4 Common Reasons For Back Pain and What to Do About It (Updated 8/12/24)

The alarm goes off, you roll over to turn it off as you take a glimpse at the time, 6 AM.

Sigh, it’s okay, time to eat before heading to the gym. As you gingerly roll out of bed, you go to stand only to feel stiffer than usual. You make your way to the kitchen and are met with an immediate uncomfortable sensation. You continue to move but this sharp debilitating pain starts running throughout your back and radiating down your leg. As the sensation increases, you are frozen by the pain.

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Tell me if this sounds familiar:

You sneeze and throw out your back
Bend over to tie your shoes, throw your back out
Rotate to place an object on the floor from a seated position and are met with back pain.

What all these innocuous scenarios have in common is that they’re not the reasons why your back hurts. They were the last straw, a coincidence because no one would argue that sneezing or tying your shoes are mechanisms for low back pain. There’s no such thing as non-specific back pain, only reasons that have yet to be snuffed out.

(2024: All continues to ring true, it isn’t so much the act of bending over to do something or lifting in a particular way that injured the back, but the accumulation of the load through tissues that weren’t properly trained and have now yielded.

I also disagree to the extent that we can have non-specific back pain in that we cannot point to the exact cause of the pain. This is also a shortcoming of research in that all low back pain, even similar presentations are different, and therefore extrapolating that to a larger population has its limitations.)

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Relax…You’ll be Okay

Many individuals come into my office with some kind of “generic” back pain or self-diagnosed sciatica. Their pain is real and they don’t care so much about what it is (at least not in the moment) and are more interested in if we can get rid of the issue.

After tissue exploration and manual therapy, we stand up to perform some exercises to help improve the tissue’s capacity. I’m quick to let them know it’s not as bad as they think and that together we can solve this. Not surprisingly, most individuals I’ve worked on will remark that they feel immediate relief.

I’m not some magician, but I let clients know that bending over, sneezing, or standing up wasn’t the reason for their pain. Instead, it was one of the following reason(s).

(2024: This whole list is fine but I don’t love the framing of it from a nocebo perspective. Meaning, that if you don’t do these, you’ll have back pain, which is not true.

I still believe that much of the lower back problems that plague people often comes down to any of the following things below)

Your spine moves when your hips should

By now, most know that if you’re always putting yourself into bad spots, it’s not if but when will you get into trouble. Your body is no different.

(2024: It should really say if you’re only moving in one particular way, its a matter of when not if you will likely end up with some trouble.

The way I wrote this originally sounds real doom and gloom)

The topic of posture is at the current forefront of social media with polarizing views that you have to be a certain way for perfect posture or that posture doesn’t matter. The truth is always somewhere in the middle. If you’ve read my work on Instagram you’ve heard me say this but it begs to be said again:

“The best posture for you is one that is always changing.”

Your movement capacity is the same. Say you have a job that requires you to bend over and move 15 lb sandbags. If you were only required to move 10 bags, you could move them however you felt and likely be fine. But if you needed to do that for 8 hours each day, 6 days a week; you’re probably going to want to move in a biomechanically sound manner.

Learning to hinge, disassociate the hip from lumbar movement, and rotate well all go a long way in improving load-bearing capacity and providing you with different ways to move.

(2024: most of that is still solid, if you only know how to move one way, learning options is always a great idea)

Related to movement from the hips and not the lower back would be the ability to contract into hip extension without compensation. Lying on the floor offers a great deal of stability and lets you see what each side is capable of doing.

If one can’t get good hip extension while lying down, there stands a solid chance there is excess motion elsewhere when upright. Remember it’s not the movement itself that needs to be a particular way, rather it’s needing more options.

(2024: same same)

Your Spine Doesn’t Segment Well

Can you Cat-Cow? Many have performed this ubiquitous yoga movement, but few have used it to asses their capacity to move their spine.

Common for individuals with lower back pain is an inability to move segmentally through their lumbar spine without overly hinging through their mid-backs. When this is the case, a hinge point develops and this is the site of stress. The back is a bridge, so the load should be evenly distributed versus being placed just in one section of the vertebral column.

(2024: I agree with 90% of what I’ve written with the exception of the hinge point comment. While I may visually see a hinge point, we can’t assume that this is the exact site where you’ll have pain. Even if anecdotally all the spines I’ve assessed with some degree of discomfort show up with a TL junction hinge point.

Research says otherwise that you can have a hinge point and be asymptomatic, so there’s that.)

