
Dr. Shirley Sahrmann: Because that would make —
Tim Ferriss: Yeah, it’d make my symptoms worse.
Dr. Shirley Sahrmann: And you want to be sure, Tim, that you don’t just pull yourself over. You want to try to fall like you’ve got a heavy elbow. In other words, don’t contract the muscles on the same side, but try to get these to elongate, so like a falling over —
Tim Ferriss: Right, on the opposite side.
Dr. Shirley Sahrmann: — more passive elongation rather than an active contraction. Now, you’re not going to go real far initially, unless you’ve got a really heavy elbow.
Tim Ferriss: So the axis of rotation should be —
Dr. Shirley Sahrmann: Through the middle of your chest.
Tim Ferriss: — or the fulcrum should be the middle of the chest.
Dr. Shirley Sahrmann: Yeah, right. I always like to say, I don’t care how far you go, I care how you get there.
Tim Ferriss: Yeah, okay.
Dr. Shirley Sahrmann: 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: And are you breathing in those positions or is the stretching your intercostals? Or what is the objective of the side bend?
Dr. Shirley Sahrmann: The objective is to elongate those abdominals that are not letting you —
Tim Ferriss: Oh, I see.
Dr. Shirley Sahrmann: And the other thing is just even when you were doing this — well, you don’t have any symptoms at all when you’re sitting there right now?
Tim Ferriss: I have a little tightness in my low back. I’m sitting in a chair with lumbar support.
Dr. Shirley Sahrmann: Why do you do that when you have too much lumbar curve anyway?
Tim Ferriss: Well, because I’ve noticed that for whatever reason, symptomatically, I get relief with a small amount of lumbar support —
Dr. Shirley Sahrmann: With a small amount, okay. Yeah, because you’re —
Tim Ferriss: — because a flat back chair, and I end up kind of falling forward and flattening my back, it ends up hurting me much more later.
Dr. Shirley Sahrmann: Yeah, because you’re getting a translation motion. 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: I would say doesn’t noticeably — I don’t have any severe symptoms right this instant.
Dr. Shirley Sahrmann: No, but it doesn’t, okay.
Tim Ferriss: It doesn’t worsen it, for sure.
Dr. Shirley Sahrmann: But it doesn’t make it any better either.
Tim Ferriss: It might lessen it slightly. The degree of pain right now I would say is pretty low, so it’s hard for me to monitor.
Dr. Shirley Sahrmann: That’s good and again, if you look at it from the standpoint, the more you move someplace else besides your back, the better off you’re going to be.
Tim Ferriss: Yeah, definitely.
Dr. Shirley Sahrmann: I mean, 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. 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, 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: This seems to me to be very, very, very important. 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 just speak to that? Because it strikes me —
Dr. Shirley Sahrmann: You’re doing a beautiful job yourself. I don’t think you need me.
Tim Ferriss: Well, I’m great at pontificating. I just need to change my movements.
Dr. Shirley Sahrmann: Okay, Father Superior.
Tim Ferriss: No, I talk a good game. I just have to fix my movement patterns and my breathing. But I like how you phrase it. I mean, the body is going to take the path of least resistance.
Dr. Shirley Sahrmann: Exactly.
Tim Ferriss: So I’m going to follow these exercises. 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: Tell me, are you supine?
Tim Ferriss: I am supine. Yes.
Dr. Shirley Sahrmann: Okay. You’re supine.
Tim Ferriss: Yep.
Dr. Shirley Sahrmann: And then what are you going to do?
Tim Ferriss: 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 also experienced is if I do a workout that seems to be focused or is focused on a lot of core musculature 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: Well, I mean, it depends on what your workout is. But what would be bad in the long run is if you’re doing a lot of holding your legs up and moving those around while you’re supine, because again, you’re going to be using your iliopsoas, and it’s going to be pulling on your back. 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 with an increased lumbar curve and that your lower abdominals aren’t as taut. And lower abdominals, I mean external obliques, not just the ones that are lower. And when you contract those muscles that they tend to flatten your back and decrease your symptoms.
Tim Ferriss: Yes. Mm-hmm.
Dr. Shirley Sahrmann: And so that would be to me, what the advantage is when you’re supine and starting to do the exercise. What would be not the long run good is if you’re holding your legs up and trying to do something with your legs while you’re holding that position because you’re building in too much activity from the iliopsoas. So if anything, in that position, I would just have you slide your leg down and try to keep your pelvis from tilting. Put your hands on your — I’m sure you probably know what ASISes are: anterior superior iliac spine.
Tim Ferriss: I do. On the front of the of the hip. Yeah.
Dr. Shirley Sahrmann: That’s what I thought. Yep, yep. And just make sure they don’t tilt as you slide —
Tim Ferriss: For people who are wondering, could you just describe what that is since —
Dr. Shirley Sahrmann: It’s a little bony prominence on the front of your pelvis, and some of your major hip flexors attach there. But it’s also an indication of what your pelvis is doing as far as tilting forward or tilting backward. And in your case, what you want to do is not have it tilt forward. So the importance of that exercise would be that you can move your legs without your pelvis tilting anteriorly.
Tim Ferriss: Got it.
Dr. Shirley Sahrmann: 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. 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 because your tensor is going to be pulling on your pelvis as well.
Tim Ferriss: 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 as opposed to directly in front of your hips. Now is that predominantly a diagnostic or is it also a training move, that sliding heel?
Dr. Shirley Sahrmann: All of the above.
Tim Ferriss: All the above. Okay.
