Fix Knee Pain w/ Dr. Farnsworth TKE .4 FREE CEU's for Personal Trainers

Your knee pain might not be a “weak glute” problem or a fancy gadget problem. It might be one missing piece of motion: full knee extension. When the knee can’t straighten, the quad stays inhibited, your gait gets weird, and every step becomes practice at not using the muscle that’s supposed to protect the joint. That’s why we brought on Dr. Justin Farnsworth, physical therapist and founder of Rebuilt Strength Method and Pro App, to give coaches and lifters a clear plan they can actually run on the gym floor. 

We dig into a simple terminal knee extension screen you can do in minutes, why a low load long duration stretch can be the test and the fix, and how to decide whether you should refer out. Then we shift into anterior knee pain and patellofemoral pain syndrome, why soft tissue work can turn down symptoms briefly, and why the real long-term answer is building tissue capacity with smart loading. 

Dr. Farnsworth breaks down his go-to isometrics for knee pain relief, including the Spanish squat isometric and how to adjust depth so sensitive knees can still train. We also talk progressions back to squats, split squats, step ups, and step downs, plus a straightforward routine to keep extension once you get it. If you coach clients with knee discomfort, want better knee rehab outcomes, or you just want stronger quads without fear, this one is packed with tools. 

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Transcript

Welcome And Why Pain Skills Matter

SPEAKER_00 0:02

All right. Hey there, Hunks and Hunk Cats. Welcome to the Show of Fitness Podcast. We have a really special treat for you guys today. Not because you get me a younger, bigger biceps host, um, since Chris couldn't be here today, but even more special, we have a phenomenal guest joining us today, and Dr. Justin Farnsworth. Uh Dr. Farnsworth, thanks for being with us today. How are we doing?

SPEAKER_01 0:23

We're great, man. We are great. We are in western New York. It's finally stopped snowing. Five days ago it was snowing. It's 60 degrees outside, so we are all finally coming out of our winter depression. So we're happy.

SPEAKER_00 0:34

That sounds nice. Yeah, I'm in uh Boise Idaho. We were having phenomenal spring weather last week, and then all of a sudden it decided it wanted to start pouring rain on us and thunderstorms and some snow back in the mountains. We call it uh second winter up here. So, or faux spring. We kind of hear that one too.

SPEAKER_01 0:49

So hopefully we have more weather coming soon. We get false spring. We get false spring till Memorial Day, basically.

SPEAKER_00 0:55

Okay. All right. Well, really appreciate you taking the time uh to be here. I know you're a very busy guy. Um, so quick little background, and if you want to add anything to this, um, but just for those of you that are tuning in, uh, Dr. Farnsworth is the not only a physical therapist, but also the CEO and founder of Rebuilt Strength Method, as well as Pro App. So it's the shirt he's rocking right now. So programming around pain. And from what I've gathered from your bio is that since 2021, you've with these in-person seminars um and helping coaches, trainers, therapists working with uh clients that are in pain, you've been able to help over 5,000 uh coaches um during these seminars, which is an incredible amount. That's something you know we're trying to do with our in-person seminars, is reach more um more trainers and help the industry. And so the amount of volume you've able to do is incredible. Um, and so we're just we're honored uh for you to be here. And then also we have the opportunity, we'll circle back around to this at the end too, but for you to come to our Santa Monica location and host a one-day seminar in uh our gym there in Santa Monica October 23rd, I believe, correct?

SPEAKER_01 2:00

Yes, October 23rd. We have a special hookout for show of fitness coaches. Um excited to be there, man. And and honestly, it's it's interesting. You know, I've I've taught more courses in this industry than anyone, period. So since 2021, I've been teaching courses two to three times per month, basically nonstop. And I think the most important thing for coaches is coaches are not taught what to do when a client has pain. That's not inside the education. And there are two options. The first option is to say, well, it's not my scope. I'm just gonna punt. I'm gonna send them to rehab. And then what you do is you send them to rehab, and nine out of 10 rehab professionals are unequipped and undereducated on how to actually make that person stronger so they come out better. So now they get stuck in the medical system of I have pain. I had an image that told me not who I am forever and what I can't do. And then they go to rehab, of which I've been a I've been a doctor for almost 14 years. Um, I've worked in rehab. I was a professional athlete. I actually worked with professional athletes before that. I've been in this industry for 25 years. And what you end up seeing is this underpreparedness, underdosing, under load. And now that person becomes a statistic of the person that's like, I didn't get better in rehab, and I'm one of the 70 to 80 percent of Americans that's actually overweight and doesn't move my body. That's the first option. The second option, get comfortable working with people in pain because you're going to, whether you like it or not, no one's gonna come in and say, I'm fine. I have nothing going on, my back's never hurt me, my knees felt great. If you get a 15-year-old kid, awesome. But even those kids are having problems because they're sitting all day. Like we have 15-year-olds that have the worst movement skill I've ever seen. It's like I used to not have to teach kids how to squat and jump and just run because they did it all day falling out of trees. And now they just they don't even know how to move. I like I wonder what those kids are gonna look like when they're 35. Like it's not gonna get better, right? Um, but so the other option is like get used to working with people in pain because you're going to. And it's not get used to working with people in pain and try to diagnose and fix them because you can't and you won't, but it's about identifying here's their pain point, here's the knowledge I have, and here's how I can use exercise as medicine. And frankly, when you can't do that as a coach, you lose your confidence and you're gonna lose your client. When you can do that as a coach, if you have a client and you can solve their problem, they will be a client forever. And then here's the beautiful part when you have a client for five, six, seven, eight years, you can affect long-term health and long-term change. That's why we all got the industry in the first place. Like that's the goal of why I created this course for people.

