Every week, my newsletter subscribers get links to some of the goodies that I’ve come across on the internets.
Here were the goodies that my peeps got their learn on from this past July.
If you want to get a copy of my weekend learning goodies every Friday, fill out the form below. That way you can brag to all your friends about the cool things you’ve learned over the weekend.
Biggest Lesson of the Month
Maximize proximal before spending time distal. I’ve just seen too many patients where we applied some type of axial intervention, which led to profound changes distally. Position governs all. Thank you for making me realize this daddy-o.
Quote of the Month
Only those who dare to fail greatly can ever achieve greatly. ~Robert Kennedy
My boy Scott Gray put together a rock solid post on diagnosing an ACL tear. I’ve been very big as of late on filling the differential diagnosis hole in my game, and this one was beyond helpful. I wish I had heard of the lever test last year when I had a guy pop his ACL in-game.
I’m still making my way through this beast. It’s a thesis, but the references and explanations of the science behind breathing, position, and recovery is outstanding. Not only that, but changing your recovery position has had a profound effect on improving my clients’ conditioning.
So proud of my guy Eric Oetter, who put this incredibly practical guide to load management together with the brilliant Tim Gabbett. EO is doing phenomenal things with the Grizzlies, and this provides a small insight into his process.
Short answer – It depends. I have a coworker who I discuss with the problems of this argument. I’m an avid meat eater because gainzzz, and it turns out that makes the difference. If you aren’t listening to Ronda Patrick by the way, you’re welcome.
This Rhonda Patrick joint talks about all the wonderful things lactate does for us. This molecule always gets a bad rap, but did you know in brain injuries (concussions, TBIs, etc), it’s one of the few substrates that is capable of providing our brain fuel? This was a very fascinating hour in which I learned a great deal.
What if I told you that there was a way you could keep eating what you are eating yet still lose fat and gain muscle. Would you do it?
If so, then this is your study. By simply restricting the eating window to 9-12 hours in mice, and having them eat earlier in their day, these bad boys lost some major weight. He did a similar study in humans as well. He goes into detail about this and more. Both the paper and the podcast are quite interesting
I’ve been on a little Rhonda Patrick (#bae) kick as of late. In this interview, Dan Pardi talks about all things sleep, circadian rhythms, and more. If you can maximize sleep duration, intensity, and timing, you are winning at life. Never thought of sleep described in this manner.
An oldie, but a goodie. I’m taking my time with this one because it’s a big book and filled with so many practical applications. This book inspired me to check my email, and respond, less frequently. He’s given me so many ideas on streamlining my life. You’ll love the tips he has for elimination and automation. Incredibly practical.
Given that I’m pretty green at being a PT mercenary, this website has been gold for me. If this doesn’t inspire you to consider travel PT, nothing will. The money is real, and it seriously feels like I’m on vacation all the time.
I recently had to prepare for a salary negotiation, and just reading a few chapters from this book made the process go exceedingly better than I anticipated. Negotiating, like many things, is a skill. This book will teach you the fundamentals to a skill that will benefit so many aspects of your life.
As y’all probably know, I am a major hip hop head. Like, pretty much all that I listen to. I found this cat on Spotify while at the gym, and was blown away. Has fire lyrics over insane samples. Listen to the joint called “Moses” which features Twista and Bun B. Un…be…lievable
I’ve lately been trying to read something a bit less technical right before bed to help me fall asleep (which has been working well btw). First book I chose was this gem by the creator of XKCD, Randall Munroe. He basically goes through and answers ridiculous questions in the most scientific manner possible. It’s a brilliant combination of interesting and funny.
My favorite so far? “What would happen if you had a mole of moles?” #deep
As an official Ron Hruska groupie, the tour continued to the Big Apple to learn a little Postural Respiration.
And in NYC, everything is bigger.
The biggest city I had prior been exposed to was Chicago. The cities feel similar, only NYC has twice as many people on the same size streets.
I felt like this course was one of my less understood areas in the system, as Respiration was my first live PRI course. Taking this class the second time around really cleaned up a lot of things for me, and Ron was on point as always.
So let’s dive into the cranium…I mean pelvis….I mean thorax. Oh sorry, wrong course.
Laying the Foundation
The three foundational courses aim to inhibit tone, twist, torque, and tension in the human system by various methods.
In Postural Respiration, trunk rotation inhibits the system.