Dr. Shirley Sahrmann: I mean, that’s the nice thing about going through an exam in which you’re looking for this path of least resistance, the motion that is occurring too readily because it’ll occur too readily with all of the activities. 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. Yeah, so when you’re taking 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 because nothing is more scary than “Here comes the pain, what did I do? How did I do it? 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 then — 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: Yeah, this personal experience has been incredibly frustrating, kind of horrifying, because it’s the first time in my life — if you tear a labrum in your shoulder or you break an arm or break a collarbone, it’s oftentimes reasonably straightforward, or it seems that way. 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 identify what the cause was. And there’ve been times when 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. 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 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, “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. 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 session look like?
Dr. Shirley Sahrmann: Well, first, it’s looking at what they look like. I mean, for me, just like if I saw you standing, I would know a whole lot more than just looking at you sitting because 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 a roadmap to a whole lot of things. And I think it’s also worth noting that it’s why people stand the way they stand is to minimize energy expenditure. So you can see what the passive tensions are, which are reflective of how hypertrophied the 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 much do their hips flex? 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 is higher, the hips are stiffer, et cetera. So how do they forward bend? How do they rotate? Because many people will twist rather than really be able to rotate. And then side bending. Does it hurt? Where do I see motion?
Tim Ferriss: By twist, you mean their pelvis follows them instead of that sort of —
Dr. Shirley Sahrmann: No.
Tim Ferriss: No?
Dr. Shirley Sahrmann: See, that’s the other thing that’s interesting is because I’m sure with you, people have looked at what your range of motion is in your hips. 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. So one, does your hips not move and therefore you have to move in your back —
Tim Ferriss: The back.
Dr. Shirley Sahrmann: — 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 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: Fascinating.
Dr. Shirley Sahrmann: So we’re looking for — 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. If when you —
Tim Ferriss: The movement of the pelvis —
Dr. Shirley Sahrmann: The movement of the back —
Tim Ferriss: — or the iliac crest.
Dr. Shirley Sahrmann: And the same thing, 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. And then if your symptoms, as you’ve reported, get better when you bend over, again, I know that extension’s causing your symptoms. 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 be more comfortable than when they’re down straight. If I abduct your hips, I know what’s causing it that way. Do you see what I mean?
Tim Ferriss: Mm-hmm.
Dr. Shirley Sahrmann: 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. I’m going through an exam looking for that movement that shows up consistently. If I stop it or improve it, symptoms go down. So we do in the 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: And is the assessment largely the same for athletes versus non-athletes? It’s pretty much —
Dr. Shirley Sahrmann: That’s a really interesting point because in some ways people have a hard time because I’m looking for little baby things. Ironically, there’s really good research that’s been done by Linda Van Dillen, and these movements that cause the symptoms occur very early and they’re only a few degrees. 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. You’ve got to stop that, and then you can build on bigger ways. There’s a therapist by the name of Robbie Ohashi who’s put these into — it’s like a movement spectrum. It’s not the exact words. I’m blanking on it right now. Where you do isolated exercises, combined exercises, and then more putting them together for your sport, whether it’s tennis 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. Yeah.
Tim Ferriss: Do you have an opinion of, I’ve not experienced this personally, but something called DNS? I think it’s dynamic neuromuscular —
Dr. Shirley Sahrmann: Neuromuscular Stabilization.
Tim Ferriss: Yeah. And it seems like they build based on some sort of motor skill development chronology from childhood. So you’d start with supine or prone, and then move to crawling or something like that, quadruped, and then kneeling and so on. Do you have any perspective on this or could you —
Dr. Shirley Sahrmann: Well, to be perfectly honest, I think you’re already grown.
Tim Ferriss: Okay, got it. Yep. Certainly, if my shiny pate is any indication, then yes.
Dr. Shirley Sahrmann: Looking at your well-shaved head, 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.”
Tim Ferriss: That’s hilarious. Definitely going to use that. Yeah, I know. Yes. No, grass cannot grow on a busy street.
Dr. Shirley Sahrmann: I don’t think you need to stage it like that. That’s why I go through the whole exam and look at the finished product that needs some fine-tuning, 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. And so that’s why you’ve got to change the way you’re doing basic things. Do you know what I mean? I do. And look at that because that’s what caused the problem. That’s what you need to change.
Tim Ferriss: What is, I believe you call it collapso-smasho.
Dr. Shirley Sahrmann: Where did you get — I didn’t put that down. 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. And in the older individual without muscles, it’s collapso-smasho. In younger individuals like yourself or others who have done a whole lot of abdominal exercises, I call it squeezo-smasho because the passive tension from those muscles is adding to the compression. And the older people are people who are hypermobile, and it’s kind of collapsing down without enough support. So 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: So how do you find the Goldilocks amount of —
Dr. Shirley Sahrmann: No pain and they look great.
Tim Ferriss: Keep fine-tuning.
Dr. Shirley Sahrmann: And the other thing is obviously we aren’t all built the same. I think that’s one of the other important things is looking for structural variations and building that into the assessment. That’s the part that’s tricky. People don’t always pick the right parents, and when they find out, it’s too late to go back.
Tim Ferriss: 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. Could you speak to that and perhaps also mention what corrective measures can be taken? What does it mean for people to wear their shoulders too low?
Dr. Shirley Sahrmann: Well, it means that they should sit up at 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 this game, you’ll see that their shoulders look really dropped. They look lower. So at the end of their shoulder —
Tim Ferriss: They look like they’re sloped downward.
Dr. Shirley Sahrmann: Yeah. If you know there’s the cervical vertebrae between C6 and C7, you should have — that’s about the level where your shoulders should be. And so if that’s way down, you can look at your clavicle and you see that there’s not this six degree angle, but your shoulder is lower than your —
Tim Ferriss: Oh, I see. So the clavicle should, from inside to outside, have roughly a six-degree upward angle.