Why Full Knee Extension Comes First

SPEAKER_00 4:57

Yeah, that's incredible. I I my philosophy when I'm working with clients is the same thing, and where it's just like I always say it's like I love, you know, when clients go through, you know, transformation, maybe weight loss or aesthetics, but my I really get fired up when it's they see the quality of life improving. Um, and so I think what you're doing is such a phenomenal thing for our industry to not only do it yourself, but now teaching coaches and giving them the tools in which we have things up like for us trainers and therapists that we can implement so we don't have to be afraid of working with clients of pain. As you said, so many people, I remember watching one of your videos where you did uh a hand raise of who's in pain, and I think it looked like you might have had 100% participation, but if not, it was at least 90%. And so we all deal with it. Um, now we could go on forever talking about like all the different pain points that people go through, but specifically today we want to discuss knee pain and knee discomfort. Um, and so I know you're big on uh TKE, so terminal knee extension, about how to screen for that as a prerequisite to see if like someone's very vulnerable to knee injury. So if you can maybe kind of walk us through what that screening process looks like, um, and then what are the strategies that you implement and us as trainers can implement with uh with clients to gain optimal range of motion when it comes to TKE.

SPEAKER_01 6:16

Yeah, I love that. So let's just break this down. Let's start at the beginning, right? So here's the tool for coaches, and this is very important. If you have a client that walks in and they have no pain, please, for the love of God, just train and exercise. Done. Move on. Okay, like squat hinge lunge, push, pull, carry, jump, rotate, throw, all of that. Awesome. But when you have a client that comes in and they're like, hey, I have a history of knee stuff, there are some very specific things you need to look at. Um, number one on that list, and it sounds so remedial, do they have full knee extension? Yes or no. Uh, I've worked in medicine 14 years. One of the biggest things I did, I worked in New York City for four years, four and a half. And I was one of the big ACL rehab professionals inside New York City. That's not a lie. That's something I worked my butt off to be able to do. And whenever you see a post-op knee, like an ACL or a knee replacement or a meniscal repair, even though those go a little bit differently because they're locking extension. But the biggest first goal is does their knee go all the way straight? And here's the reason why, right? So your knee is a hedge joint, it's kind of boring. It bends and extends like a door, okay? It has to rotate a little bit, the tibia and the femur to lock and unlock. But for our purposes, it does what your elbow does. Does this and it does this? Now pretend here's my knee, here's my foot, there's my hip. Okay. So let's pretend that's the structure. If you are unable to get into extension and even a little bit of hyperextension where the knee locks out, what ends up happening is you effectively start inhibiting your quad. So here's my quad right here. Okay. Now I wish my biceps were as big as my quad. That'd be super cool, but they're not. But pretend this is my quad, all right? Yeah. And so when I don't have full knee extension, I walk around with a flex knee. When I walk around with a flex knee, my quad is inhibited. It literally will not turn on. And everyone who's watching this right now, if you don't believe me, all you need to do is sit down. Do this right now for me, all right? Sit down, put your knee straight. Just do that real quick. Is your knee straight? Good. Yeah. Fire up your quad. Just squeeze the hell out of it. What does it do? Does it make your knee go straight or does it make your knee bend?

SPEAKER_02 8:27

Go straight.

SPEAKER_01 8:28

Makes your knee go straight. So if your knee doesn't go straight, can you fully utilize your quad? The answer is no. So what we see medically is people that come in, they lack full knee extension. We'll talk about how we test and train that first, but the mechanics matter more importantly. They lack full knee extension. Um, so their quad's inhibited. So when they walk, they're the ones that feel like their quad's going to give out. Literally, your quad delays in firing. So normal gait cycle is that this is my heel, this is my toe, this is the ground. We go through a heel strike, right? When you go through a heel strike, again, even sitting there right now, put your heel on the ground and lock your knee out. That's the initial phase of gait. That's your initial contact, right? So as soon as my heel hits the ground, my knee kind of locks, and that locking mechanism facilitates my quad to start turning on. So when I go to what we call mid stance, where my foot goes flat, my knee starts to bend, the quad slows my knee down. Because imagine if your quad did slow your knee down, what's gonna happen to your knee as it goes forward? It's gonna collapse. Those are people that come in and they don't feel like their quad like does the job. So they shift off, they limp, or they walk around with a peg leg, right? And they don't even let their quad work, right? So that's and then now imagine doing that every step you take. You know, now the average American doesn't walk enough, let's just be real. But let's pretend you're walking five, six, seven thousand steps a day, half of those on one side, half of those on the other. So you've got 3,000, 4,000, 5,000 hits a day of your quad just not doing its job. Now compound that on a week, a month, six months, a year. And what ends up happening to the joint? Well, the quad is there to offload your joint. So when you hit the ground, it helps provide support to the knee joint, right? That's why quad weakness is one of the biggest predictors of knee pain. But more so than that, lacking knee extension is the biggest predictor of needing a knee replacement. It's the biggest predictor of patient satisfaction after any knee surgery, the biggest predictor of knee function, because if you don't have extension, you're not gonna have a quad. So mechanically, that's like step one.

Quick Screen For Terminal Knee Extension

SPEAKER_00 10:28

Obviously, there's a ton of people that are out there that have knee pain and discomfort. We can expect if your clients coming in that's you know, and they have knee discomfort and we screen them, we're gonna get a good amount that don't have that optimal knee extension. What's like the easiest screens for us to do in which to be able to kind of see what the knee extension's currently at? And then what are ways in which we could start improving it? Because I know you're big on hey, we don't want to be fearful around like movement, we want to promote movement. And so then it's okay, like so how can we start working on optimizing the full knee extension and getting clients to a point where they can then get the quad stronger to then eventually get them out of that knee pain and discomfort.