Your Hips Don’t Move Well

Single leg stability: You should be able to drop down to about an equal depth on both sides. This is an easy way to assess whether one hip moves better than the other. Things to note would be how smooth each side feels and if the foot/knee collapses during the squat.

(2024 neuromuscular retraining is still important)

The RNT split squat is a great way to help shore up the strength and their stability on that side. The band helps pull your knee into compensation, so you use your muscles to maintain proper tension and alignment during the exercise.

(2024: Still a fan of using your own muscles to correct positional problems)

90-90 Hip Transitions: These are a fantastic way to mobilize and loosen up the hips before activity. I also like them to discern if there’s a control issue somewhere along the chain. You go from transitions to a lunge and squat pattern during them as well here.

(2024: These are only helpful if you can get into this position correctly. If you try to get into the 90-90 position and your knee is barking at you loudly, how do you expect this to go? The inability to get into positions is a requisite to express movement where you want it.

You Have a Structural Problem

Spinal Compression Test
Take a seat and sit up tall
•Get into a good “posture” with your arms by your side (slight arch in your back)
•Grab the chair with your hands and pull up to compress your spine.
•Did you have pain in your back now that it we added a bit of compression in the rounded position?
•If so, it would mean that even when your spine is in a good biomechnical position, it doesn’t tolerate compressive forces well.
(2024: Oh the cringe I feel for feeding into this nocebo narrative. Look I can gather this same information subjectively from you. What does this test tell you? Posterior spinal tissue and potentially others are unable to handle a simple load going through them.)

Shear Test:
•Same as above but let your back round out
•Did this recreate your pain?
•If so, it would indicate that your pain is triggered by lifting out neutral, flexion intolerance.

(2024: Same for this crap…I mean this test. I could have gathered this from a conversation where you tell me being slumped or flexed hurts your back more and it feels better when you’re not in this position.)

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What to do if these tests come back positive?

Flexion Intolerance
•Try not to slouch too much when standing or sitting
•When bending down to grab things, learn to hinge properly or kneel down in addition to improving core strength
•Lie stomach down a few times a day.
Extension Intolerance

• When standing, try to vary positions. When seated, sit back into your chair.

• Work on improving mechanics during movement and core strength as well.

Ultimately should you have an issue, be sure to visit a professional to help rule out any serious problems. The advice shared here should help the majority of individuals get on the right track, but you always want to be sure to not overlook a larger problem.

(2024: What if all these “tests” are done and it’s fine? You may discover you’re not flexion intolerant but extension intolerant as pain only happens with extension-based movements like standing positions. Advice would be the opposite focusing on less rigidity through the lower back and focus on fluidity with movement.

I suppose the problem is that when anyone has back pain, it’s such a nuanced problem specific to each individual. Therefore sifting through social media or any website will try to sell you a paint-by-numbers approach. Again, this may help some, but what about individuals who don’t get better? This all goes back to, no two presentations for back pain will be the same, even if they have an identical diagnosis.

Don’t buy a choose-your-own-adventure for your lower back pain, hire a qualified professional.)

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A post shared by Gary Heshiki (@garyheshiki) on Jul 15, 2019 at 9:06pm PDT

Closing thoughts in 2024: The majority of insidious low back pain has a few things in common. Poor spinal segmentation and a lack of variable coordinated movement.

All “neutral” spine movements have flexion involved, in fact even in those that visually appear neutral throughout experienced spinal flexion through the lumbar vertebrae. (Thesis paper here).

• The primary goal is to settle down any acute flare-ups

• Manage the spine based on what it’s showing you.

  • Can it flex well?

  • Does it extend well?

  • Does any hinge point correlate with an area of lower back pain?

  • If it lacks sagittal plane movement, does it compensate sagittally or laterally?

• How is this person’s breathing? Are they able to demonstrate good IAP (Intra-abdominal pressure)?

These are just a few things I’d would start with just from an observation standpoint. From there I would assess with my hands and put together the pieces of the puzzle along with the information I get from our discussion as to what to tell you and where to go with treatment.

Trouble with Standard Model Therapeutic Screening

You’ve woken up and you have pain across the back of your hips and gluteal area with some discomfort out into your hamstring. You go visit your therapist or chiro who pushes on your vertebrae to tell you that L5-S1 is not moving well (they can’t actually feel it move). They may then ask you to do a squat, and you shift away from the side that’s bothering you. It makes perfect sense that you move away given it hurts on the opposite side. You sit back down on the table and get your muscle strength checked, glute med/min and ankles are weak and it’s causing your hips to be off balance.