Dr. Shirley Sahrmann: Should have a little tilt to it, upward angle. Right. So it could be too low. And then the other way I like to talk about it is just the weight of the world, the husband, the children, the bra straps, all of that pulling down and women’s shoulder girdles aren’t as stiff. And what’s important about this is it’s not only a factor of what it does to your shoulders, it also does a number on your neck because the muscles that help to hold your shoulder blades up attach to your cervical vertebrae. And the really big important thing on trying to address that is using, I think the muscle that’s named the serratus anterior.
The serratus anterior attaches to your ribcage 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: It seems like perhaps in weight training, I don’t know if this contributes to the sloped shoulders and maybe the flat or downward angle of the clavicle, but the advice to depress and retract your shoulders is common 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 he has someone maybe retract on some type 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 fixed, depressed and retracted position 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: Number one is also you have to be sure when people have worked out, now it 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, is this big muscle, and people do lap cool downs, et cetera, or they do climbing things or hanging things, and that muscle will pull your shoulders down. So you’ve got to make sure that that muscle hasn’t got too short and that you can get your arms up over your head in the first place. Number two is what you really want to do is use the upper trapezius and the exercises where you’re down here is using the rhomboids and the middle trapezius, and those don’t —
Tim Ferriss: And just for people who are listening, this is like a rowing motion, is that what —
Dr. Shirley Sahrmann: 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, but particularly the rhomboids downwardly rotate. So it’s going to make it more difficult to get your scapula to upwardly rotate and to get the upper trapezius to work. 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 got to get ready to do it 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: How far are you standing from the wall?
Dr. Shirley Sahrmann: Right up there facing.
Tim Ferriss: Oh, got it. Okay, got it.
Dr. Shirley Sahrmann: Right up there facing, your elbows are flexed. You’re sliding the little finger side of your hands up there to get it. And then if you just let your shoulders drop, you’ve gained nothing. But you’ve got to also hold them up as you lower your arms, you see.
Tim Ferriss: Keeping your shoulders up as you do this exercise.
Dr. Shirley Sahrmann: Keep them up, get them up to where they should be worn, not closer to your ears than your iliac crest.
Tim Ferriss: Got it. So you’re looking to keep the shoulders in the position where the clavicle is angling up slightly.
Dr. Shirley Sahrmann: Where you want to wear them. Yeah. And the other thing is it just makes such common sense. You can’t spend the rest of the day have them hanging down either. So you should have a chair that has armrests on it so that they’re up when you’re got your armrests up. 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. 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 isn’t not going to work.
Tim Ferriss: 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: Well, number one is really understanding what you’re meaning by stretching. I’ve talked about this as we’ve gone on through this, but I keep using the term stiffness because I feel like I was misled during my early days as a physical therapist when I didn’t use my own sense of looking carefully 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 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. So stretching your hip flexors is not going to fix the lack of tension in your abdominals. And so what I find is that most often there aren’t muscles that are short, there’s a relative stiffness problem. So improving the stiffness of your abdominals will elongate your hip flexors. Do you see what I mean?
Tim Ferriss: Yeah. It’s a relationship, not just an isolated muscle that you need to stretch.
Dr. Shirley Sahrmann: Right. And that it isn’t the length of the hip flexors that’s the problem. It’s the passive tension from those muscles. Because when you’re sliding your leg down, that muscle isn’t that active anyway. 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, and that’s not when the tilting occurs. So there’s all these things that just don’t make sense. So 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.
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. It’s a matter of what is your activity? For example, when I’m teaching courses, I have a great picture of a young man who has really short, he 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 flatter back. 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. So that’s why his hip flexors were short. So it wouldn’t matter how much you stretched them, 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: 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: Right. Instead of more pushing than just the lifting. So what is it that people are doing that’s causing that muscle to get short? Other examples, and again, I find it so interesting about what intensive weight training is doing, because if you’re lifting, I’ve actually examined young women who are lifting twice their body weight. Well, how many muscles do you use if you’re lifting twice your body weight in a deadlift? Every little muscle you’ve got in your body. Well, what happens is you end up training all of those muscles to come on, and they don’t just go off, so they walk stiff-legged because there’s too much activation of these muscles.
And so they can’t stand and have muscles relaxed because everything comes on. It doesn’t say, “I’ll only come on when I’m weight training.” You’ve trained them to come on, and now you’ve got much more output for a given muscle than you would otherwise. So it’s too much. So you’ve got to learn also how to not activate them as much as you’re learning how to activate. I’m not against any of this, 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 my big point is you’ve got to figure out what’s making it short, that if you need constant stretching, you’ve got a problem with what’s making it short that has to be addressed.
Tim Ferriss: So I’ve been advised, and it seems to help a bit, but to do a fair amount of say, 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 lower back presentation, these symptoms I’m experiencing, could you just remind me of how I would then work on that abdominal stiffness? I could do the overhead breathing and the side bends.
Dr. Shirley Sahrmann: Yeah, that’s for that stiffness. But again, what you’re telling me, and again, I haven’t seen you standing, but —
Tim Ferriss: I could stand. We’re also on video.
Dr. Shirley Sahrmann: Okay.
Tim Ferriss: Would you like me to stand?
Dr. Shirley Sahrmann: Yeah, please, please.
Tim Ferriss: Okay. And I can tilt the camera as needed.
Dr. Shirley Sahrmann: Okay. Pull up your shirt so I can see.
Tim Ferriss: There we go.
Dr. Shirley Sahrmann: Okay.
Tim Ferriss: All right.