SPEAKER_01 11:08

Yep, step two is how like how do we do it, right? The easiest, easiest metric to determine if someone has knee extension. All right, everyone ready for this. This is gonna be mind-blowing. You sit them down, okay? So they're in so if you've got a massage table or a floor, just sit, okay? Have their legs straight, grab a foam roll, right? Put knee, hip, both feet on the foam roll, and just let it hang. So imagine, right, if I have my heels on a foam roll, now my knee has a gap of room, it can move down because the floor is not in the way, right? Now, for most people, normal knee extension sits between like negative one to negative three, which means the knee, this is the knee, and this is the foot. The knee should go below the foot by about negative one to negative three degrees. What you're gonna see with a stiff knee, so you're gonna see one leg locked, other leg kind of stuck. Okay, so and it's obvious. You don't need to pull out the goniometer, the protractor, the tape measure. When someone's stiffened a knee extension, like you'll just see it. So that's step one, identify yes or no. So again, when I've coached and teach, I'm like, look, just remember, I'm not gonna diagnose your knee problem unless I got a clinical license. But if you work with people with knee pain, which is everybody, right? At 25 to 30 percent of the population is gonna have knee pain at some point. If you're over the age of 60, you probably have an x-ray that says you've got regenerative joint disease, right? Those are the normal age-related changes. But the first step is identifying knee extension. Um, so that's step one, just like do that, just literally sit there. And then here's the beautiful thing the test is the intervention, and the intervention is the test. So it's like, well, how do I fix it? Sit there. So think about what gravity does, right? So if I got a stiff knee, pomeral, foot, elbow, boom, right? And I'm like this, and my heels propped. What is gravity eventually gonna do?

SPEAKER_00 12:58

It's gonna drop down.

SPEAKER_01 12:59

I'm just gonna do that. So we have a name for this because we're in medicine, we have to call stuff things to make myself sound smart because I have a doctoral degree. That's how it works, right? This is called a low load, long duration stretch. So when we say low load, right, it's the weight of gravity, it's not that much, right? Long duration, what does that mean? That means somewhere between probably five to ten minutes of time and just stretch, it's it's mobility. Now, clinically, and I'll I'll I'll give I teach coaches this because I'm gonna ask you a question. I know what the answer is, it's rhetorical, but do you do assisted stretching?

SPEAKER_00 13:35

Me personally, no.

SPEAKER_01 13:36

Can you as a coach do assisted stretching?

SPEAKER_00 13:39

Not supposed to.

SPEAKER_01 13:40

But can you? Can you help a client? Yeah, I mean, you guys teach like a little soft tissue work, like a sort of thing. Yeah, we do that.

SPEAKER_00 13:47

Yeah, so it's like, yeah, so we'll do the soft tissue and everything.

SPEAKER_01 13:49

So I want to be clear, we're not gonna mobilize the joint. I'm not gonna crack your neck, right? I think the words matter. Um, you can take their own hands if they want, and you can put one below the knee, one above the knee, and you can just gently either you push them or they push themselves. So don't push the kneecap, push above, push below. Um, we'll do that clinically because when you see a stiff knee, a lot of times stiff knees aren't going to get there by the weight of gravity. Of course, it's just not enough loading. So the other option, the third option is the ankle weight option. So I've had people that come in and they have like a pretty, pretty gunky tight knee, and it just is like this. And the first option is I could push on it, which is a little bit aggressive when the knee doesn't feel good. The other option is take it in ankle weight, put it below the knee, ankle weight above the knee. So kneecap here, below, above, and just maybe five pounds, five pounds. And then what is gravity gonna do? It's the not as low load, longer duration stretch. It's the same idea. Um, those three things, depending on people's comfort level, all work pretty darn well. But here's the inherent problem if you're a coach, how much time? How long is a trading session for most coaches?

SPEAKER_00 15:07

Yeah, an hour, you know, 15-minute range.

SPEAKER_01 15:10

Yeah, probably two times a week. I mean, the industry average is 2.2. So, like people don't even meet the minimum physical activity requirement seeing a coach, barely, right? It's not even 150 minutes a week. So, what can't I do? Well, I can't spend 10 freaking minutes stretching out a knee. I don't have that time. So I have a preference of allowing the like self-mo, teach the person to do it themselves, or a little ankle weight that goes on there because I I want to get it done in one to two minutes. But it if you don't have a knee that goes straight, there's nothing to do. Every post-op knee I've ever worked with, that's the first metric. We're not we're literally not doing any exercise until your knee's straight. Because if your knee's not straight, your quad's not gonna fire. And then you're just living in the same cycle of knee not straight, quad doesn't fire, knee hurts, knee doesn't go straight, so the quad doesn't fire, so the knee hurts, right? It it lives like that. So step one is get it back. Um, ASAP. So we can sit down, we can foam roll it, um, problem to foam roll, put a little ankle weight on, have them push it down themselves, and then remind them every time they go home and watch TV, because the average American does that at three and a half to four hours per day and um spends 0.31 hours exercising, and that's another problem. Um, prop the heel on the coffee table. So, like if you're gonna sit and watch TV, I need time of your heel just propped up so that we have this long duration thing. Because for the whole goal of me getting your knees straight is to never have to get your knee straight. If you're coming in every single freaking time and we have to mob it and we have to push it and we have to stretch it, we're just chasing our tails, right? So the idea would be we can get this done on a daily basis pretty easy.