While nothing is unsafe (priority number 1), it is inherently short-sighted to assume anything about this all-too-common assessment provides insight beyond an inability to control movement and a lack of strength in areas where you’d expect it to be weak. Not to mention manual muscle testing is a very unreliable “quantified” way of measuring strength.

(In my opinion, the grading scale makes sense only for gross movements not fine, where a 0 means nothing, a 3 is held on your own, and a 5 is where you can hold against some kind of resistance. Trying to specify and say it’s a 3+ or 4- is way too subjective to be used reliably.)

In this example (or any movement screen), a squat screen where you aren’t moving well only tells me you can’t squat, and nothing beyond that where you leap being told you have hip dysfunction or weakness.

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This may be a motor control problem that is dependent on neurological mechanisms such as speed and activation. If these neurological mechanisms have good incoming and outgoing information flow between the joints, muscles, and connective tissues; motor learning can occur.

A lack of balance here manifests as altered movement.

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Muscle strength is useful clinically when we look at potential neuropathic-related problems like radiculopathy, but outside of that context, being told you have weakness is an unreliable cause. Your pain may inhibit firing but remember that pain may not be coming from the area of discomfort rather your brain sending a signal that something is not right.

Like a smoke detector, it only tells you there’s an increase in heat or smoke not that there’s a fire. Pain is the smoke detector, something’s not right and we need to investigate WHY.

Find a therapist who looks at the why instead of what.

When I ponder about that statement, it means going beyond the superficial explanations of if this is “out of balance” and you need to strengthen muscles to pull it back.

Simply treating the symptoms or focusing on strengthening specific muscles may not be enough to address the root cause of the problem. Sometimes, the pain may temporarily decrease due to accidental problem-solving by the therapist, but the underlying issue may persist. In such cases, the pain is likely to resurface once you resume your activities. This happens when the therapist focuses on WHAT instead of WHY.

So what is the why behind your pain? No one can say, but to fit it into a neat box where it’s an “If this, do that” approach is not going to cut it for the majority of more complex problems that people get.

This I suppose, is the point of this article, when a treatment is based on an assessment that only looks at one subsystem (which is a part of a complex multi-systems entity like a human) it will fall short when it isn’t a muscular system problem.

Do Your Feet Turn Out When Squatting or Running? (Updated 2024)

You and Your Feet

The foot is most stable when it is straight. When your feet are turned out, the integrity of your foot's arch is not being maintained. The further out you rotate your foot, inherently it tends to get less stable. As you stress out the plantar fascia, the flat connective tissues (ligaments) that connect the heel bone to your toes, the transverse and longitude arch will collapse without external rotation.

(2024: While most of this holds biomechanically, it raises an important question about demands during your activity. Does it matter if you’re increasing physical activity? How about compared to a marathon runner? The demands you ask of your feet will greatly determine how much the “correct” biomechanics matter.)

It is important to keep your feet pointing forward while walking and stable while lifting. If turned out of alignment, the knee and ankle will be open and the hip therefore be unstable. Instability can lead to hip, knee, or ankle problems or even skeletal issues like bunions or chronic knee and/or back pain.

(2024: Goes back to the first new point, task dependent. If you’re lifting 300lbs versus picking up a 3lbs box, these little “malalignments” matter less the lighter the load. In general, the question I ask is, can you do both? In reality, the inability to do one likely matters means more to our health in the long run.)

Hips or Feet?

Is the root of the issue coming from your hips or feet being turned out? A simple test can be performed by looking at the single-leg squat.

1. Set up a camera straight on

2. Stand on one leg and drop into a single leg squat.

3. Repeat on the other side.

Start by looking if any knee rotation occurs in or out but your feet appear relatively set. If so, the problem may be coming from your hips.

Do your knees remain stable, but your foot rotates in or out? Then it’s likely due to your feet.

Possibilities also include poor motor control, tight calves or an issue with your anterior tibialis (the muscle next to your shin).

The majority of cases I work with have exhibit some combination of the two.

(2024: All of that Is still solid advice in assessing the feet from the hips during an activity with increased stability demands.)

The Good News

The good news is that you can fix muscular imbalances and improve subsequent motor control discrepancies.

Walking

The most common way doctors choose to remedy this problem is with the use of orthotics. They artificially create stability through the feet, which works great until you have to shell out a good chunk of change for a new pair. An expensive solution to a problem that can be remedied by training the intrinsic foot muscles and improving internal hip rotation.

