Mike Cantrell was in my neighborhood to teach Myokinematic Restoration by the folks at PRI.
And I couldn’t resist.
This is the third time I have taken this course, a course I feel I know like the back of my hand, yet Mike gave me several clinical gems that I want to share with y’all.
This post is going to be a quick one. If you want a little more depth, take a look at my previous myokin posts (See James Anderson and Jen Poulin). Or better yet, take a PRI course for cryin’ out loud.
Hip Extension, We Need That Yo.
Sagittal plane is your first piece needed to create triplanar activity. Since this is a lumbopelvic course, we look at getting hip extension as high priority.
If I am unable to extend my hip, here’s what I could try to use to do it:
SI joint compression
Anterior hip laxity
Gastrocnemius and soleus.
We use two tests to see if we have hip extension: adduction drop (modified ober’s test) and extension drop (Thomas test).
The adduction drop will look at your capacity to get into the sagittal and frontal plane, and the extension drop test will look at your anterior hip ligamentous integrity.
A positive extension drop is a good thing if you are in the LAIC pattern. It means you didn’t overstretch your iliofemoral and pubofemoral ligaments. Well done! The reason why this test is not a hip flexor length test has to do with the femur’s position. In the pattern, the femur is positioned in a state of internal orientation secondary to an anteriorly tipped and forwardly rotated pelvis.
Due to this orientation, the femur must be externally rotated during performance of an extension drop test. This would put the psoas on slack. If you still have a positive test, then we know the anterior hip capsule is intact because that’s the only thing holding the hip up.
We spent a good portion of the day learning about gastrocs. In the LAIC pattern, the right gastroc runs the show as a hip extender AND hip external rotator.
The slight inversion action that the gastrocneumius performs helps pick up the transverse plane slack that the right glute max is malpositioned to do so. This is why the right calf is usually larger than the left.
This test’s pinnacle is the 5/5, to which gives us ground to become alternating and reciprocal warriors.
Just because you can hit 5/5 on both sides does not mean you can alternate well.
I was a prime example in class. Mike had me demonstrate my HAdLT in class, to which I easily hit 5’s on both sides.
Despite my quest towards neutrality, I have not been able to keep good thorax and neck positioning. Thanks wisdom teeth.
So Mike checked my right shoulder internal rotation, to which I had about 70 degrees. Way better than the previous 10 or so degrees I started at.
Then Mike had me perform the left HAdLT, which pushed me into my right hip.
Shoulder internal rotation worsened to 30 degrees.
He then pushed me into my left hip with the HAdLT.
Shoulder internal rotation now 90 degrees.
Even though I can crush the lift test, I do not alternate well because I lose position at other areas.
To truly be an alternating and reciprocal warrior, one must be able to perform alternating activities without losing position anywhere in the body.
Why Can’t I Swing my Right Arm?
In many folks with a LAIC/RBC pattern, you will notice that there is minimal right arm swing. You would think that the right arm would be activity secondary to right lateralization and hemisphere dominance. Not necessarily so though.
Arm swing is dependent on trunk rotation. If the trunk can rotate, then the arms can swing.
In the pattern, it becomes very difficult to rotate the trunk to the right, which mean there is no need for right upper extremity extension. So how about instead we just plaster the arm the side? Not a bad idea.
Crazy Good Cues
To close, Mike is a cueing machine. I picked up three new favorites that we’ve been playing around quite a bit in the clinic.
Press heels down on a chair to decrease TFL. Don’t use a ball because the TFL will attempt to adduct the femur via internal rotation. Then slowly add the ball.
Sigh upon exhalation if you have a patient who is rectus-dominant.
Plantarflex the first big toe to feel the left IC adductor in standing.
“Orthopedic symptoms are the result of bad neurology.”
“Good posture compromises respiratory dynamics.”
“Think before you stretch.”
“Stretching is the equivalent of kicking a horse while pulling on the reins.”
“99% of righties have a left thing.”
“Doesn’t matter what the diagnosis is.”
“Give me sagittal or give me death.”
“Most strength deficits are motor control deficits.”
“Total arc depends on what moment in gait you are in.”
I officially eclipsed my longest work day ever. Started seeing patients at 7:30 am and finished training my last client at 10 pm.
So exhausting, but the bright side is my new schedule prevents me from waking up that early ever again! Hooray for sleeping in…sort of.
I figured while I had some time in the airport before my next course, I would write a little something about a patient I evaluated right before my lunch break on this long day. Needless to say, I didn’t get much of a break.