SPEAKER_00 16:41

Okay. All right, yeah, and this is where um, and I like how you kind of frame that where, you know, we're asking about the you know, like kind of what's appropriate and stuff to do, and that's where you know, for me, I kind of like I mean kind of misunderstood you at first about like, yeah, we don't want to like you know manipulate joints and other stuff as as trainers, but this is where, and we talk about all this with our trainers, is that hands-on engagement is really beneficial because one, as you said, we don't have the time, like you know, like we don't want to spend 15-20 minutes just trying to straighten out a knee when we're there for a plethora of reasons um and want to get into that that training uh session, but there are times when they can you know venture outside the scope of practice for a personal trainer, and that's where so you know, doing the soft tissue is great, doing some of that um you know, that hands-on stretching, where can involve the client. But at what point would a trainer, would you say, like with is there any point where you see like a severity of knee extension where it's like they need to be referred out to? Is there like kind of a specific point, or is it more of just like pain tolerance or when there's a traumatic injury?

SPEAKER_01 17:48

I mean, yeah, so if someone walks in with their foot on backwards, probably send them to the doctor. Like, I mean, common sense is a superpower. If they fell outside of your gym and shattered their kneecap and it's out sideways, well, past that, like, no, not in terms of knee extension, maybe in terms of like a knee diagnosis, and it's the simple stuff. Like, and it's uh it's also kind of comical because a lot of the time with the knee, like if they come see me in rehab, I'm just gonna make them exercise. Like, yeah, we're gonna and we're gonna scale it a certain way and we're gonna diagnose it, and maybe their knee's swollen and they can barely walk. Like, yeah, go go see a rehab professional, but there's nothing in terms of knee extension loss that dictates they need to go see a doctor today, unless it's a sudden onset, their knee is stuck because you'll have meniscal tears where the the meniscus will get a bucket to handle tear where it rotates and then it flips into the joint, and then literally it's it's in the way, and your knee will not move. Yeah, that needs to go get taken care of. But the the people I'm talking about are usually gonna be your post-op knees, so your knee replacements especially come out of PT underrehapt. Um, a lot of your knee surgeries might have had it, but then they lose it because they don't keep checking to maintain it. I do this every time I teach at um a course we just did in Tucson, Arizona, and there was an attendee there who had an ACL reconstruction that failed, so she's gonna go get another one, and her knee didn't extend at all. And it's like, why don't you have this? You should have this. She's like, I guess I just stopped doing it. Like, that's another thing that happens, and like PTs don't see people for two years. We get them for six weeks, maybe ten, if I'm really lucky, like 12, maybe 15 visits. So relative to knee extension, no. Um, but always use common sense.

SPEAKER_00 19:31

Yeah, and I I love that you said that uh common sense is a superpower because I mean I firmly believe that too, but it's you don't always see that in our industry. And we're talking about, you know, like you said, like we need to get comfortable with uh working with people like this that are in pain and discomfort, because uh, you you just alluded to it right there, is that for most people going through physical therapy, right? They're only seeing them for you know, they're seeing you guys for a few weeks, maybe a few months, depending on the severity of something. But then it's people stop doing the their PT and then they just go back to their, you know, their four hours a day of watching TV, maybe going for a couple of walks here and there, but they don't continue to strength train. And that's where you know, we're passionate about working with trainers, and like, hey, we need to be that next step. That's why we say, you know, as trainers, we want to network with people like you and physical therapists that are in local areas because knowing that people are not going to continue doing their rehab and the stuff on their own, like we want to be that next point of continuing their strength training and their health journey. But that starts with us being, like you said, comfortable with working with people that are that are in pain. And if we're coming from a place of fear of movement, that's going to just lead to more fear for clients that have already been experiencing that.

SPEAKER_01 20:51

Um don't be fearful, but also don't like don't overstep it, go, nothing matters. That's that's the hard part about the industry, right? Where it's like, I want to empower coaches, but also like use common sense.

SPEAKER_00 21:04

Yep. Yep. Uh my wife always gets uh mad at me because whenever she shows me a video or exercise or asks me something, she's she's like, you always just respond with it depends or yes or no. And I'm like, well, because it requires nuance, it kind of depends on the the situation, and that's where you know we want to have that knowledge base, have people we can refer out to, network with, and yeah, like have common sense about stuff.

SPEAKER_01 21:25

Um Instagram won't give you that. That's the other that's the other reality. You can't you can't learn the stuff on Instagram. Instagram's about views, likes, and attention. It's not about like the nuance of what we're gonna have on a 30 to 45 minute conversation on one topic.

What Anterior Knee Pain Really Means

SPEAKER_00 21:39

Yeah. And this is where like I would encourage everyone, you know, go follow Dr. uh Farnsworth on Instagram and social media because like you put out really good information, but at the same time, that's that's a really just small picture of what it looks like to work with these clients, and this is where the value of doing those in person seminars you know comes into play because now you Get the hands-on practicality of learning this stuff and then being able to uh implement it. And that's why I think I love that you're doing those seminars. That's why, you know, again, as we said, why we do them. And we're excited to do that one in October. Before we kind of like wrap up with talking about that, you had an interesting post that Chris actually sent me. And when you're talking more about anterior knee pain and just and then kind of going back to social media stuff, you see all these kind of like, you know, gadgets and different like you know techniques and stuff on how to like work with pain when it comes to maybe like, you know, floss, massage guns, you know, these different gadgets. And you at this post is saying, hey, what you really need is when you're rehabbing going through this stuff, is you need isometrics. And that can be like probably the least sexy thing out there. And it's not gonna gather attention by doing a 45-second reel of someone just doing an isometric exercise. But those are the things that really help. Um, and so what are some of your favorite isometric exercises that you uh do or would recommend for uh people that are that have that anterior knee pain?