(2024: I am doubling down on the idea that too many doctors will refer to podiatry over consulting with a PT. This leads a patient down the rabbit hole of custom orthotics when in many cases, it could be resolved with intrinsic foot muscle strength work.)

Below is a whole post I created on Instagram around the topic:

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Build Stronger Feet 👣 - The initial shot shows maintaining a short foot-arch versus allowing the transverse arch to collapse. Collapse isn’t an issue, rather it’s uncontrollable collapse that is a problem. - Toe Control The ability to control your toes says a lot about the overall health of your feet and the muscles that cross the area. First begin by tapping the big toe up and down while maintaining the other four up. Then switch! Aim for controlled reps of 10. - Single Leg Balance Frontal Swings Taking the position from before maintaining your arch, now we add in movement making it more reactive in nature. Because the motion comes from the side, it’ll challenges you more dynamically. And dynamic stabilization is much more important because eventually you’ll have to test it out by running and cutting but initially this is where you begin building those intrinsic foot muscles. - Single Leg Balance and Reach An extension of the last exercise is a forward, side and backwards reach with the free leg. Good foot positioning allows the hip to do its job and by proxy aides proper alignment of the knee. - Concentrated Calf Raise Wall Nice and slow, we look to push through the ball of our foot up onto our toes, stabilizing via the big toe. If you can “stick” the position by pausing it’s a plus. - Single leg RDL w/ Band The band goes under the ball of your foot by the big toe. Proceed to add some tension to the band and perform SLRDLs. The goal is proper foot position, otherwise you’ll lose the band!

A post shared by Gary Heshiki (@garyheshiki) on Mar 7, 2018 at 9:04pm PST

It’s All in the Hips

Practice standing, walking, and running with neutral feet.  People watching in public places and see who walks/runs neutral and who has funky movement.  If you can spot the error in others than you will be more cognizant of your own movements. In most cases, being aware of the issue is more than half the battle.

Organizing our feet is easier if you are in a braced position as well.

(2024: ehh….okay there were a lot of nocebo statements made back when I wrote this originally. Primarily the idea that you can have a wide range of walking and running gait WITHOUT any pain. IF you develop pain, then we understand there might be a link loose in the chain. Otherwise, until there is some kind of reason to address anything, buyer beware when being told your position is why you’re in pain. Pain is far too complex to reduce it down to one singular cause.)

1. Being Aware of Your Balance

A few key components to achieve a neutral resting position (balanced posture) are the following:

1)  Engage your glutes (pelvis rotates posteriorly)
2)  Engage your abs (ribs rotate downward)
3)  Move your shoulders back and down (palms should be touching the side of your legs with thumbs pointing forward)
4)  Tuck your chin backward (like a turtle retracting its head back into the shell or double-chin)
5) Weight distribution (tripod positioning, heel, ball of the foot and outside of the foot)Internal hip rotators

Tension is held in the following: Calf complex, fibularis complex, bottom of feet.
Strength of: TFL, glute medius, glute minimus.

(2024: This is still gold, especially being aware that your ribs rotate in conjunction with your breathing mechanics. I will be exploring this further with more PRI studies)

Keep in mind there is no perfect posture, the best one is a changing one.

(2024: 1000% doubling down here, the best posture is the next one you take on)

2) Strengthening the Hips

My favorite movement to use is the RNT split squat. It works to train both hip and foot muscles in one movement.

Place a band around your knee and have it pull you INTO collapse which will force the muscles to engage harder and thus help groove the motor pattern. You can load it with a dumbbell or kettlebell in a goblet position at chest level for added resistance.

(2024: I still love these for individuals when they have poor spatial awareness during movement. Believe it or not, some people are unaware that they are allowing extraneous movement when they didn’t intend on it.)

Clamshells are a great exercise, big coaching cue is to make sure you aren’t rocking backwards as your open the hips. Think about keeping the hips stacked on top of each other.

Glute bridge variants are fantastic, you can start with the basic two legged bridge and progress to a single leg version, before trying things like marching or incorporating sliders.

• Improve general glute strength (single leg work like the RNT split squat, clamshells, Glute bridges)

• Strength in plantar muscles

• Strengthen dorsiflexion (mainly the anterior tibialis, your shin muscle)

3) Begin Mobilizing and Incorporating gait patterning

Single Leg RDL: Fantastic movement to train the hip in multiple planes of motion. Problem? It’s usually too hard on balance and subsequently a lack of tension in the right places.