When these powers combine, the goal is to simultaneously maximize phases of gait and respiration. This development allows for total-body freedom to move, breathe, live, and create amidst our incessant desire to run on our built-in right stance autopilot.
There is nothing wrong with right stance, but it becomes wrong when it is all you know.
“There is nothing wrong with half the gait cycle until it becomes the full gait cycle.” ~Ron Hruska.
Make a Memory – The Zone of Apposition
Zone – An area that serves a particular purpose
Apposition – The condition of being side-to-side or close to one another.
With these definitions in mind, the zone of apposition (ZOA) is the cylindrical aspect of the diaphragm that lies next to the inner aspect of the lower mediastinal wall.
Since there are few proprioceptors in the diaphragm itself, the ZOA is largely influenced by ribcage orientation. The ZOA flattens if the ribs are elevated, anterior, and in external rotation; and domes in the converse. To maximize respiratory capacity, this space must be persevered at all costs via the rib’s governor—the abdominals.
“You can take my eye before my ZOA.” ~Ron Hruska
There are many ways that our respiratory system can be influenced. Here are some of the more important ones to think about:
Right diaphragm (respiratory) is large than the left (postural)
Right vagus nerve is longer than the left
Better lumbopelvic stability on right
Left thoracoabdominal rotation
Reach with right
Better Right ZOA to improve left chest expansion
Limited left hemidiaphragm respiratory function
Decreased right chest wall mobility
Increased accessory breathing muscle use
Eccentric-oriented rectus abdominis
Weak obliques and transversus abdominis
Wide infrasternal angles
Unilateral or bilateral rib flares
Being right-sided creatures
Poor sitting positions
The Result = the Pattern
Factor in the above influences with countless others, we begin to love right mid-stance, aka the left AIC pattern. The left AIC consists of:
The left innominate being anteriorly tipped and forwardly rotated.
The left lumbar spine being lordotic.
The spine being right oriented.
But what happens at the thorax?
The Brachial Chain
The right and left brachial chain (BC) consist consists of the following muscles:
When the left AIC pulls me into right stance, the right BC compensates to view the environment in the following manner:
The left ribs externally rotate; the right ribs internally rotate to center the body.
The thorax abducts to the right and begins rotating to the left (still right-oriented).
The left scapula is oriented in elevation and adduction; downward and external rotation; appearing retracted.
The right scapula is oriented in abduction and depression; upward and internally rotated; appearing protracted.
In the case of the superior T4 syndrome, the right scapula could appear retracted by the subclavius muscle compensatorily.
The Right BC may or may not be present in a Left AIC or PEC individual. There is also the possibility of someone being a bilateral BC, in which both scapulae protract on the ribcage and bilateral ribs flare. The Bilateral BC is like the PEC of the thorax.
Youz Best Assess
We can assess the BC with very common orthopedic tests, and due to the above positioning, we would expect the following results.
Decreased left horizontal abduction [<35] (if full, costoclavicular hypermobility or left anterior shoulder instability).
Decreased left shoulder flexion (if full, likely multidirectional instability).
Limited left cervical axial rotation
Limited right apical expansion
Bill Hartman does an excellent job below explaining what apical expansion is.
If one is a bilateral BC, then all motions should be limited on both sides, and if one is a superior T4 (explained later), you would expect limited left apical expansion.
Much like all the introductory courses, right BC treatment is fairly algorithmic. We follow a progression utilizing the BC opposition muscles, which include the triceps, lower traps, serratus anterior, and internal obliques/transversus abdominis. With these muscles, our goal is to create left thoracic abduction, left posterior mediastinal expansion, and right apical expansion.
ZOA nonmanual –> right lower trap and right tricep.
Here’s a ZOA nonmanual example:
And here’s a right lower trap / right tricep activity:
The right lower trap and right tricep activities work by retracting and posterior tilting the right scapula and rotating the left lower spine; promoting thoracic flexion.
The ultimate goal is to get to right lower trap and right tricep activities, but this progression assumes all your BC tests went negative. That rarely happens, so you may have to use some manual techniques:
ZOA nonmanual –> ZOA manual –> superior T4
Here’s an example from PRI of one of the manual techniques. There are several so I won’t show you all of them:
Suppose after you do the above and you get a positive left apical expansion test. That would indicate a superior T4 syndrome.