Spanish Squat Isometrics For Relief

SPEAKER_01 23:02

Yeah, I love that great question. So I think I just a few a few nuances, if I may. All anterior knee, just because you have anterior knee pain doesn't mean you just do one thing. Like anterior knee pain, we we have a word for it patella formal pain syndrome. Like knee pain is really two things. It's either the front on the outside or it's intra-articular, meniscus, cartilage, and we have tests to you know figure out which one is which. In fact, one of the most sensitive tests for a meniscal tear is if you have joint line tenderness or not. Like, believe it or not, if I poke your joint line and you don't have pain, I can pretty confidently rule out a meniscal tear. It's pretty cool. Like it's actually pretty simple. It's one of the few places we have that if you poke the thing and it doesn't hurt. Now, if I poke the thing and it hurts, it doesn't rule it in. It just tells me I can't rule it out. That's how medical testing works, all right? The other thing you have in the front of the knee is this patellopheral pain syndrome. So let's talk about the knee for a second, right? So if I have a kneecap, the thing in the middle of your knee, poke on it right now, right? In fact, do me a favor, just poke it. People listening, find your kneecap, just poke it, okay? If you take your finger and you go right underneath your kneecap, so go down until it feels fleshy and you touch that thing, that's your patellar tendon. That can get irritated. Take that hand, go above the kneecap, right? Right above the kneecap, poke in a little bit, so probably be tender. There's your quad tendon. Now take your hand and just trace your kneecap around. So go to the outside first, go below, go to the inside, right? Um inside and outside, you have this thing called retinaculum, which are just kind of soft tissue structures that hold the kneecap in place. Imagine if you didn't have anything holding your knee your kneecap in place when your knee was straight, it would just dislocate all over the place. Um, also on the inside, you have your medial patellofemoral ligament, another thing that connects your kneecap down that tears when you dislocate a kneecap. Every kneecap dislocates laterally. They don't dislocate medially, it goes to the outside. So when that happens, sorry, you tear those. Then you also have the connection. The kneecap sits on your femur inside what we call the trochlea, and it's like a key in a keyhole. So you don't have a different key that fits in the keyhole. Um, you have little bony, if you look at the kneecap, it's not flat on the back side, it's got little ridges in it, and those articulate, they connect with the femur behind it, and they kind of provide congruency and it helps it slide. The reason I say all this is everything I just talked about can hurt. All of those can have relative pain signals to them. So when we talk about patellofemoral pain, it's really the black hole of the knee. It doesn't tell you exactly what hurts, it's really just a conglomerate umbrella that talks about anterior knee pain. That's it, right? In the absence of joint line tenderness. Now, when you look at the research, okay, what helps with people that have pain? Well, let's be real, foam rolling a quad and getting a massage, it always feels good. Like in fact, it's not a waste of time. So if you look at the rehab research, physical therapists that use manual therapy and exercise, they always have superior outcomes to those that only use manual therapy and those that only use exercise. So I am extremely exercise-based, but we just have to appreciate a little bit of TLC to the local soft tissue feels good, right? So, what does it do? If I take a foam roll or a massage gun and I bash the heck out of your quad, what is that actually doing? Am I deforming tissue? Am I elongating tissue? Am I breaking up scar tissue? No, I'm just doing a quick control alt-delete, the same thing you do when you rub your elbow after you bump it on the wall. You you give it some input, and what does it do? Well, it's a very complex path that honestly 13 years ago I had memorized for a test at some point in grad school. But you touch this, and there are neural connections that'll go here, cross over, come back down the spinal cord, and it does it like this, and it just says I feel better. So I truly do think for some people, 45 to 60 seconds of like whatever massage gun, lacrosse ball, voodoo, I don't care if it's all the same thing. Okay, dry needling, it literally is all the same thing. Control, alt, delete. There's a time on investment, 60 to 90 seconds. In fact, we know foam rolling. Foam rolling, maximal return on investment is about 90 seconds. There's an article, International Journal of Sports Physical Therapy. I think it was Hughes et al. in 2019. It's free. Go look it up. They basically looked at like what's the cap on foam rolling for pain relief and for a function? It's like 90 seconds. So it's quick. After that, though, right? What do we have to do? So the volume of pain is turned down and the pain's, and now I need to load your tissues. I need to make your cup, your theoretical cup of your knee needs to not be a shot glass. It needs to be like the 40-liter Yeti. Because the bigger my cup is, the more shit I can handle. I can step down the stairs wrong and not have my knee hurt. I can go for a jog, play with my kids, get off the ground, and now my knee doesn't hurt. It's the people that have a small shot glass of their knee that like, I see the wind blowing right now here. It's like the wind blows the wrong way, and now they have chronic knee pain, right? Yeah. So what we know for pain reduction, isometrics. So my favorite time, and we've studied this. Um, and this is specific to patellar tendinopathy, but I think we can be pretty confident that if you've got anterior knee pain, doing IS is not a waste of your time. Um, isometrics done on a five by 45. So five sets of 45 seconds with 60 seconds of rest. That is specifically the Spanish squat isometric. So that's the one where you have the band attached to a rack in front of you. You have the band behind the fleshy part of your knee on both sides, and you sit down somewhere between 65 to 75 degrees. So, again, not to get too like nerdy and nuanced, but this stuff matters. This is what makes a coach and a clinician a specialist and really good versus just like an average coach. When you've got really sensitive knee structures, right, the more you bend your knee, the more when structures are sensitive, they will hurt. So people that have very sensitive knees, we don't have to squat that deep to start off, right? The deeper you squat, the more stress relative you're going to have on the front part of the knee. That doesn't make it bad, it's just naming what it is. So when you look at EMG studies around the quad, the quad is most on between 20, uh, 35 to 65-ish degrees inside of a squat. Meaning when I did the Spanish squat ISO, I don't have to go that deep. Because the whole idea is to break up the arthrogenic muscle inhibition that occurs. The joint hurts and the quad shuts off. And if the quad shuts off, you go to squat, the joint hurts, and then you live in that cycle. So when we Spanish squat ISO, band behind the fleshy part of your knees, chest up, knees forward if able. If not, we can make the shin more vertical to offload the front of the knee and find the range of motion you can sit into and just generate some tension. Now we don't need all out, right? The idea of this isometric is a yielding isometric. So when we talk about isos, you got overcoming, you have yielding. Yielding means I hold it for about 30 to 45 seconds, and I feel like my legs are shaking and I feel like I'm gonna fall over, like I'm gonna lose my position, right? We know MVC, maximal voluntary contraction for pain relief. I believe it's around 40 to 60 percent. If I remember, someone can fact check me on that. I can go relook that up, but it's not an all-out effort, right? That's a different mechanism for pain relief. So you sit there, chest up, and you just look at the clock for 45 seconds. Um, and then you wait 60 seconds, you do it again, right? Again, here's the problem. We have an hour to train. That's 10 minutes of time. It's like, how do I do this, Just? Like, how does this even fit into my session? Well, this is easy. ISOs, you don't need to warm up to do ISOs. ISO can be the one. Like, yeah, I don't have to foam roll and stretch and do a corrective exercise and activate my glutes to do an isometric. I do this in a course all the time. We go from sitting to standing doing ISOs, and no one gets hurt. You just do the ISO, it's the first thing you do. And then when you're done with the ISO, maybe we do a little stretch to like the ankle or the quad. And then I come back to my second ISO. So we actually have a prep sequence that could still last eight minutes, but we're just doing things inside of it.