(2024: Fun fact, the single leg RDL has one of the highest glute med EMG activation patterns. You can take that and run with it however you’d like.)

Here I’m performing a TRX assist SLRDL where you hinge back, and reach with your arms and hands forward and back. As you go further, you can spread the arms to widen your balance.

Seated 90/90 mobilizations: The full movement might be too difficult for some, you can work on the 90-90 shifts first

(2024: I disagree with this so much, that I am striking it through. Primarily as it disregards a larger point: can your hips even do this? What happens then is a person seeing this, trying to mimic the position instead of trying to understand the larger issue at hand which is the ability to feel proper motion from the correct areas of their hips)

Split stance kneeling adductor mobilizations: Good adductor length is important in maintaining good balance during lower body strength exercises. While it may not directly influence hip and foot dynamics, it can still have an indirect negative effect.

(2024: While I agree with my younger self here, adductor STRENGTH likely matters more than the mobility of your groin area. If you strengthen your adductors at both lengths, it will have a greater carryover to other activities all while increasing your mobility.)

Good ankle dorsiflexion: here is a whole post I made about this before.
First about good foot balance

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Foot Position and Improving Hip & Knee Stability - A follow up to last nights post about hip stability, tonight I’ll be tying in our feet to the equation. Our feet have the ability to help us drive up out of a squat or contour as an athlete dynamically cuts through a court or field. Our feet also have the ability to slow us down or decrease neural drive by losing ground contact. - •Our weight should be distributed somewhere between the ball of our foot to the heel. •Too much pronation, or loss of 4 outside toes decreases hamstring recruitment and shifts more onto the quads •Too much supination, or big toe off the ground and we get decreased quad recruitment with more work going to the hamstrings. - So where do you go after you improve intrinsic foot strength and/or hip stability: Loading it via resistance training. One way to check you’re ready for more is to change the angle of your feet - Start feet Straight Ahead •Start with the feet straight ahead, achieving subtalar neutral. •Squat down to a depth while keeping the ankle centered. •You’ll want to watch if the midfoot collapses inward during motion, squat to or beyond your desired depth. - Feet Turned out •Achieve a centered ankle position •Drop down to depth desired •This position is “easier” for your hips but often may come at the expense of foot or back position. In which case I’d argue this isn’t a good position for lifting •Hugely important during almost every sport which requires change of direction. - Feet Turned In •Turn the feet in with the ankle neutral •Drop down while paying attention to positioning of the knee throughout. •Important for athletics (a position many basketball players take off from when dunking) or weightlifting/CrossFit when athlete catch a barbell overhead during the jerk. - “Knees Out!” This is a really common cue. Instead coaches and lifters should focus on their feet. This is key because if your feet are neutral, you will automatically be using your hips to achieve that centered ankle position. Think about using your hips to help in getting to neutral, and often better knee-hip function will follow

A post shared by Gary Heshiki (@garyheshiki) on Jun 11, 2019 at 8:57pm PDT

551 Likes, 33 Comments - Gary Heshiki (@garyheshiki) on Instagram: "Foot Position and Improving Hip & Knee Stability - A follow up to last nights post about hip..."

Ankle PAILs and RAILs

1. Start by placing the ankle in as deep of dorsiflexion as possible. Then relax for at minimum 1 minute

2. Then start by contracting down towards the floor for 10 seconds as hard as you can manage (PAILs)

3. Immediately without changing positions, try to pull your foot up towards your shin. Even if no movement occurs, continue pulling. It’s all about intent (RAILs)

4. Then relax into the new end range and repeat 2 more times. You can begin the PAILs contraction once you feel like the tissues have “relaxed”

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A post shared by Gary Heshiki (@garyheshiki) on Jul 8, 2019 at 9:09pm PDT

2024: Ultimately, a lot of this still holds true but I would approach changing anything with some trepidation. Not everyone needs “fixing”, in general the rule of thumb needs to be when there is no problem being reported, don’t go out searching for one. And run the other way if you’re being sold that there is.

Doing Your First Pull Up

Pull-ups have a way of humbling the strongest of lifters. This is due to the fact that you got to pull your own weight, literally. A lot of people have a huge goal of doing a pull up but many of the programs out either sit behind a pay wall or don’t take into account the importance of screening for pre-requisite movement and the importance of taking a bottoms up approach.

Part 1: Screening the body

• What does the body need to be able to do and what is required to perform a pull up?

• Why it matters to manage these issues before embarking on your pull-up journey.

