The TMCC pattern says the sphenoid is in right rotation and that we want to promote left sphenoid rotation, but the frontal occipital manual technique seems like it is also promoting right sphenoid rotation. I am unclear on what I am trying to achieve with this manual technique. Also, upon the exhalation phase it says to guide the left wing of the sphenoid anteriorly with the right thumb as the index/middle finger drives the right wing of the sphenoid caudally. This seems awkward and difficult to coordinate. (I feel comfortable with the inhalation phase of pulling and supinating). Any clarification on the technique would be greatly appreciated.

The mastoid (temporal bone) is anterior (posteriorly rotated) on the right side and the occiput is in flexion on C1, or in anterior rotation.  So essentially the posterior temporal bone is in extension on the occiput and the occiput is flexed at the OA joint.
The right frontal occipital manual technique promotes right occipital posterior rotation and therefore left sphenoid rotation as the sphenobasilar joint on the right is directed into flexion and the OA joint into extension.
Consider the right thumb as a stabilizer of the sphenoid on exhalation and remember the sphenoid is not your main manual point of interest; the temporal bones are.

How do you approach to post-operative patients from a PRI perspecitve? We have so many ACL reconstruction patients and I would like to know how you use PRI?

You will need to stay close to the physician rehab protocol early in the process (to complement early phases of necessary healing), but as soon as they can bear weight and walk without assistive device or external bracing, they should be able to incorporate functional PRI activities.  Remember, PRI activities are just gait and breathing, so if you can walk and breathe you should be able to incorporate PRI activities into the program.  We have been able to greatly accelerate post ACL reconstruction rehab protocols by finding the appropriate left AFIR and right AFER muscles as early in the process as possible.  And if both left and right “hole control” and hamstring activation is optimized, the risk for post surgical complication goes way down.

-James Anderson, MPT, PRC

I was recently lecturing to a group of dentists, and most of them were interested in the “dressier” shoes.  Do you have a list of recommended dress shoes?

I would try to apply the same principles to dress shoes as to running shoes.  Most dress shoes, however, don’t have adequate arch support in them.  Obviously, backless shoes aren’t good for our patients with lack of calcaneal support.  Here’s a list that I put together for one of my patients this past spring.  Shoes can change so if you find some that you like please feel free to share:

Aravon Farah
Aravon Farren
Aravon Flora
Aravon Jodi
Clarks Show stopper
Clarks Wave Cruise (Mary Jane shoe)
Clarks Wave Wheel (tie up shoe)
Munro Jolie
Munro Kellie
Munro Passion

-Lori Thomsen, MPT, PRC

My patient is unsure if she is achieving neutrality at home.  Do you have any tips she can use as a self test other than how she feels?

Home ‘neutrality’ can be tested by lying on her back and placing one hand and arm over the edge of the bed and then the other. If the left range of horizontal abduction is not limited and reflects values of the right then I would consider her neutral. Active neck rotation to the left should feel as easy when going to the right, if neutral.

It is unclear to me how to facilitate an “Adductor Magnus (ER) -> obturator”.  It seems to me that for ipsilateral FA instability the suggested movements are using AF IR/FA IR/FA ADD (left Adductor exercises in appendix). I don’t understand how the ER function of the Adductor Magnus is facilitated!? And are the same movements used for the right hip?  In the treatment hierarchy for lumbo-pelvic-femoral control the suggested exercise for (only) the right side “Adductor Magnus (ER)->obturator” is one of the right Gluteus Maximus exercises from the appendix. I can understand that with this movement ER is facilitated, but I can’t really see any big involvement of the Adductors.

In the treatment hierarchy, the Right Adductor Magnus, an ER muscle is co-contracted with the Right Glute Max in the transverse plane initially to gain “Hole Control” and position the right obturator from a lengthened passive insufficient position to an optimal position as an external rotator.  This comes first in this hierarchy as you do not have instability of the left femoral acetabular joint. 