Progressions Back To Squats

SPEAKER_00 30:53

Yeah, that makes a lot of sense. That's what we try to instruct our trainers on when you know we're going through like the courses and everything, is is just like the way in which you structure stuff is again having that kind of common sense of like you don't like you could pair stuff up. And so that idea of doing your isometric within like that warm up, that prep period, and it's like when you have that 60 second rest, and then you know, if you're gonna do like a total body, you know, day, then it's like okay, warm up the you know, shoulder to your band pole parts, and you know do some thoracic or something like that, you know, in between, and then you can jump right back into it that way, you're not wasting a bunch of time. So I think that's a really good recommendation um for for our coaches um to be able to implement that. And then once you're done with those isometrics in the beginning, are then are you jumping right into doing uh your full range of motion exercises? Are you kind of keeping it just to that um working on those isometrics for the for the knee and then or are you looking to do more full range of motion training throughout the workout?

SPEAKER_01 31:53

Yeah, I love that. And I'm gonna answer you the same way you answer your wife. It depends. Like it depends. So here's the thought like if I have a full body day and we're gonna squat, I'm gonna do those ISOs. If I've got a full body day and I'm gonna do like a hip hinge, I'm not really gonna worry about those ISOs because the knee's not gonna be the weak length that's gonna be an issue, right? So the idea would be is we would do our Spanish squat ISO, that's the first option. Another option is a split squat ISO, half 90-90, half kneel, take the back knee off the floor. It's another good option. You can even load those, get stronger. Isometrics, when you're stronger in ISOs, dynamic stuff gets easier. We have evidence for this, it doesn't work the other way. Stronger dynamically is not stronger isometrically, stronger isometrically is stronger dynamically. We would want to try to get in as full of a range of motion squat as we could. And again, just think about even like the pattern, like a squat. A lot of people commonly have knee pain on a squat. So then it's like we got to play with the squat. Um, one of the easiest ways to have someone not hurt on a squat is to go to a box and keep the shins vertical when they have knee pain, right? Because the knee's not going forward, the quad's not taking much demand, and it's a safe place. It's like if you've got kids, they don't play in the front yard first. I'm looking at my front yard with the road. My daughter plays in the backyard. We do that first, and then eventually I get her to the front yard. Exposing tissues is kind of the same idea where it's like, think about the knee. What can we do to offload the knee first? We can sit back, we can sit to a box, we could actually put the weight behind you. So, not that I'm a huge fan of like the barbell back squat when someone has knee pain, but as a concept, when the weight's behind me, it's going to be more hip dominant. Versus think like a front squat. What does a front squat do? Front squat, knees forward, more full range of motion, goblet squat, knees, heels elevated, so it's like you have to kind of play with the entry point to what a squat is. Um, I've had people that are very, very high level who will Spanish squat ISO and then will hit a five by three front squat with like 250, 275 pounds on the bar. And that's like their mat that they can manage that fine because now they can feel their quad when they squat. I've had people clinically where the Spanish squat ISO was their squat pattern for the day. Like that was their their cup is so small that like that gave them quad soreness for two days, and then we progressed to what we all do, which is like a goblet box squat, and then a goblet squat, and then a step up, then a step down, a split squat, and like that's how I would typically grade it. So I wish I had a perfect algorithm answer of always do it this way, but it it does kind of depend. But the idea would be we would like to get some sort of knee dominant pattern, whether that's a single leg pattern, like a split squat, or whether that's a bilateral pattern, something like an actual squat itself under load.

SPEAKER_00 34:37

Yeah. So no, I but I mean, personally, I love that answer, not just because it validates what I always say to my wife about like it does depend, but it's something that I'm always reiterating to our students, you know, where it's um, because my main focus is doing the seminars, but then also teaching programming. I always say when we're going through our different client avatars and we're working with that we need to meet our clients where they're at. Um, and so that means sometimes we have to regress movement, you know, as maybe it's you know, the Spanish squad um isometric, and like you said, maybe it's a heavy loaded front squat. But the idea is meet the client with where they're at, get them to, you know, not be fearful of the movement, not be in pain, you know, pain during the movement, and then progress them. And that's where you know we we wanna be able to properly load them up and just help them with that, you know, that movement. But I think it really comes down to, you know, I preach it all the time, and if you kind of feel like you're saying the same thing with be them where they're at. And it's gonna depend on you know the demographic, what if they're returning to everyday you know life stuff, if it's sport, if it's you know, if there's been uh trauma in the past with the you know their post-ops, you know, surgery. So um I think that's really good advice for our trainers and coaches out there to hear. I also say it's one of those words, like it's very obvious that we've only really just hit the tip of the iceberg with this stuff. Um, and so that's where if you guys have not been to one of our seminars, please please go to it. But please go check out Dr. Farnsworth with the Pro App Um seminars. We're gonna do that accommodation one um in Santa Monica, October 23rd. Um, you got a bunch of other seminars from now until then, right? So uh where can people find the seminars at and sign up for those?