Dr. Shirley Sahrmann: Now turn sideways for me. Oh, yeah.
Tim Ferriss: Oh, boy.
Dr. Shirley Sahrmann: No, no, no. I mean, I don’t know what you’re talking about, your tummy sticking out.
Tim Ferriss: Oh, well, yeah. I mean, if I want to look in a second trimester, I can do this.
Dr. Shirley Sahrmann: Which one’s the real you?
Tim Ferriss: This is probably the real me. This is the real me. 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 the pressure off my back.
Dr. Shirley Sahrmann: But you see, you don’t have an increased lumbar curve. You’ve got an increased thoracic curve. In other words —
Tim Ferriss: Like the kyphosis on the back,
Dr. Shirley Sahrmann: Yeah. And part of that kyphosis, yeah, right up there. And part of that kyphosis comes from your rectus abdominus pulling down on your thoracic spine.
Tim Ferriss: Interesting. Right here.
Dr. Shirley Sahrmann: Yeah. And see, when you lean back like that then, well, I’m telling you though, the rectus and the other abdominals become your anti-gravity muscles. So they’re constantly being used.
Tim Ferriss: Meaning I lean back and then these are pulling me forward.
Dr. Shirley Sahrmann: Yeah, you lean back to get away from those, but the rectus needs to be a little bit longer.
Tim Ferriss: Okay. This needs to be longer.
Dr. Shirley Sahrmann: To decrease, and the best way for you to do that is to do the quadruped thing and then let your thoracic spine go down.
Tim Ferriss: Now, so that would be almost like the cow? No, no, the cat. The cat cow, I guess. As I’m on my hands and knees —
Dr. Shirley Sahrmann: All you need to do is think about letting your chest go towards the floor and you feel the load on your shoulder blades. Okay. Now let me watch you just easily, like you’re going to contract your tummy to pull it in. Yeah. You see you do sway back. Okay, stop. You did lean back.
Tim Ferriss: Yeah, if I’m going to —
Dr. Shirley Sahrmann: Don’t, that’s it. That’s better. That’s better. Now, do you have any symptoms like that at all?
Tim Ferriss: No. There’s a little bit of tightness here, but it actually, it doesn’t bother me right now.
Dr. Shirley Sahrmann: Yeah, okay. Yeah. And it looks like your hips are fairly straight. So go ahead and turn, put your back to me so I can just, put your back to me for a minute and put your hands on your iliac crest. Now, with your hands like that, it looks like they don’t look so bad to me. Let’s do what we talked about before, put your feet apart and let’s just see what happens. Does that, if that changes your symptoms at all?
Tim Ferriss: Yeah, it seems to. Wearing very slippery shoes.
Dr. Shirley Sahrmann: Is it better?
Tim Ferriss: Yeah, it’s better. I would stand, this would help if I was 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: Does it matter which leg?
Tim Ferriss: Right leg, because where I feel most of the pain is localized around this bony process here.
Dr. Shirley Sahrmann: Right, right. Yeah. So that is going to be the tensor on that side. Now let me do one more thing. Just bend over and come back up.
Tim Ferriss: From the side like this?
Dr. Shirley Sahrmann: Yeah.
Tim Ferriss: Okay.
Dr. Shirley Sahrmann: Wow. Yeah. Now you need to work a bit on how you come back up from forward bending. And don’t worry about going over that far. 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: Oh, when I get to the top, you’re saying?
Dr. Shirley Sahrmann: Yeah. Yeah, about the last 30, 40 percent.
Tim Ferriss: So hinge more at the hip? Is that what you mean?
Dr. Shirley Sahrmann: Yeah, just think about going over and coming back up by making your hips extend.
Tim Ferriss: Okay.
Dr. Shirley Sahrmann: Hold it there. Now hips, just come back up with hips, hips, hips, hips, hips. Yeah, that was better.
Tim Ferriss: Better like that.
Dr. Shirley Sahrmann: Yeah. And try not to let your back sway back. You use the momentum of your upper back coming back to finish up.
Tim Ferriss: I see. I get a little —
Dr. Shirley Sahrmann: And then you get a little extension and that’s not good.
Tim Ferriss: Overextension. Yeah. Right.
Dr. Shirley Sahrmann: Right, right.
Tim Ferriss: Got it.
Dr. Shirley Sahrmann: Yeah.
Tim Ferriss: Anything else that I can — yeah, I mean I can do more. Certainly. This is helpful.
Dr. Shirley Sahrmann: And I think if you can easily practice, you’ve got those, the lower abdominals or 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: So this is the external obliques. And then what was the other musculature you mentioned?
Dr. Shirley Sahrmann: 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: Yeah, I’m good. I’m good. And this would be in a standing position when I would have just a little bit of tension in the external waist.
Dr. Shirley Sahrmann: If you do that as much as you can because you see, it eliminates your symptoms, that’s all you need to do. And then work on that little increased thoracic kyphosis.
Tim Ferriss: Or I guess reducing this kyphosis by lengthening —
Dr. Shirley Sahrmann: If you decrease that, then you won’t sway back so much.
Tim Ferriss: I got it.
Dr. Shirley Sahrmann: And if your rectus abdominis elongates better, you won’t have that tendency for a thoracic kyphosis.
Tim Ferriss: And to extend then elongate the rectus abdominis, for people listening this is the six packs, this stuff running down the front of the abdominal area.
Dr. Shirley Sahrmann: I’m having a hard time hearing you, Tim.
Tim Ferriss: Sorry. Yeah, that’s right. I forgot about the microphone over here. That to elongate the rectus abdominis, I could get in that quadruped position and basically drop my chest to the floor as I’m pushing my hips backwards if I’m here.