This syndrome is a compensatory pattern that occurs when respiratory demand increases. The right scalanes increase their tone, which externally rotates the upper four ribs on the right. This change would correspondingly result in left rib 1-4 internal rotation. The vertebrae in this region also begin rotating right. This rib positioning would explain why apical expansion would be limited on the left.
I ‘splained it here in the video below:
When we run into this pattern, we have to use a few other tricks up our sleeve:
Subclavius manual technique –> left lower trap and left serratus exercise
The left lower trap and left serratus exercise helps by rotating the mid-thoracic spine to the right, internally rotating the ribs. A desired kyphosis would also be created
Here’s a video of some young man doing this classic activity
One of the biggest pieces that I picked up from this class regarded patient education. With all the PRI nonmanual and manual activities, our goal is to give the patient a frame of reference. Finding and feeling these movements, muscles, and positions is what helps drive the patient into alternating and reciprocal activity.
We use nonmanual techniques to promote motor learning with these references, and manual techniques are merely a way to guide the patient to these references.
So if anything, the course itself taught me to reinforce why feeling this activity in this area is important to the patient’s experience. How is this technique is going to help them, why do I have to put my hands on your ribcage. The more we inform the patient the better.
So there you have it. Another great PRI course, and my understanding is a little less hazy. I look forward to the next one. If you haven’t made it to a PRI course yet, please do so. You can thank me later.
Wait, you didn’t think I’d forget some good quotes right???? 🙂
(In)famous Ron Quotes:
“The appendages tell you what sense you are in. Sympathetic. Parasympathetic.”
“This is not an anatomical and biomechanics course.”
“Asymmetry is a gift. Why would you destroy it?”
“Every muscle you have has a purpose.”
“If you don’t inhibit something you are dead.”
“There is no such thing as a shoulder. You have two of them.”
“There is no such thing as a body. I see two.”
“I love fascia, but fascia is not restricting you. Tone is restricting you.”
“The diaphragm is the only muscle in your body. It’s the first and last one you will use.”
“You’re treating four patients in an hour? I’m going to pretend I didn’t hear that.”
Pavel Kolar and crew actually contributed to quite a few chapters in this edition, and this one here was overall very well written. Believe it or not, it even had quite a few citations!
Why they don’t cite many references in their classes is beyond me, but that’s another soapbox for another day. Onward to a rock-solid chapter.
En utero, the diaphragm’s origin begins in the cervical region, which could possibly have been an extension of the rectus abdominis muscle. As development progresses, the diaphragm caudally descends and tilts forward. When the child is between 4-6 months old, the diaphragm reaches its final position.
Throughout this period, the diaphragm initially is used for respiratory function only. As we progress through the neonatal period (28 days), we see the diaphragm progress postural and sphincter function.
The diaphragm is integral for developing requisite stability to move. Achieving movement involves co-activation of the diaphragm, abdominal, back, and pelvic muscles. This connectivity assimilates breathing, posture, and movement . If this system develops properly, we see the highest potential for motor control.
The largest developmental changes in this system occur at 3 months. Here we see the cervical and thoracic spine straighten and costal breathing initiate. 4.5 months shows extremity function differentiation, indicating a stable axial skeleton to which movement may occur.
Further progression occurs at 6 months. Here costal breathing is fully established. We also have increased diaphragm and lumbar spine stability. This part is necessary for support to occur in the quadruped position, as the proximal attachment of the psoas has a firm place to pull the baby up onto palms and thighs.
In an Ideal World
Per development, an ideal breathing pattern ought to involve the diaphragm descending in the caudal direction, with elastic recoil promoting ascension upon exhalation. As a result, the organs shift caudally as well, and the abdominal wall expands in all directions.
From a muscular perspective, we see an alternating dance of muscle activity. Inspiration requires concentric diaphragm and pelvic floor activity, which compresses the abdominal cylinder to establish intra-abdominal pressure. Ab wall expansion occurs via eccentric activity of the abdominal muscles, quadratus lumborum, spinal extensors, and hip external rotators. When we exhale, the reverse occurs: diaphragm and pelvic floor eccentrically return to their starting position and the ab wall concentrically tightens up.
Regarding the ribs, we can break them up into segments that do or do not attach to the sternum. The top 7 ribs usually attach to the sternum anteriorly, thus are influenced by sternal movement.
