Yin & Yang: A Way to Look at Cueing, Assessment, and Return to Play

I will preface this blog by setting some ground rules. I am not a doctor. I am not a physical therapist. I am not an athletic trainer. I have not produced research in this field. You very well could have been a coach for longer than I have been alive. This will have some absolute comments, some things that have derived from a super small group of athletes, and even some cases that are on the basis of N = 1. 

This is something to challenge a thought process and give insight into how mine has come to be. I remember graduating college, getting my CSCS, and feeling like I was on top of the world and knew it all. I went to my first conference, turned my nose up at the first few presentations for not fulfilling me by challenging thought. 

We took a lunch break, and I sat hoping I would be able to learn more later in the day. And that I did. 

Dan Fichter took the front of the room and I have no clue what the title even was. He started talking about subjects and things that were never talked about in school and I had never found in a textbook. Reflexive Performance Reset was the basis of it all, where he brought out laser pointers, got people on the table and found a pinpoint in their back that then released their calf tightness, taught them how breathing and eye movement has an instant impact on performance outputs in closed and open settings. It was the first time I had heard of an OODA loop. In capital letters, my notebook page still reads SHERRINGTON’S LAW OF INNERVATION. Yes, it’s also circled, starred, and underlined. (More about that later)

The Dunning-Kruger Effect was all of a sudden very real. The more I read, the more I saw, watched, assessed, the more places I coached at and visited, the less I felt like I really knew. It challenged me over and over and I questioned why I even went to school–I learned plenty there, but still. 

Now, here we are in 2024, where fascia and force are some of the common words being thrown around the performance as we move into a “new age” for some people, including myself. I sat at a conference and talked for an hour or so with a colleague and he asked where my passions really lie in the human performance field. Throughout my career, both as an athlete and as a coach, I spent a lot of time around injury, so I find myself continually coming back towards that and finding extreme levels of enjoyment and challenge with athletes that we can put in the box of ‘return to play.’ 

Part of this article is to make a case that a performance coach belongs at the table with these rehab conversations right next to physicians, physical therapists, sport coaches, and athletic trainers. The lines need to start to blur between these if we want to move the needle forward for the newer populations that are now injured and compensating more than ever. There are less healthcare professionals (yes, a lot of performance coaches are those, too) that are looking at the body as a global unit, rather looking at an injury or compensation pattern locally. The understanding of the kinetic chain, the impact of the nervous system, connection of reflexes, how tendon and ligaments create and dissipate force, a skeletal system dictating movement qualities and leverage, are all some of the things that should impact our thought processes a lot more than they currently are.

We are too obsessed with muscle and not obsessed with the intricate workings of the human body. If you have been lucky enough to spend some time with real human cadavers, or better yet seen complex orthopedic surgeries live from a few feet away, I hope you have a greater appreciation that we can consider this as the most beautiful, unique machine that we could ever create. But yet, we continue to put specific people in boxes and think that their processing of movement and return from injury is exactly like the person that came before them? That’s too complacent to me. 

Yin & Yang, Isaac Newton and Sherrington

Whenever we begin an assessment, it is easy to immediately start putting the athlete in a box. Tight ankles. Grinding shoulders. Tight hips. Lack of core stability. But then what? Most practitioners just immediately assign basic rehab or ‘prehab’ exercises to try to balance their body back. We then enter this wheel spinning circle that does not provide the body of the person we are trying to help any progression of benefit that is going to stick. 

If you throw a big rock into a pond, it makes a splash right? But after that splash, we see ripples venture themselves outward to bring the surface back to near normal. So if direct sight of the injury or the muscle we are trying to engage in a specific movement is the splash, then what are you doing for the ripples? That is where the thought of Yin & Yang comes into play. 

Classical Chinese philosophy defines yin and yang as an opposite but interconnected cycle. There is no force that is stronger than the other. These forces compliment each other to create a balanced and dynamic system that is stronger as one than it ever will be as separate parts. These notions created reasoning for diagnosis of illness and disease in early medicine. 

When we look at the symbol, we see a piece of each color still left between the other. The pieces are not whole without the other. 

To put it into the more common language of our educational system, think of Isaac Newton’s Laws of Motion. #3 is listed as: “For every action, there is an equal and opposite reaction.” If we put in an input, then we should get an output–but does it end there? Input is the rock being thrown, output is it hitting the water, so what are the ripples? An opposite reaction. 

If we were to place the actual symbol of yin and yang onto the body, we may just find deeper meaning to movement, contraction, production and dissipation, and so on. Because of slings and lines, your right hand is connected to your left foot. The left side of your brain dictates the movement on the right side of your body. Low back pain is rarely ever rooted directly in the back, rather from hip flexors, adductors, and deep core muscles. 

The foot impacts the kinetic chain and up, so if there is a dysfunction there then there is dysfunction everywhere else because every step you take can possibly be taking you deeper into movement patterns that your body is not going to like. Our brain is completely hard wired through our feet through our reflex system but yet we continue to overlook the feet on assessments of lower body injuries or pain.

Charles Sherrington studied these exact balances in the body through the nervous system affecting the muscular system and therefore movement. He found that whenever an agonist muscle receives an impulse to contract, there is an equal inhibitory impulse that tells the antagonist muscle to relax, actually lengthening that muscle. This is what he called reciprocal innervation/inhibition. This concept showed that specific reflexes are part of an interplay between the nervous system and its impulses with the muscular system and organs and the impulses directing those. Complementary forces creating a balanced system…interesting. 

Finally, I heard Fichter recently drop a line that hit the nail right on the head: “Spend more time connecting dots than collecting dots.” Collecting dots is an easy part of the job. Connecting dots is hard. The toughest question in this field is to answer why. The more you chase that answer, the more challenged you will ever be. 