Dr. Shirley Sahrmann: Just in that position, just let it go down. Yeah. It’s amazing how much you can improve your alignment and it looks like you could change pretty readily.
Tim Ferriss: Okay, great.
Dr. Shirley Sahrmann: And the big thing, so we started off because you were doing the bridging exercise. I wouldn’t be tempted to do that. One, you’ll do a much better loading of your gluteal muscles by that bending over and coming back up with your hip extensors. 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: Could you say more about that, please?
Dr. Shirley Sahrmann: Well, it’s 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: Yes, please.
Dr. Shirley Sahrmann: I was working with this older woman, I thought old was my age now. And so 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. And the reason being that your gluteal muscles, as you know, attach to the pelvis, so they posteriorly tilt the pelvis, but if the spine doesn’t want to go along for the ride, it stays there and you get a translation motion between where pelvis is moving and the vertebrae are not moving.
Tim Ferriss: Right. The gluteal muscles are basically pulling the pelvis out from under the spine in a sense.
Dr. Shirley Sahrmann: Exactly. Exactly. Exactly. Not a good idea.
Tim Ferriss: Not a good idea.
Dr. Shirley Sahrmann: Now, if your spine moves easily, then that’s all right. And you can get the same effect if you would put your hand where your spine is and tighten your glutes, you’ll see your spine doesn’t move. Do you see what I mean? 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 want to go along for the ride and you’re going to be one of them.
Tim Ferriss: So in what ways do I need to be careful then, or I guess —
Dr. Shirley Sahrmann: I just don’t think that’s a good exercise for you.
Tim Ferriss: Got it. The bridging?
Dr. Shirley Sahrmann: The bridging.
Tim Ferriss: Yeah. I feel, especially if I do bridging single-leg, but even double-legged, I remember it’s been recommended to me by a number of PTs and I’ve told them, I’m like, “Guys, this really bothers my back.”
Dr. Shirley Sahrmann: Yeah, yeah. It’s arching your back. It’s not a good plan.
Tim Ferriss: Yeah. Okay. I’ll skip those.
Dr. Shirley Sahrmann: I would skip those. When do you have time to do all this?
Tim Ferriss: I don’t. I don’t. That’s honestly, Shirley, been one of the compounding factors that has been so frustrating. It’s 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. And I’ve found the movement-focused approach to make a lot of, at least intuitive sense to me. If our entire conscious experience of reality is modeled on a brain that is evolved to move us through space, 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, much like the immune system. So it makes a whole lot of sense. Now, you just mentioned older woman, but she’s now my age. 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 you are? I would love to know more about that.
Dr. Shirley Sahrmann: Well, next month I’ll be 86 years old.
Tim Ferriss: It’s incredible. It’s just amazing. I would never have guessed in a million years.
Dr. Shirley Sahrmann: I’m so lucky. I’m so fortunate too, because I don’t mind saying both of my parents had dementia and I’ve now exceeded their ages both in life and in dementia. Right now I don’t know that I have any.
Tim Ferriss: I certainly can’t, I would not think you have any. Very, very sure.
Dr. Shirley Sahrmann: So far, so good.
Tim Ferriss: So far, so good.
Dr. Shirley Sahrmann: As I told you, that very early, number one, choosing to be a physical therapist. And also I was very fortunate because growing up I refused to grow up and I played sports. In my day, it’s, when are you going to grow up and stop all that stuff? And that was very good. We also didn’t have air conditioning, and we only had one car. So instead of paying more for a bicycle than a car, I had to ride a big old bicycle and ride it everywhere. And 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. And as a physical therapist, even though I got a PhD in neurobiology because 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 learned a bit about nutrition, breaking all the family tendencies.
So basically, 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 had always had this tendency to look at how people moved. And I 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. So I had to figure that out. And then I applied my own ideas to myself. In fact, I don’t know how folks who you want to get at, but there’re really some funny stories connected with that.
Tim Ferriss: Let’s do it. Oh, yeah, no, we love funny stories around here.
Dr. Shirley Sahrmann: Well, and it really related to doing this quadruped little exercise because, so one funny story was, I was really poor going through getting my PhD because I didn’t have any income then and was living off of a minimum amount of money. And so 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 it was an older woman at that time and we’re out playing golf. And she says, “Shirley, you’ve got your pants on backwards.” And I said, “I’m working on my PhD. I think I ought to be able to know how to put my pants on.” And so we started looking at the darts, and sure enough, I had them on backwards. Well, 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 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: Which quadruped movements were these?
Dr. Shirley Sahrmann: It’s just the idea of being in quadruped and just letting your back go down and then locking back. I tended to sit, ride the bicycle. I was a catcher for three different softball teams, so I was really in a posterior tilt with a really flat back, and I had never really gone the other way.
Tim Ferriss: And just for people who are listening, if you don’t know, just to imagine, if you imagine the pelvis as a bowl of soup, posterior tilt, you’re kind of pouring soup out the back of your pelvis,
Dr. Shirley Sahrmann: Holding it in the middle.
Tim Ferriss: Yeah. Yeah. Right. Yeah. Got it.
Dr. Shirley Sahrmann: So your whole back goes flat then.
Tim Ferriss: And when you’re pushing your hips back, you were facilitating more of a natural curve in the lower back.
Dr. Shirley Sahrmann: I was getting my hips to bend and letting my back go down so I was getting more of a curve, and I think also decreasing a bit of a tendency towards the thoracic kyphosis. The other thing that was really interesting, I used to bowl with a bowling ball. 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 finger grips no longer fit me because my fingers were longer.