Physiologically normal breathing involves the sternum moving anteroposterior via sternoclavicular joint rotation. It is this movement that contributes to the pump-handle activity of the upper ribs.
The lower ribs laterally expand and open during inhalation, creating a bucket-handle movement. This motion occurs because the thoracic cavity expands anterolaterally by diaphragm and intercostal muscle activity.
But Life Isn’t All Love and Happiness
Breathing sometimes can occur pathologically. One example is paradoxical breathing. Here we see the diaphragm’s central tendon become fixed, leading the diaphragm to be eccentric upon inhalation and concentric upon exhalation. As a result, the lower ribs cranially elevate and intercostal spaces narrow. Accessory muscles begin assisting the breath, creating upper rib elevation.
Because the diaphragm does not assist postural stabilization as well, the paravertebral muscles kick into overdrive to keep us upright.
The sternum begins moving cranio-caudally, the acromioclavicular joint moves instead of the sternoclavicular joint. This change is one reason why we see shoulders elevate with accessory breathing. Hence, we can see why thoracic position is important for creating an ideal environment to breathe in.
These changes can correlate to pain states. In people with chronic low back pain, Pavel Kolar found increased flattening of the diaphragm’s lumbar portion. Another study demonstrated that decreased diaphragm activity during trunk stabilization posed a greater risk for developing low back pain.
The diaphragm can play a large influence on the viscera not only from an intra-abdominal pressure perspective but with digestion as well.
The diaphragm influences eating via the vagus nerve. In order for a bolus to reach the stomach, the diaphragm’s crural portion must relax. The reverse occurs when intragastric pressure must be attained, such as when the esophagus closes off from the stomach contents. So we can see that if diaphragm activity is not up to par, there is an increased risk of gastro-esophageal refux disease occurring.
Breathing has been something I have been interested in very much since I first learned about its power from Bill Hartman and through the Postural Restoration Institute, and this excellent book is a great way to get a full overview.
The first chapter covers too much anatomy to go through every little detail in my short blog post. So study up. Here are the highlights.
Structure, Function, and You
In order to have favorable respiration, structure makes all the difference. Adequate thoracic, ribcage, and breathing muscle mobility must be restored and maintained in order to uptake a quality breath. This can be achieved via re-education and training.
Realize too that psychological distress can also play a huge role in how we breathe. Disorders such as anxiety and depression can have corresponding breathing dysfunctions. It may be the way the body responds to ensure survival.
Ergo, when attempting to change breathing patterns favorably, one must address both structural and psychological factors.
Homeostasis is the body’s process to normalize itself. If too many homeostatic-disrupting tasks are occurring at one time however—such as nutritional deficiencies and toxin ingestion—homeostatic function can become overwhelmed. This systematic stress can lead to breakdown and a switch to heterostasis, in which the body must be treated. We can restore homeostasis via the following:
Take away as many undesirable adaptive factors as possible.
Enhance, improve, and modulate defensive and repair processes.
Treat symptoms without further burdening the system.
A general rule of thumb when addressing these areas: The weaker a patient is, the lighter the intervention must be.
There are several benefits to having optimal respiratory function:
Allows gas exchange.
Enhanced cellular function so the brain, organs, and body tissues perform normally.
Permits normal speech.
Involved in non-verbal expression.
Assists in fluid movement.
Mobilizes the spine.
Enhances digestive function
Air takes a fascinating journey when it enters our body. It goes through the following passageway
The two breathing strategies we utilize are nose and mouth breathing. Nose breathing is slow and rhythmic; utilized for sleep, rest, and quiet activity. But when we need large air volumes, mouth breathing comes into play. Mouth breathing requires much less resistance compared to the nose, and involves intercostal and anterior neck muscle activity.
Regardless of which strategy is used to breathe, the following occurs at the diaphragmatic level:
Diaphragm descends during inhalation; pulling the central tendon down.
Abdominal viscera resist the diaphragm from descending.
This resistance fixes the central tendon, causing the ribs to displace laterally.
At the same time, the sternum moves superiorly and anteriorly.
The combination of the above two leads to thoracic cavity expansion.
Greater breath volumes lead to accessory muscle utilization.
Abdominal muscle tone allows for correct viscera position so an appropriate amount of central tendon resistance can occur.