How To Keep Extension Long Term

SPEAKER_01 36:24

So um there are two options. Uh, we actually just launched, like yesterday, my website. Finally, six months later, it is done. It is www.j uh drjustinfarnsworth.com. Boom, it's my name. Um, everything's on there. The other option is just through you'll if you go through Instagram, there'll be a link to the website. Under the website, you click education tab, everything's gonna be listed right there. Um, I do have a question for you though. Yeah, because I'd be I'd be remiss because we did our first two steps of extension, but can I finish the third step? Because the third step is.

SPEAKER_00 36:59

I just want to be respectful of your time. If you have time to go through that third step, let's do it.

SPEAKER_01 37:03

I have time because we need to. So it's it's incomplete. And the reason it's incomplete is because we talked about how to measure it, how to get it. We didn't talk about how to keep it because that's yeah, that's the most important part.

SPEAKER_00 37:13

That's the most yeah, that's what it's all about.

SPEAKER_01 37:16

Um, there is a four-step process that I go through to get someone's knee straight and to keep it straight. So I'm gonna give this to all you guys. So we measure their knee, their knee's not freaking straight. Great. What did we say we're gonna do? Noop, drop it and and make it go straight. But you need to now actively keep it straight. So, again, this is the most remedial rehab looking thing ever, but it works. And the whole goal of this is to do it and then just please like go train, go get stronger, go squat, go lunge, go leg press, whatever. But the knee's got to go straight first. So we got their knees straight, right? It's up on the thing. Maybe we push shot it, maybe we had an ankle weight, whatever. Now, in this elevated position, you need to do quad sets, you need to teach the knee to go straight with a deficit, which literally just means fire your quad and make your knee go straight as you pull your toes to your nose. So when you pull your toes to your nose, and in fact, you're humor me, do it right now. You're sitting there, right? Yeah, pull your toe to your nose, toes to nose, drive your knee straight. So toes to nose is gonna cause the calf to stretch, which helps make the knee lock backwards, right? It's like a nice jeep for that. So step one, okay, do like 10 of these. Okay. Step two, get rid of the foam roll, go flat. Do another 10 with a flat leg. So think about this. If I'm sitting straight and I pull toes to nose and I fire my quad, my heel should come off the ground if my knee actually has extension by like that much. Because you'll see people they do lazy quad stuff, they just sit there and they do this. When can I finally work out? It's like, no, you need to do this hard, and the heel's gonna come off the ground like one inch. Then everyone's favorite quad exercise is the straight leg raise. Now we need to use it, okay? So the straight leg raise is where you just fire the quad and then you lift the leg, but you lift the leg without the knee bending. That's called an extensor leg. We don't want lazy quads, we want active quads. Now, the best way to do this is instead of having someone's trunk upright, imagine if this is my legs and this is my trunk, and I did a straight ray leg raise with a trunk that's upright, my hip is going to get super pitchy. It's just repetitive hip flexion, it's annoying. But if I recline, or if I go all the way flat and then I lift my legs, it becomes a lot more kind of quad dominant without the front of knee pinch. So, what I've done forever, and it takes less than five minutes. Knee extension, push it, stretch it, get it. You can't do anything else, you get it. Leg up, boom, ten of these just go boom, but they aren't one, two, good, two, two, great. Get rid of that. Ten of these, heel off the ground. Good. Now, lift it, hold it, hold it, hold it, two, one, down, reset. Lock it, heel off the freaking table and floor, lift it, set it down three, go, go. Do that, do that for two to three weeks, and they'll probably not need to do it again. So that's just that that's the three-step process.

SPEAKER_00 40:16

Yeah, I love that. And it's it's simple, easy to follow. And um, and then is that something that you're saying for uh trainers to have the clients do when they come in with you, or is that something we're instructing, like, hey, every day do this for you know, we we know in this industry you tell a client to do something every day, odds on them doing it are pretty low, but uh ideally it would be hey, every day you're sitting watching Netflix or you know, Disney Plus or whatever that you're you know doing this at least once every day to work on that.

Confidence Value And Client Buy In

SPEAKER_01 40:45

Yeah. Ideally, it would be every day. Ideally, it would be every day with an app they check in with you to say they did it, because we know people are much more likely to follow through when there's some accountability. Because again, here and here's here's the value, right? If you're let's say you're coming to see me for knee pain, or you're coming to see me to train and your knee doesn't feel great, you don't have extension. I'm just like, yo, dude, the faster you get this, the faster we just don't have to do it. Like, I really don't want to do it. I would rather like do box trucks, and but this is like fundamental. If you don't have this, I can't do box trucks. So when we can pull back the value of what we do and connect it to what their goal is, then I think now it becomes valuable versus just like, hey, your knees go straight, we need to do this. And then lastly, when you're the coach that can identify that and you can do it, they will feel better. They will feel better now. I've had patients come in, doc said I needed knee surgery, it's bone on bone, and their knees stuck straight, sorry, stuck bent, and then we push it, it's not comfortable. Like you get it straight, and I literally had a lady come back in, like the next visit going, my knee pain is gone, I canceled my surgery. Like, you're amazing. I'm like, I'm not amazing, I just did what I like you needed, right? Um, and as a coach, by the way, showing your value over and over. Imagine having a new client coming in with knee pain, and you take five minutes to do this thing that no one else did, and they're like, This feels really good. And then by the way, hey, do you want to sign up for a package? Like, sales equals service. If I can sell you and help you and you show up, I can serve you, and now you cannot be the statistic of being overweight when you're 50, knocking off the ground when you're 40, falling or breaking a freaking hip when you're 60. Like, but being able to have that as a coach and be confident in how you can help someone and be able to say it in real time and explain it to them and show them the value is just something we don't have in this industry anymore. So it's like that that what that's what makes this a career for people just a hobby than just a hobby. Yeah, so many people, this is a hobby.