Tim Ferriss: So could you explain that? So your grips had been molded to fingers that were —
Dr. Shirley Sahrmann: Well, my finger flexors because yeah, my fingers were always flexed from everything I did. And I never really thought about stretching them out. And so when you’re in quadruped, you would have stretching those around.
Tim Ferriss: Right. Okay, I see. So for people who are listening, because we’re making movements with our hands and gestures with the hands, instead of being the keyboard position, we’re going to make the video available as well but some people will only hear audio. So instead of being sort of that keyboard, hawk talon position, when you’re in quadruped, as if you were doing a pushup but not that pushup position, if your hands are flat on the floor, then you’re going to be stretching those flexors.
Dr. Shirley Sahrmann: Stretching across the wrist and across the fingers, yeah.
Tim Ferriss: Yeah, got it. So you had to change your bowling ball. That’s wild.
Dr. Shirley Sahrmann: 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 few years of this quadruped rocking, I didn’t walk in the same way and my shoes weren’t worn off to the side from just walking.
Tim Ferriss: Interesting. So worn off to the side, you mean the shoes on the inside were worn or on the —
Dr. Shirley Sahrmann: Like the outside of the right and the inside of the left. So there were all these little changes that took place just from 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.
And I also want to tell you about one thing people need to know about that exercise. And then I do a modified, I do pushups, modified pushups. And then in prone, and I think that if you could do this carefully it’d be good, is in prone, I passively, I flex my knee so that my leg as much as possible is falling on my thigh. Do you understand?
Tim Ferriss: So is this similar to what you’re describing, you’re laying down on your chest —
Dr. Shirley Sahrmann: Yeah, I’m laying down, face down, bend my knee, and I try to get my leg, just one knee, to fall back on my thigh. Because I don’t want to hold it down at 90. In other words, if you bend your knee, you can go to 90 degrees. If you go more than 90 degrees, your leg is falling on your thigh.
Tim Ferriss: I see. Right. Your lower leg is sort of falling onto your hamstring.
Dr. Shirley Sahrmann: Yes.
Tim Ferriss: Okay, got it.
Dr. Shirley Sahrmann: That’s your thigh.
Tim Ferriss: Yep.
Dr. Shirley Sahrmann: And 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. But it’s a way to stretch, it’s a way to use your gluteal muscle. Because if you use your hamstring, you’ll get a cramp. You’ll get a bad cramp in your hamstring. So just a little bit of hip extension to use my gluteal muscle.
Tim Ferriss: How many repetitions are you doing on each side or what is —
Dr. Shirley Sahrmann: I just do 10 repetitions on one side and then 10 repetitions on the other.
Tim Ferriss: And you’re doing roughly 10 repetitions of the quadruped rocking as well?
Dr. Shirley Sahrmann: Yep.
Tim Ferriss: I’m not sure if that’s the right amount.
Dr. Shirley Sahrmann: 15 pushups, 15 modified pushups. Modified is your knees are bent. I don’t go to my toes.
Tim Ferriss: Got it. Okay.
Dr. Shirley Sahrmann: And then still in the prone position, knees flex to 90 degrees, and then I do hip rotation in both directions, letting my lower leg come in and then go out. Come in and go out.
Tim Ferriss: So just if I can translate, and please correct me if I’m getting this wrong, but you’re bending, you’re laying on your chest, one leg bent to 90 degrees and basically windshield wiper with that lower leg on each side.
Dr. Shirley Sahrmann: But I do both at the same time.
Tim Ferriss: You do both at the same time. I see.
Dr. Shirley Sahrmann: So they’re not quite — one’s maybe 80, the other maybe 70. Because it doesn’t take all that long.
And then with my knees extended straight, with my lower extremities straight, I alternate doing hip extension, but I think about using my gluteal muscle. I think about activating my gluteus maximus. And again, only about 10 degrees of hip extension.
And then in that same position I do hip abduction. In other words, one leg out to the side 10 times. Because you use your gluteus medias and that better if you’re working against gravity and extension than you do when you’re supine. Supine, you tend to recruit the tensor too much.
Tim Ferriss: I see. Got it. And is there anything that follows that abductor?
Dr. Shirley Sahrmann: Yeah, then I go supine, turnover. And I think this is really — I’m pretty good about not having a kyphosis, but I have to adduct. In supine, I adduct, pull my shoulder blades together and slide my arms up over my head so that my arms are all the way up over my head as much as I can. And I’m on a hard floor. And I’m starting with my hips and knees bent, arms up overhead, and then slide one leg down, slide the other leg down. And believe me, for an older person who’s got a tendency towards collapse-o-smash-o, really just getting yourself as stretched out as possible is so important. I mean, really.
Tim Ferriss: Sounds like for me with my kyphosis that would also be important.
Dr. Shirley Sahrmann: And the biggest worry is going to be with the older person, that if you have a kyphosis, you’re not going to be able to get your arms on the floor all the way up over your head. And no pain. You don’t want any pain on top of your shoulder because that’s not going to be a good plan. So they may need to have a pillow up there when they’re first starting so their arms don’t go all the way back. Because you want to avoid any kind of pain on top of your shoulder. But happily, I know how to do it. I can do it.
And then I do actively hip and knee flex. Bring one knee towards my chest, put it down, then the other one. And 10 times with each leg.
And then with one foot on the floor, I do a straight leg raise. But I don’t 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. I want it that if I rotate it out, you’ll use the psoas more. And I think about tightening my abdominals. Because I have had a significant problem, and I don’t want to put too much stress on my lumbar spine from the iliopsoas. I want to use it, but I want to protect my back. That’s why I have one foot on the floor.
Tim Ferriss: I see. That’s why you’re doing one leg at a time.