• What should a finishing position for all back exercises feel like?

Part 2: Training the Core

• Why it’s important to start from the floor before moving up to the bar.

• How jumping the gun and beginning with a band assist pull up isn’t the best use of your energy and time.

• Basic exercises to start with

Part 3: Strength Training

• Using the finishing positions from part 1 and bringing it all together.

• Basics of rowing and pulldowns.

• Tips on manipulating your positioning and tempo to increase effectiveness.

Free Program
Download a sample 3-month program

A few key points:

• The sets and rep schemes are fairly consistent with how I would program for most individuals.

• The weight recommendations are just that, a recommendation. If it’s too heavy or too hard, make it appropriate to fit your starting point.

• Progress appropriately

  • Begin with the core work on the floor.

  • Once you start hanging from a bar, the dead hang and scap pull-ups should start to get easier with minimal swinging.

  • If you get to the isometric holds and negatives, you should be fairly stable. If you look like you’re on a swing, you’ve moved on too quickly.

  • The inverted row is a nice way to manipulate your bodyweight by changing your position while maintaining that isometric hold. It’s analogous to the holds you do hanging from a bar.

  • When doing any of the movements, when you complete the motion, you should FEEL the finishing position. If you don’t feel it, it’s likely too hard.

If you have any questions, feel free to drop a comment or send me a message!

Have trouble figuring this all out? Sign up to work with me online where I’ll design a program centered around your current abilities, gym set up and other goals.

Got Knee Pain? Work on Being Able to Lock Your Knees Out

Photo by Meghan Holmes on Unsplash

Lock your knees out. Especially when you lift!

But have you heard the advice that you shouldn’t lock your knees out because it’s bad for you? Ever wonder why that is?

This myth has origins in stories of soldiers standing at attention for hours on end only to end up fainting as they had their knees locked out. It was postulated that this was due to compression of the popliteal artery (a branch from the important femoral artery).

Secondarily, this also centers around old beliefs about arthritis and how excess wear and tear might cause a breakdown. Instead, researchers now are finding it may not be a disease of breakdown but rather uncontrolled local inflammation in the knee joint. (1)

Screw-Home Mechanism

The screw home mechanism is an integral part of ensuring good knee stability. For most healthy individuals this is something you don’t think much about. However, for anyone with prior operations or lingering anterior knee issues, this is an important concept to understand around general knee function.

The medial condyle is 1/2 in. longer than the lateral condyle. This allows the femur to screw home when fully extended and this stabilizes the knee joint. This is an essential aspect of being able to walk and support yourself during the swing phase (Standing on one leg while the other one swings through).

The movement of internal rotation of the femur on the tibia associated with the later stages of extension of the knee constitutes a locking mechanism, which is an asset when the knee is subjected to strain.

In general, it works like this:

• Closed chain (like squatting) the femur moves on a stable tibia (shin bone). (2)

  • The Femur rotates externally to unlock the tibia.

  • The femur rotates internally to lock on the tibia.

• Open chain (like a leg extension) where the tibia moves on a fixed femur. (2)

  • Tibia internally rotates to unlock

  • Tibia externally rotates to lock

I Don’t Have Knee Problems…Why is This Important?

• Most knee problems occur at the terminal extension with a lack of VMO function. Ah, for some, I’m sure you recognize the VMO, this is why so many coaches prescribe terminal knee extensions. Why isolate one motion when you can easily train this whenever you hit leg day!?

• As you flex your knee, the PCL relaxes and the ACL is tightened. The reverse is true, as you extend your knee the ACL tightens and contributes to stability while the PCL relaxes(3). Seems important to ensure these structures are exposed to stressors so they can improve stabilization (albeit minimally).

• If you lack terminal knee extension, you will likely rely on a few strategies.

  • Think of an elderly person who shuffles their feet. They can’t lock their knee out, therefore, decreasing the amount of time they stand on one leg during the gait cycle. So they shorten that time by shuffling their feet instead.

  • You can’t lock your knee out, you either walk with more flexion and increase stress on other structures or you walk with some limp. A limp also increases the reliance on other structures, namely your hips to help keep this show running.

• This is why you may not need to squat “ass to grass” but you do need to expose your knee to deep flexion to end-range extension. Pain-free deep flexion tells our brains via our receptors in the deep knee capsule stuff to maintain these structures. This in turn supports our ability to access such positions.
  

  The easy take-home is to do leg presses or lunges maybe. It doesn’t have to be heavy, it just needs to be deep.