At the gas exchange level, air travels via the following pathway:
Lung function can also be affected by fascial links throughout the body. There is a direct fascial connection from the base of the skull to the diaphragmatic apex. Thus, stress in one area along this pathway can affect areas along the same location. As an example, changes in cervical spine or diaphragm position can lead to changes in breathing patterns.
You can also see fascial connections between the diaphragm, cervical spine, and pleura. You can often see that the pleura can be affected with impairments in the prior regions. For example, there have been dissections in which degenerated lower cervical structures also have corresponding fibrotic change to the pleuropulmonary attachments.
Ain’t no Bones About it
From a spinal perspective, breathing has a large effect on joint mobility; namely in the frontal plane. Every time we inhale, the odd segments (C3, T7) become more mobile, with the even segments increasing mobility during exhalation. This effect decreases as we travel down to the lower thoracic segments. The exception for this mobility is the cervicocranial junction, in which all three planes become more mobile upon inhalation. Taking this phenomenon into account, it may be helpful to utilize breathing cycles during mobilizations depending on which segments you wish facilitate.
Neural Regulation and Breathing
The brain works on controlling respiration in order to maintain balanced concentrations of oxygen and carbon dioxide. Respiratory control centers are located in the brainstem via three primary nuclei groups:
Dorsal respiratory group – Found in the medulla. This area creates inspiratory movements and is responsible for the basic breathing rhythm.
Pneumotaxic center – Found in the superior part of the pons. This area controls the filling phase of breathing.
Ventral respiratory group – Found in the medulla. This area causes both inspiration and expiration. However, this area is inactive during quiet breathing.
While not a brain area, the Hering-Breuer reflex is an important neurological phenomenon. Located in the nerves of the bronchi and bronchioles, this reflex prevents lung overinflation via sending messages to the dorsal respiratory center via the vagus nerve.
Most of the above is in reference to quiet breathing. We can use a cortical overriding system via spinal neurons to respiratory muscles to consciously change breathing patterns.
This strategy is utilized in day-to-day activities such as speaking and singing. There is also some evidence that the cortex and thalamus drive some normal respiratory function. These areas are likely what we target and are likely originators for breathing pattern disorders (BPDs) and hyperventilation syndromes (HVSs).
You cannot talk breathing without mentioning the autonomic nervous system (ANS). There are two divisions of the ANS; the sympathetic (SNS) and parasympathetic (PNS) nervous systems. The SNS deals with flight, fight, or freeze responses; and its neurons connect to the head, neck, heart, larynx, trachea, bronchi, and lungs. So we can see a vast number of areas that are affected if the SNS is dominant.
The PNS, on the other hand, deals with visceral functions aka rest and digest. These areas govern the lungs, cranial, and pelvic regions.
There is also a third nervous system called the non-adrenergic noncholinergic (NANC) system, which contains inhibitory and stimulating fibers. The main neurotransmitter for this region is nitric oxide.
When inhibitory neurons in the NANC are active, smooth muscle relaxation and bronchodilation occur via calcium ions, with the opposite occurring via NANC’s stimulatory C fibers.
The Muscles of Respiration
The two thoracic-based muscle groups that influence respiration can be broken down into extrinsic and intrinsic. Extrinsic muscles position the torso; which influences shoulder, arm, neck, and head placement. As we learned previously, the position of these areas can influence breathing mechanics.
The intrinsic muscles predominately focus on moving thoracic vertebrae or the rib cage, and are the money muscles associated with respiration.
To get more specific, there are several muscles that work on inspiration. The king of course is the diaphragm, which provides 70-80% of the inhalation force. Other muscles that assist inspiration include lateral external intercostals, parasternal internal intercostals, scalenes, and levator costarum.
When we need an extra inspiratory kick for more demanding activities, we will often use accessory muscles to facilitate this process. These muscles include sternocleidomastoid (SCM), upper trapezius, pectoralis major and minor, serratus anterior, latissimus dorsi, serrratus posterior superior, iliocostalis thoracis, subclavius, and omohyoid.
We also have muscles that can perform exhalation, but understand that exhaling is primarily a passive process. We exhale based on elastic recoil from the lungs, diaphragm, pleura, and costal cartilages.
But sometimes you may want to utilize muscles to force an exhale. The guys for this would include interosseous internal intercostals, abdominal muscles, transversus thoracics, subcostales, iliocostalis lumborum, quadratus lumborum, serratus posterior inferior, and latissimus dorsi.