Dr. Shirley Sahrmann: Well, yeah. It’s certainly one leg at a time.
Tim Ferriss: So could you just reiterate why, so given the past lumbar issue, why you would want to engage the psoas instead of the TFL in this case?
Dr. Shirley Sahrmann: Because I think it’s a good muscle to use. I need to be able to flex my hip. But the tensor, it has a real low threshold for activation. Interestingly enough, if you would scratch the bottom of your foot, the first muscle would go off, will be your tensor fasciae latae.
Tim Ferriss: No kidding. Wild.
Dr. Shirley Sahrmann: 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 don’t want to listen to me.
Tim Ferriss: They’re not returning the calls?
Dr. Shirley Sahrmann: No, I know. And it is this little bitty wimpy muscle and you say how can it cause so much trouble? But it sure does. It plays a role in what happens to the knee. It plays a role in what happens to the back and the hip. It’s an evil thing.
Anyway. But 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: No kidding.
Dr. Shirley Sahrmann: Yeah, we didn’t throw her out of school or anything. But anyway, I couldn’t wait to do all the tests that we do to look for the length of the tensor. And she was a fair athlete, so it wasn’t like 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.
So anyway, all that to say that’s why when I do the straight leg raise, I try to laterally rotate my hip, because I’d rather use the psoas than I would. And it’s not causing any problems. Clearly if I thought I was injuring myself, I would not do that.
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. My leg goes out to the side, it wants to rotate your pelvis, but contracting your abdominals prevents that rotation. So that’s another way I’m trying to work my abdominals.
And then I stand up. I’m so proud of myself because I can get up from the floor without any difficulty, and many people at my age or many years younger than that can’t do that. And put my back to the wall and then do what I was telling you to do, arms up overhead and do the little side bend thing.
Tim Ferriss: And you do this every day? Or how many —
Dr. Shirley Sahrmann: I do. And I walk three to four miles a day.
Tim Ferriss: Amazing.
Dr. Shirley Sahrmann: Sometimes ride a stationary bike.
Tim Ferriss: Well, these are things I’m paying more and more attention to. I’m so impressed.
Dr. Shirley Sahrmann: 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 is, 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’ve found this in some patients that as you rock back, your hips should just flex. But if you are monitoring the femur, you can sometimes see that it medially rotates. That is really bad.
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. 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. Many people, particularly men, come with what we call femoral retroversion. Do you know what that is?
Tim Ferriss: I don’t.
Dr. Shirley Sahrmann: Okay. Well, you probably have it. Femoral retroversion — no, it’s a structural variation. And so the femur, as you know, has a head and neck on it. It’s angled. Well, it’s also rotated on the shaft. And if it’s in the ideal world, the average, not the normal, the average is that that rotation is 15 degrees. So the head and neck of the femur are pointing 15 degrees forward. 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: That’s true for me, for sure. My internal rotation is terrible compared to my external rotation.
Dr. Shirley Sahrmann: But that’s because you came that way and it should never change. No, I mean it. And men need to know that. 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. And if your glutes are really good, that’ll also immediately rotate your hip when you’re sitting. That’s a problem.
But 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: Right, more of like a wrestling par terre position, meaning —
Dr. Shirley Sahrmann: I don’t know. I never wrestled.
Tim Ferriss: Yeah. I can pick up the slack on explaining that. That’s from —
Dr. Shirley Sahrmann: Not with a referee, anyway.
Tim Ferriss: Okay.
Dr. Shirley Sahrmann: Anyway.
Tim Ferriss: 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 lines would converge, in other words, behind you.
Dr. Shirley Sahrmann: Your feet would be a little bit closer together.
Tim Ferriss: Exactly. You’re funny. All right, so that makes a lot of sense to me and I’m certainly comfortable with that. 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?
Dr. Shirley Sahrmann: Really good.
Tim Ferriss: That’s also something really good that alleviates my low back symptoms. 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 it alleviates some of my lower back issues.
Dr. Shirley Sahrmann: You’re getting it fore and aft. Because you’re probably in this — this is one of the syndromes I have of the hip, that I’ve described of the hip. Because if your tensors really develop, it’s going to be holding your femur in medial rotation when you’re standing because it’s pulled taught then. If your gluteals are really well-developed, when your hip’s flexed to 90 degrees, they become medial rotators too. So they’re trying to hold your hip in medial rotation. And you’re probably getting that twist on your back then. Do you see what I mean? So when you laterally rotate your hips, then you’re taking that pull off of them.
Tim Ferriss: Taking the pressure off of it, yeah.
Dr. Shirley Sahrmann: You’re not getting that extra pull on your pelvis from those gluteal muscles being pulled so taught. And that’s where you should be. That’s your normal thing because you have femoral retroversion.
That’s one of the things that’s bad is because when people go in and they’re taught deadlifts and they say 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. Also, when they do things that rotate, like play golf, their feet should be turned out. Because if they’re straight ahead, they’re at the end of their medial rotation range. Do you see what I mean?
Tim Ferriss: Yeah, that makes sense.
Dr. Shirley Sahrmann: So then it will be the knee or the back or the hips that are going to go.
Tim Ferriss: Makes a lot of sense, yeah.
Dr. Shirley Sahrmann: It’s also interesting.
Tim Ferriss: Yeah, super fascinating.
Dr. Shirley Sahrmann: Yeah, it’s like the backbone is attached to the pelvic bone. 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 because it’s the result of all of these interactions of the body. That’s what’s so important.
Tim Ferriss: And in a case like mine where if you look at family photos, especially on my mom’s side, the feet point way out. A lot of the guys stand, they stand like ducks. And now at the same time, I’ve been told, and I agree with this, that if one were to watch me walk, I have, probably because I have at times 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 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 going to be setting me up for knee problems?
