Third Time’s a Charm
Impingement and Instability is one of those courses that I could take yearly and still get so many gems. In fact, I probably will end up taking it yearly—it’s that good.
Cantrell provided the most PRI clinical applications I have seen at any course, which is why he continues to be one of my favorite people to learn from.
Basically, if you haven’t learned from Mike yet, I pity you. Get to it!
I have way too many gems in my notes to discuss, so here are a few big takeaways.
I Sense a Disturbance in the Force
This course focuses on esthesia, namely sensing and feeling particular body-spatial areas. More specifically, reference centers.
Referenced areas occur as a reaction to the environment. In certain environments (e.g. stressful, threatening, painful), we will tend to reference certain body-spatial regions compared to others. The norm is to extend in order to combat gravity. Continual threatening inputs will perpetuate a LAIC/RBC/RTMCC/PEC.
The above pattern will occur to increase oxygenation and reduce dyspnea. Airflow is priority number one, and the neuromuscular system has damn efficient ways of maximizing this.
The clinical goal is to provide alternate references via learnable nonmanual activities until habitual movement strategies manifests. Until movement variability is maximized and we can achieve any desired joint position.
The ZOA is the Real
PRI folks, myself included, love getting caught up in the cool vision, dental, and auditory components. But the most underrated treatment piece is a zone of apposition.
This natural orthotic is often forgotten, and greatly underappreciated. True ZOA acquisition likely eliminates unnecessary interdisciplinary integration.
Can’t get a person neutral? ZOA.
Can’t get someone to feel a muscle? ZOA.
Revisit the foundation often throughout treatment; as dyspnea becomes more prominent with progressing nonmanual techniques.
HALT Right There
Passive movement variability and neutrality merely demonstrates unstable potential. The HALT answers if one can manage that instability.
If one has a higher right HALT compared to the left, it’s probably fake. What is likely occurring is the right adductor is overpowering that individual up despite reduced left abdominal integration.
Focus on left abs in these instances. Mike was a huge fan of plank/trunk lift variations to build this awareness. Playing with these activities this past week has made my patient’s HALT scores change quite dramatically. These activities are integral in bringing someone from a 2 to a 3. Here are my two current favorites
Brachial Chain Cleanup
I’ve been sorely mistaken on the bilateral BC.
In the RBC pattern, the left ribcage is externally rotated and the right internally rotated. This creates the ribcage leftward counter-rotation from right spinal orientation.
In the BBC, the ribcage position is the same.
What creates the BBC is increased left pec activity to the point where the left scapula becomes protracted similarly to the right side. This positioning creates the often seen left internal rotation deficit.
The right rib cage cannot externally rotate because of right intercostal hyperactivity via the RBC. What can happen is ribs 8-10 may start to externally rotate by ZOA loss. This change is your classic inferior T8 syndrome.
Mad love for Subscaps
An often neglected muscle is the subscapularis. It does some cool stuff:
- Inhibits a lat by re-teaching HG internal rotation
- Provides muscular support for a possible SLAP tear (HG IR >80 degrees when other BC tests are positive)
If you have someone who keeps losing BC positioning, still has symptoms, or is at the end stage of programming, go after this guy.
Here is a nice little way of integrating a subscapularis into any activity:
And my current favorite to get a subscap on either side.
Cantrell the Cue Monster
Cantrell is an outstanding coach. One of the big cues he gave for the weekend was incredibly simple yet worked so damn well.
In many exercises and activities, one often cues pressing down into a table or pulling a band down to engage the core.
What can sometimes be problematic with this cue is rectus abdominis and lat overactivity. A simple fix? Flip the resistance direction
- “Without movement variability life sucks.”
- “While you’re doing symptom management it would be nice if you treat the problem.”
- “Parlor tricks are slop unless you know why the magic works.”
- “Hanging by your lat does not fix anything.”
- “If you can’t suck, you suck.”