Wow. That’s all that really needs to be said. I have had a great deal of exposure to PRI in the past, but I have only had one formal class under my belt. Needless to say, I was looking forward to learning more. James Anderson and the PRI folks did not disappoint.
Myokinematic Restoration was easily the best class I have taken all year.
It also helped having another like-minded group attending. You learn so much more when you are surrounded by friends. Here is the course low-down.
Disclaimer for the Uninitiated
I know there are a lot of misconceptions about PRI on the interwebz. Even though posture is in the name, PRI has little to do with posture in the traditional sense. We know posture does not cause pain, and PRI agrees with this notion. But it’s not like they can change the name of the organization now. What? Do you think Ron Hruska is Diddy or something?
After discussions with James and his mentioning this aloud in class, the target of PRI is the autonomic nervous system. Not posture, not pain, not pathoanatomy, but the brain. Essentially, they have figured out a window into the autonomic nervous system via peripheral assessment.
Moreover, PRI is not in the pain business, though many think this is the case. Hell, even in the home studies they mention pain quite a bit. But realize those were done in 2005. Would you like me to hold you to things you have said 8 years ago?
Throughout the entire two day course, pain was mentioned in two instances. The first time was this direct quote from James:
“ PRI does not treat pain.”
The second time was mentioned in the case of various pathologies, in which James put a disclaimer that PRI just puts these things in here per clinician requests.
What PRI treats is position, neutrality, a state of the autonomic nervous system that is shifted towards parasympathetic but can freely alternate between sympathetic and parasympathetic states.
So if PRI doesn’t treat pain why use it? I say because the autonomic nervous system influences pain states. The potentially indirect effects on pain when the autonomic nervous system is favorably influenced seem desirable. And from my own personal experience, for whatever that is worth, my limited understanding of PRI has netted me quite a bit of success with my patients. It also requires my patients to spend less time in the clinic since they do not require my hands; good news for everyone.
Back to the Basics
The basic PRI concepts rely on asymmetry. All body systems –neurological, respiratory, muscular, visual, etc.—are asymmetrical. This asymmetry cannot be changed, but we can strive to reduce one-sided dominance as best we can.
The side that is dominant in human beings is the right side. This lateralization is normal, but what we don’t want is the right to be overly biased. Too much right dominance essentially creates a low level left sided neglect.
Myokin’s utmost focus is on a polyarticular muscle chain known as the anterior interior chain (AIC), which is composed of the following muscles:
Diaphragm – king
Tensor fascia lata
You have two of these chains, a left and a right. For a variety of reasons, such as our asymmetrical build and left hemisphere/right sided dominance, the left AIC is more dominantly active compared to the right.
You can notice this dominance just by comparing right and left hemidiphragms:
Right has a larger diameter.
Right has a thicker & larger central tendon.
Right has a higher dome, and is better able to maintain this shape.
Right has more crural fibers and fascia.
The right crura attach 1-1.5 levels lower on the lumbar spine than the left.
Basically, the right diaphragm is built for success, whereas the left diaphragm is often more contracted, smaller, and less concentrically effective. This difference helps perpetuate a more active LAIC. The path of least resistance for you to have an effective breath is by activating these muscles.
Because the LAIC is the more dominant chain, this throws the body into an asymmetrical position. The left innominate is more anteriorly tilted and forwardly rotated with the right more posteriorly tilted and backwardly rotated. This position puts the right hip into internal rotation, adduction, and extension; and the left hip compensatorily into external rotation, abduction, and flexion.
Chains and Gait
These chains oppose each other during gait. For example, when you are standing on your right leg, your LAIC is active, causing the swing leg to further put weight on the right leg. You cannot fully use one chain unless the opposite chain is inhibited, so the RAIC is quite during this phase. Inhibition allows for alternating and reciprocal gait; the goal of PRI.
Realize that as long as you are in weight bearing, you are in a phase of gait. We can base this off of pelvic positioning. Since pelvic position can be altered with breathing, it is fair to say the every time you take a breath you are put into a phase of gait. Breathing and gait are one in the same.
To assess neutrality, many common tests already utilized in the therapy realm are used. The two big tests are:
Modified Ober’s test (adduction drop)
Modified Thomas test (extension drop)
With the LAIC pattern, you will see a positive Ober’s on the left but not on the right. This finding is due to either restriction from the anterior-inferior acetabular labral rim, transverse ligament, and piriformis muscle; or impact of the posteroinferior femoral neck on the posteroinferior rim of acetabulum that does not allow femoral adduction.