Dr. Shirley Sahrmann: Usually if you’re not using your gluteal muscles and that it’s because you’re swayed back. If you’re swayed back, your line of gravity is behind your hip joint. If your line of gravity is behind your hip joint, you don’t need your gluteals, those other muscles. So if you reduce that kyphosis and get rid of the, which isn’t bad, it’s just not helpful for what your condition is. And then you go forward.
And then the other thing is if you also push off, in other words, when you’re walking, and this could be another way in which you’re reinforcing what your tensor is doing. If you tend to walk by pulling your leg through rather than pushing with your feet and letting it swing through, and if you push with your feet, you’ll activate the extensors more. So the two things, the things that may be contributing to your — 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 is behind your hip joint, then the gluteals do not have good definition. I call it missing for lack of action.
And so then you pull your legs forward with your hip flexors. You’re just reinforcing the overuse of the tensor. But if you decrease your kyphosis, so your line of gravity is a little more running through your hip rather than way behind it, and you roll over your feet and you push with your feet. Do you know what I’m saying? So you roll over so that you’re pushing with the ball of your foot and your leg swings out, you’ll use your gluteals more. Just pushing instead of pulling.
Tim Ferriss: Makes perfect sense.
Dr. Shirley Sahrmann: You want to chase your center of gravity, not pull it.
Tim Ferriss: Yeah, this kyphosis has been with me since I was a little kid. I’ve tried foam rolling, manual release, strengthening the mid-back. But I have not worked on rectus abdominis.
Dr. Shirley Sahrmann: If you were little — there’s a condition called Scheuermann’s disease, which isn’t really a disease. But if you had it, particularly it happens in your teenage years where you get a — you’ve heard of it.
Tim Ferriss: No, I haven’t heard of Scheuermann’s disease. But ever since, I would say since I’ve been 12, 13, I’ve had this kyphosis lordosis combo.
Dr. Shirley Sahrmann: Well then you’ve probably got Scheuermann’s disease.
Tim Ferriss: Okay. I’ll have to look it up.
Dr. Shirley Sahrmann: It’s S-C-H-E-U-E-R-M-A-N-N. And it’s kind of a idiopathic compression fracture of the thoracic spine. It means you won’t get rid of it.
Tim Ferriss: Oh, man. Okay. Well, can I do something to —
Dr. Shirley Sahrmann: But I think if you just don’t sway back more. You know what I mean? Just stay forward a little bit. If you can make peace with that.
Tim Ferriss: Well, I can try to work on the elongating of the —
Dr. Shirley Sahrmann: Well, it’s just not going to change.
Tim Ferriss: Right.
Dr. Shirley Sahrmann: The big thing is don’t let it get worse.
Tim Ferriss: If I have it, yeah.
Dr. Shirley Sahrmann: If that’s what you have.
Tim Ferriss: So what are the main steps to —
Dr. Shirley Sahrmann: I’m not saying that’s what you have, but I’m saying. But if you —
Tim Ferriss: It’s possible.
Dr. Shirley Sahrmann: Yeah, because it happens around the teenage years.
Tim Ferriss: So what would be the keys to not letting it get worse, would you say?
Dr. Shirley Sahrmann: Don’t have an increase. You can still do the same things, Tim, but just don’t say “I will be absolutely perfect. I have to settle for kind-of-perfect instead of absolute perfect.”
Tim Ferriss: Yeah, that’s probably a good MO for most of my life, I would say.
Dr. Shirley Sahrmann: Well, most of us don’t get that close. There we go.
Tim Ferriss: Probably further away than I would like to admit. 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 worth saying or discussing before we begin to wind to a close?
Dr. Shirley Sahrmann: Well, it’s probably just a little repeat of all the things we’ve been talking about. It’s been really great and generous of you to allow me to discuss your issues. But 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 it’s still hard to get a straightforward story about what’s going on and how best to suture. And that’s what worries me a lot is, number one, is I look on the internet for exercises and most of them people can’t do. And they’re not taking into account the variations in how people are. Here you’ve been through all this exam and nobody said you have femoral retroversion, which you need to know because you came that way. You need to stay that way.
So I would like to see that there’s more respect for how difficult exercise is. It’s not like here’s the way everybody should go out and do this one thing and then all will be well. I’d like to see this recognition of that movement is as 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. That’s, to me, why you go to a doctor is to get a diagnosis or find out what condition you’re working on. And I think that would do a lot to help reducing all this variability in treatment.
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 good direction. I can’t help but say this too. I help a good friend who’s actually on a dementia floor. I go to help feed her twice a day. 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. I’m older than most of them.
And I think if people had a chance to address these things early on with the discipline like you show and good direction, we could cut down on and improve the quality of life. I know you’ve interviewed Dr. Attia and much of what he says, Medicine 3.0 or something, and if we did that 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: Agreed. Agreed, agreed. What a great conversation. I’ve learned so much and I’ve taken so many notes. I have a lot to dig into. It’s 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: I hope you’ll get back to me if I can help further. If I find out that these things are going along, I would be more than happy to.
Tim Ferriss: Thank you.
Dr. Shirley Sahrmann: Just a little more formally.
Tim Ferriss: Absolutely. I appreciate it.
Dr. Shirley Sahrmann: We can do it on this.
Tim Ferriss: Yeah, 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 have this conversation. I think it’ll be really helpful to people.
Dr. Shirley Sahrmann: As my dear friend Maiko said, you are tremendous. 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: Thank you. 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, but also to yourself. And as always, thanks for tuning in.
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