This lovely lady is a nurse with a history of chronic left hip pain. She has predominately been treated surgically via labral repairs and muscle reattachment. Her most recent symptom exacerbation involved putting on her socks about a month prior. She heard a pop as she bent over and could not walk.
She initially saw two ortho docs. One specializes in total hips, the other in scopes. Since she was not appropriate for a total hip, this doc referred this lady to his associate.
After some imaging was done, she found out that she could not have surgery because she had several muscle tears. Or in the language that the doctor used:
“I have nothing to work with. Your hip is shredded up like cheese.”
This lady knew no other treatment but surgery, and hearing this news was devastating for her. Thoughts of a brutish life and an end to her fulfilling job flooded her mind. This doc referred to PT while conveying to the patient that this avenue was a mere dumping ground.
She walks back into the evaluation room, limping with the cane in excruciating pain.
Healthcare practitioners are the hardest people to treat. Knowledge is power, but the extensive biomechanical knowledge she had was detrimental in this case.
The subjective basically consisted of her telling me all the biomechanical issues she had. This pain is the bursa; running around the gluteus medius and minimus, down the illiotibial tract, blah blah blah puke.
But I listened intently to her story and how this recent episode devastated her life.
I finally asked her what her goal was for therapy? She replied…
“When you have a hip like this, what goal can you have?”
There were so many strikes against me for this lady. If you factor in what her history, what doctors said, her thoughts on her complaint, her belief that therapy could do nothing, her lack of goals, and her pain severity; let’s just say I was quite overwhelmed.
After I composed my thoughts, I knew what needed to be done.
I performed an abbreviated objective exam to determine movement sensitivity and autonomic nervous system status via PRI testing. Based on my tests and measures, she was classified from a PRI perspective as a normal human being from the planet where?
I told her this finding, and proceeded to go into explaining how pain works. You never know how someone so indoctrinated into a biomechanical model is going to react to this thought process, but it was the only shot I had.
I used the analogy of pain as a sophisticated home security system. One so sophisticated that it can differentiate when calling 911 is appropriate; 911 being pain. Her hip trouble history was similar to being robbed in the past, so her home security system called 911.
If you have been robbed once, you will likely take extra precautions not to get robbed again.
Therefore, when she does something nonthreatening like put socks on and gets excruciating pain, it is not necessarily because she got robbed. It is as if her main console (i.e. her brain) calls 911 just because someone suspicious is walking near the street to her home. This episode was the result of her security center calling the cops at an inappropriate time.
Surprisingly, she totally understood this explanation, and gave me the following response:
“I never had anyone explain it to me that way.”
I sealed the deal by using her current hopelessness to my advantage. I mentioned that she felt this was the only option she had left. I felt I could help her as long as she put in the work.
She was sold.
The treatment we worked on was simply working on her breathing in hooklying. I helped her guide her ribs down to get as much exhalation as possible. We worked on this for about 10 minutes until she got the concept.
I reassessed all her hip motions…No pain. She got up and walked…No pain. She looked at me and asked:
“What the hell just happened?”
I told her we got her home security system reset via the autonomic nervous system.
She walks back into the evaluation room, limping with the cane in excruciating pain. She leaves the evaluation room smiling and holding the cane.
I don’t know what pisses me off more with this case, the words her doctor used, or the fact that this lady had never heard how pain works.
She was a healthcare practitioner who had no idea that pain worked in this way, and that scares me.
We see two very influential professions who think purely from a biomechanical model, and likely explain complaints to people in this fashion. Think of the number of people these clinicians will see, perpetuating biomechanical faults as the sole cause of one’s pain. We can see now why our jobs are challenging.
Pain neurobiology is becoming more prominent in the PT realm, but we are only small fish in a very big pond. And due to our status, we will have a hard road ahead converting medicine to this model. I was lucky in this case, but I cannot tell you how many times I lose a patient when I go this route.
A few get it, some superficially get it, and many will not buy it.
But I see a paradigm shifting over the horizon. A light at the end of the tunnel. I got another healthcare provider to realize current pain theories, and she is eager to learn more. I feel we need to focus more of our efforts here.
We need to stop arguing with each other over which treatments do and do not work and the rationale why. We are all attacking the same thing under the same framework. We are all reducing the perception of pain as a threat. And that is all pain is. A perception.
We need to shift our focus to educating those professionals not initiated on how this science works. We need doctors, nurses, therapists, front office staff, and everyone else involved in health care all on the same page. And until we do so, we will be stagnant in our current state.
The arguments we make regarding treatment will not matter until we educate the masses on the underlying framework for their pain experience.