The Thomas test in this pattern can be either positive or negative. A positive Thomas correlates with the adduction drop due to the limited extension. A negative Thomas test, barring a positive Ober, would implicate iliofemoral and pubofemoral ligament laxity. If we think back to the position of the innominate, the left femur will have to externally rotate in order to face forward, which can stretch the anterior capsuloligamentous structures. Here is the same thing better explained by Bill Hartman:
You should also see limited right trunk rotation (unless there is iliolumbar ligament laxity), decreased left SLR (unless you have an overstretched hamstring), an apparent shorter left leg, and decreased left hip internal rotation and right hip external rotation.
PRI also has a test called the Hruska Adduction Lift test, which is used to assess acetabulofemoral control in a way that correlates with gait. The scope of this test and interpretations are too much to fully write about in a short summary, so perhaps when I get better understanding all the nuances, performance, and meaning I will post on this test further. Until then, PRI instructor Mike Cantrell wrote a great piece on the lift test here.
Taking the above tests, namely the adduction drop and lift test, the goal is to satisfy the following questions:
1) Can the person adduct? (adduction drop)
2) Can the person internally rotate on both sides? (Measurement, adduction lift)
3) Does the person have internal rotation strength on both sides? (adduction lift)
In order to inhibit the LAIC, there are several key muscles that are to be activated:
Left Hamstrings [sagittal repositioner]
Left anterior gluteus medius
Left ischiocondylar (hamstring portion; IC) adductor [frontal repositioner]
Left glute max (sagittal fibers)
Right adductor magnus
Right glute max (transverse fibers) [Transverse repositioner and the other key to maintaining neutrality].
Bilateral obturator interni (the key to maintaining neutrality)
Left abdominal obliques.
The goal is to influence the left hemidiaphragm away from its overly contracted state in order to allow better reciprocally alternating respiration, position, and gait.
Treating the LAIC
The LAIC patient has a positive adduction drop test and Thomas test. So the name of the game is to reposition and develop hole control. What hole control means is allowing the obturator and glute max to control the femur in the acetabulum to allow for reciprocal gait pattern.
For the LAIC, we want to activate the following muscles in the following order:
1) Biceps femoris in ER/extension
2&3) R Glute max & obturator & adductor magnus via ER
4) L Anterior glute med via IR
5) L IC adductor via IR
6) Medial hamstrings via IR
By performing the exercises in this order, we first reposition, then establish hole control, and then retrain the person to turn to the left side.
There are certain instances in which ligaments can get stretched out and become lax. This is where the concept of ligamentous muscle comes into play, in which muscles increase their tone to reinforce capsuloligamentous structures.
The theoretical reason this order is performed is because the IC adductor approximates the femur into the acetabulum, while the left anterior gluteus medius strangulates the joint by further driving internal rotation.
For a patho LAIC, we go for the following muscles in a slightly different order:
1) Biceps femoris to reposition
2) L IC adductor via IR
3) L anterior glute med via IR
4) R glute max via ER
5) R adductor magnus via ER
6) L medial hamstrings via IR
In this instance, we reposition, then build ligamentous muscle, and finish by establishing hole control.
If after a successful reposition you notice mobility changes in hip rotation, you may want to proceed in the following manner:
Decreased left IR (v Right): Stretch posterior capsule
Increased left ER (v right): go after L IC adductor and L anterior glute med
Increased right IR (v left): Kick in R glute max and R posterior glute med
Decreased right ER (v left): Stretch anterior & inferior capsule
Favorite James Quotes
“The diaphragm owns you.”
“If you don’t have position and throw in demand, someone else will do it.”
“I find it offensive when people say iliopsoas. We don’t call it the hamductor obturatoridiosus.”
“Screw PT school, subscribe to Oprah.”
“The whole body is in a phase of gait.”
“The problem is the brain and the diaphragm.”
“Nobody is Weak.”
“External rotation is worthless without internal rotation.”
“PRI is from start to finish brain therapy and parasympathetic awareness of the left side.”
I cannot recommend enough courses from PRI. I base this off of the methodology, effectiveness, and thought process. They appreciate the nervous system’s power just as much as anyone. Please check them out and tell ‘em Zac sent you.