Cueing: N = 1 #1

I recently started working with a volleyball athlete who suffers from the ‘common’ pain and injury that we see these athletes endure: low back pain, patella tendinitis, tight ankles. She finally got to a point where intervention was the only way she was going to be able to sustain herself on the court and in life. The surface wasn’t playing nice to someone 6’3” at 16 years old and it showed in a lot of movement patterns. 

We have had and still have to spend a lot of time teaching her body to act like a machine again.

There was one day that we were performing a RDL and she felt it nowhere but her back. We created an environment where her biomechanic position was deemed proper and there were not any foreseen pressures coming that told me “that’s where that pain is coming from.” Then that ying & yang picture popped into my head. 

We had to create an environment that would bring an impulse through the hamstring better than what was currently happening. It was a biomechanical issue, it was a brain issue. This was a great opportunity to apply what Sherrington was searching for in his research. With her shoes off, we flexed her toes to the sky on the eccentric portion of the movement and you could see instantly that she felt her hamstrings for the first time in a long time. 

To create that dorsiflexion movement, the tibialis anterior has to contract. If the tibialis muscle is contracted, it inhibits the posterior lower limb muscles from contracting. Because of cocontraction, partly applying Newton’s third law, the hamstring engages as the quadricep is inhibited. If we were to draw lines on the body, it could create an X, or better yet a yin & yang symbol. 

The brain created the contraction in the tibialis and then immediately signaled back that the hamstrings were working. We read a lot about muscles in our education. Maybe we should spend more time understanding the neurology of movement and how that interplays how all of our systems work together to actually create it. 

Assessment: N = 1 #2

There will be times as professionals that may leave you scratching your head, and recently there was one no different. I had a collegiate student-athlete come to me with a grade two strain in her right biceps femoris that she continually reaggravated during soccer. 

Time is of the essence with her season looming. She bounced around from doctor to doctor, AT to AT, physical therapist to physical therapist. Nothing seemed to work, and no one had the answers, or at least would push enough to find it. 

Going through our assessment, there was no tell all sign that said ‘this is why this injury occured’ or even ‘she can’t do this because of the injury.’ They talk about writer’s block, I had an assessment block. Then, after some basic heel to toe walking, lightning struck.

Her right heel physically would not lift up nearly as high compared to her left. Her right glute would not extend enough to allow her ankle to access full plantarflexion. Now, if you know reflexive performance reset (RPR), you may recall that one of your primitive reflexes is found at the base of the skull and impacts and engages the glutes. When I checked that region for any tightness or pain, we then discussed that she had broken a bone in her neck in the fall and the amount of tension found was very high.

Connecting dots, not just collecting dots.

One of the more overlooked pieces of injury is the psychological toll it takes on an athlete. Then if you couple that with anxiety in fear, it is creating an environment that is tough to maneuver within. Fichter helped me with the notion that the nervous system grants you the access to strength and speed-based off the brain’s perceived threat. If you fear less, you can act more. 

So, we started our rehab fearlessly. Day 1 we started running again with constraints, like below:

This allowed her to run without letting her get to higher speeds where most hamstring injuries occur. Low and behold, she returned to the field in limited capacity weeks before other practitioners were willing to work for. 

In the weight room, we started with some specific isometric exercises to start to find the capacities that our brain was going to let us get to, like a pendulum hold below: 

Physics (yeah, that) comes into play as soon as the weight shifts outside the leg. Although there is no direct contraction through knee flexion range, the biceps femoris in this movement has to act as a stabilizer. Rehabbing it with more than just running. And better yet, isometrics need to be in every rehab/return to play program. To perform an isometric, the body needs to constantly fire inhibition and innervation against itself to hold the motion still. This constantly starts and finishes a brain loop, reducing perceived threat. A balanced system. Yin and yang. A win win for all. 

Return to Play: N = 1 #3

The final case that we have been playing with as of late is a total return to play. The text that was received had a ‘please fix me’ dynamic to it. After two seasons lost at the hand of injury, it was time for something different. The most recent was a slipped disc in her back that debilitated her ability to be the high level softball player she is.

Her performance career was extremely barbell strength driven. The constant pounding of loaded weight with limited direction took its toll on the body over time. It was a lot of two footed, square peg round hole kind of programming that seemed to not be paying dividends at this point in the career. So, at this point she needed something different. 

Deriving from reflexes and neurology, the system in which we apply for return to play is Triphasic in nature, stealing everything from Cal Dietz himself, and turning it into an immediately applicable plan for us bringing her all the way back to performing at a high level. 

Eccentric based movements allow us to reinstall range of motion, reteaches the body’s ability to hold tension, reinstall hypertrophy into specific muscle groups, and reinstall movement quality. We work in the notion that we cannot move bad slow. By slowing the movement down, we are allowing the brain to self correct itself in comfortability and may eventually opening itself up to different movements, as it begins to feel safe and calm with the slowness. 

The isometric portion, like we talked about above, teaches the body to own the specific position. This can establish a range of motion gains much stronger than just classic and simple mobility training. This allows the body to be reintroduced to torque earlier than the classic ‘yeah, you are cleared to play.’ This also provides some level of analgesic effect which provides the athlete a feeling of accomplishment and a taste for actually returning to between the lines. 

That final phase, or what we can call ‘late stage’ return to play, is exposing the athlete to total body force. Coupling movements, like the one below, gives the athlete the wherewithal to actually be one again. 

The body does not understand the difference between one movement to another, but it does understand stimulus. Give it the stimulus it seeks, it will go to great lengths for you. Give the athlete you’re working with the stimulus it needs, and just imagine what you all can accomplish together.