SPEAKER_00 42:40

Yeah, and I would yeah, I just I couldn't co-sign that like more strongly because I think like what we do with like the soft tissue stuff and and everything we're always talking about, like show your value. And I I've had, you know, probably not as extreme, but similar things where I have clients that have been post-op or like with um with like rotator cuff, shoulder issues, and I'll do some of the soft tissue and do some of the isometrics, and they're just like, oh my gosh, like you healed and fixed me. I'm like, no, like don't don't think I've got some you know like divine healing powers or something like that. But it's it's that idea of when you can get them feeling better and then they're you know can do their full range of motion training and can be consistent with you know that we're adding so much value to their life, and that's where you know sales always scare the crap out of coaches and trainers. And I get asked a lot, it's like, you know, how are you close, you know, you know, your sales, how are you so confident? Like, it's really just I believe in the value in what I give to my clients. I'm not looking for gimmicky stuff. It's um it's but it's like there is true value in what we're doing with this hands-on intentional approach and being able to work with clients that are in pain and just create like that that hope for them. So um, you know, I'm so glad we got a chance to sit down and you know, talk about this and share with uh you know the trainers uh about how they can start implementing this stuff. And you know, this is just what we we want to change this industry. We want to make it so that people are getting good information, helping more people, not getting all that pseudoscience. Stuff off of you know TikTok and Instagram, but learning from actual professionals like yourself. So um can I say one thing before you wrap up?

SPEAKER_01 44:07

Because I just I want to give people confidence because I I've worked with new grads in physical therapy, I've worked with new coaches, people that just feel like a fraud and you're not a fraud. But just here's the reality if your client doesn't come to see you and exercise and help their health, what the hell is the other alternative? Right? Like if they come and they have pain, and look at I've worked with enough people, I have flared up clients and patients before. That was my fault. And I used to be like, oh, like I'm a freaking loser. It's like, no, it just tells me we're on the exercise highway. I have to change lanes a little bit. So now when I hurt people, I don't actually say this, but it's like, well, good. Not good like you got hurt, but like I know what not to do. And I don't traumatically hurt people, but we'll flare things up every now and then. That's just living on the edge of trying to get people strong, healthy, and well. But ultimately, if they're not gonna work out and exercise and move their body, what the hell is the alternative?

SPEAKER_00 45:04

It's it's nothing or it's right, it's this. Let's get on the phone and they're gonna live on the couch.

SPEAKER_01 45:10

Yeah, they're gonna be the 50-year-old who can't get off the floor, they're gonna be the 60-year-old that's in the nursing home, they're gonna be that grandparent that sits in the chair, watches their grandchildren play, and goes, I wish I could be out there right now. Like that's the alternative. It's not like there's this middleman of like, I'm gonna kind of work out. It's like you either are or you don't do anything. And when you don't do anything, you can do less stuff, and then you do less stuff, which leaves you doing less stuff. Like that's the cycle. So when you as a coach are confident enough to tell people that, it frees you up to realize you don't have to know all the answers. Programming is so much more about not doing something stupid than doing everything perfectly. So if you just can be able to show up, have a good time, show how many them how you can help them and make them consistent and hold them accountable, you will change this industry and you will change their life, just period. So, like be confident in doing that because a lot of coaches just can't. A lot of healthcare providers can't.

Seminar Details And Final Takeaways

SPEAKER_00 46:05

Yeah, I love that. I think it's a great point to kind of wrap this up with. Um, and so doc, again, just thank you so much for uh for being here. Uh reminder for uh everyone and just getting just this uh incredible value we got with doing this podcast, but also like there's so much more to learn and to invest in for yourself to add that value and to be helping the industry. As Doc just kind of talked about the importance of helping our clients and getting to that in-person learning. So please show up to a seminar, whether it's with us, whether it's with Dr. Farnsworth, or come to that October 23rd one and Santa Monica, in which we're doing that combination uh one-day um seminar. And um, I think we can sign up for that one on your website. And we have a code which is just SUF, and that's for$100 off for that. For those of you that are listening, so get signed up for that. Show up, be there, keep leveling up. Um, Dr. Gens, thank you so much for being here. Um, any last thing before we hop off for today?

SPEAKER_01 47:02

No, man, I appreciate your time. Uh pump to see everyone. Yeah, it'll be one day. Um, it's gonna be awesome. We're gonna talk about four big things how to program, use exercise as medicine, how to program for people that have low back, hip, knee, and shoulder pain. It's the big four, and it's the big four that all of us see. So it's giving you the real tools in real time to help someone now, not theory that you can't apply. Uh, I'll tell people this the course I've built, it's 60 to 70% hands-on for a reason. I like talking. You don't want to hear me talk, you want to do stuff. So we're gonna give you stuff to do. You will go back, you will not only improve your clients, you will build your business because you'll be the person that can help people who have pain that no one else can figure out. So uh pumped to be there. I appreciate you guys hosting me, and it's gonna be it'll be a party. It's gonna be a ton of fun.

SPEAKER_00 47:47

Yeah, we're we're so looking forward to it. So um I appreciate your time, and we will see you next time. Thanks you all for tuning in today and for showing up. Have a great one.

SPEAKER_02 47:58

See ya.