On the application of the Adductor Magnus, you see it is activated later in the progression as an external rotator muscle.  Initially you do need (as you nicely describe), left AF IR/FA IR/F ADD to position the left obturator from a short actively insufficient state with the left IC Adductor along with the left glute max.  These patients once securing the left hip and ligamentous muscles (left adductor and left anterior glute med) now need “dual hole control” so the exercises are less one sided and more concomitant with the right side.  You are going to activate the transverse fibers of the Adductor Magnus with the transverse fibers of the right glute max. You will then in turn activate the right obturator.  So in short, you are not going to isolate the transverse fibers of the Adductor Magnus without the glute max.

-Jennifer Poulin, PT, PRC

I was writing to see if you had a football cleat you recommend.  I am seeing a lot of athletes these days and was wondering.

I haven’t looked at football shoes specifically, but just like running shoes, you want them to have a stabile heel counter.  It should be firm and not be able to collapse in or give laterally.  Most cleats aren’t going to have good arch support.  They should also bend at the toe box.  I did a video blogabout what to look for in shoes at the Hruska Clinic website.  This might be applicable to apply to various shoe types. You might consider adding an orthotic with good arch support.

Is it possible to get a 3/5 or greater on the Hruska Adduction Lift Test on patients who are not repositioned.

That would not be possible for a patient lying on their left side (Right Adduction Lift Test) for the Left AIC or true PEC patient because the left side of the pelvis is truly out of position to attain adduction and IR needed to get past a 2/5.  But a patient lying on their right side (Left Adduction Lift Test) could get a 3/5 because the right side of the pelvis is not out of position to attain adduction and IR and although the left adductors would be in a long state, they could still lift the hips off the table to move from a 2 to a 3.  This would not be true for a PEC with both sides of the pelvis positioned forward with both hips in some ER, but it would be true for the standard Left AIC (left pelvis forward and right pelvis back).
The exhale activity I demonstrated is an attempt to factor out their strong tendancy to cheat with their back during testing (yielding false negatives for compensatory activity, or higher scores than they were actually able to get with just their hip musculature).  It doesn’t reposition the pelvis or fully shut off the AIC, but it allows the leverage deficits present because of the AIC to stand out without compensation from the back extensors.  In other words, just blowing out is not going to allow a patient lying on their left side to get to a 3/5.  They are going to need to get fully repositioned, demonstrate left AF IR strength and left FA IR strength with the appropriate musculature during left FA adduction before they employ the opposite adductor to left their pelvis in order to actually get a true 3/5.  Just blowing out cannot afford all of that for a patient lying on their left side (although it may be possible for a patient lying on their right side because their right pelvis is not forward like the left and the right hip is positioned in more of an adducted and IR state).

James Anderson, MPT, PRC

I received your question about left SI pain.  I’d love to share a couple of thoughts to answer your questions and try to clear a few things up.

On the topic of left SI torsion and compression, let me clarify a couple of points:
On a very general level (for the non-pathological left hip patient), right SI pain can be described as torsion and distraction and the left SI can be described as torsion and compression.  But if you look closely at the pathomechanics of both right and left SI joint pain, its a little more complicated than that.  The right SI joint is experiencing a right rotated torsion as the sacrum rotates right on a right oblique axis, which gaps the posterior aspect of the right SI joint.  If the left hip becomes so pathological that lumbo-pelvic and hip position prevents the ability to position into left AF IR, then the left SI joint can develop a pathology.  When the left hip does not properly position itself or properly function, then the left SI joint shifts into pathological mode.  This is notable for a right rotated torsion across the joint as the sacrum rotates away from the left illium on the same right oblique axis, which gaps the anterior aspect of the left SI joint.  So in actuality, both joints experience torsion and distraction, but the direction of sacral movement away from each illium yields a different area of joint separation (the back on the right and the front on the left). 
James Anderson, MPT, PRC

The main difficulty I have with BC patients and specifically T4 patients is the “when” for progression of activity. I sometimes feel I progress too quickly to upright activity or not quickly enough into serratus work, and now I really feel I have missed some left low trap work with patients. Do you have anything objectively that you look at for progression of patients?

You asked about an objective test for the upper half progressions.  The answer is pretty simple: The Hruska Adduction Lift Test.  From 0-2 we are doing a lot of focal left AF and FA testing, but when we move on to levels 3-5, we are really assessing the ability to get a full and well supported left ZOA with proper integrated trunk rotation.  When you can’t get further than a 2 or a 3, then you have BC position and TS strength (including abdominals) problems.  If you are having problems understanding the proper progression of patients, then you may be misunderstanding the following:
1) what the Hruska Adduction Lift Test is really for.  Its a gait performance test; with left AF IR and left ZOA isolation tested out for each phase of gait.
2) you are focusing on ST upper half work and overlooking the much more important TS training with all upper half muscles to complement and support left AF IR and left ZOA.
3) you are overlooking the tri-planer position and function of the diaphragm and all of what must occur for balanced breathing across the trunk.

I have a question in regards to the pectineus stretch.  The muscle is divided into two different portions.  The superior fiber is stretched into FA flexion, FA adduction and FA internal rotation.  Does that mean the superior pectineus is a FA abductor, external rotator and FA extendor? For the inferior pectineus stretch, the stretch position is FA abduction, FA external rotation and FA flexion.  Does that mean the inferior pectineus is a FA adductor and internal rotator?

There is general disagreement as to whether the pectineus rotates the thigh medially or laterally.  The muscle runs from the pubis medially to a lateral distal attachment behind the femur which makes it look like a lateral rotator but because of the location of the AXIS of rotation of the femur it can appear that the muscle itself passes in front of the axis.  In that case one could say that the muscle medially rotates the femur. 

With flexion past 90 degrees the axis moves and we know that EMG activity increases for medial rotation.  No matter what, it adducts and adduction power actually increases with flexion.  Thus the picture on appendix page 86 in supine is focusing on the fibers that happen to laterally rotate the thigh. (if the patient happens to have any fibers that laterally rotate the thigh).  The picture on 83 shows an ER stretch and that focuses on medial rotators. 

Pectineus is a medial rotator on the whole with some debate on the ER component and no question on flexion and adduction.  It would seem that the idea of flexing the hip (and doing ER or IR) is where the problem is since the pectineus is a hip flexor and flexing the hip would put it on slack.  The best stretch therefore would then be page 84!

Reference Duchenne GB, Physiology of motion 1949 
                Kendall and McCreary, muscle testing and function, 1983 p 178
                Travel and Simons, Myofascial Pain and Trigger Points Vol. 2 1993 p 239
-Michael Cantrell, MPT, PRC

To understand the positional and compensatory influence of the Left AIC, you need to look at the AIC as several muscles working together as one functional unit, and that this functional unit has rotational influence on the pelvis toward the right.  After this unit directs the pelvic girdle toward the right, it is compensatory activity at the left hip that actually ERs the hip enough for the knee and foot to be positioned straight forward for walking.  In other words, the Left AIC directs the pelvis toward the right, but it does not fully turn the femur into the needed amount of ER to walk forward, including ER from midstance to pushoff.  The deep ERs of the hip have to assist with this.  That is the compensatory part. 

The right hip has to IR to walk, but the pelvis that is already directed toward the right because of the influence of the Left AIC already has the right hip in the IR needed for walking without requiring any compensatory activity.  So all of these muscles on these 3 pages are in a bad position for performance before they are even asked to move the pelvis or femurs because of what the Left AIC did to the bones that position each of them.  This document linked above outlines the faulty position of all of these muscles to help the clinician understand the why so many of these muscles work more actively than they should or fail to become active enough during human movement patterns.  All 3 planes of motion are taken into consideration, because without an understanding of all 3 planes, a full understanding of muscle position and muscle function will be lost.

If you have a Left AIC pattern with a right oriented pelvis and lumbar spine, with an upper spine above that orients toward the left (transverse), right ribs flexed left ribs extended (sagittal), and right thoracic abduction (frontal) why would you pressure the sternum more on the left lateral edge because that would help to further orient the spine towards the left transversely.

You need to clarify a couple of things to have your info completely accurate.
Most patients in this pattern are oriented towards the right throughout their entire spine, just less so across the upper thoracic spine.  This right orientation comes in association with left upper trunk rotation (left ER inhalation ribs and right IR exhalation ribs).  Because the left thorax is hyper inflated, the left border of the sternum is further forward and needs to move posteriorly with left rib IR exhalation of ribs- which turns the thorax back to the right (upon inhalation) on a spine that is being re-oriented back to the left (something that occurs during exhalation).  This should explain the pressure on the left border of the sternum.