What is the difference in AF vs. FA exercises?  In the Myokinematic Restoration home study video, Mr. Anderson says a common misconception is that AF is weight bearing and FA is non weight bearing. What’s an example of an AF exercise compared to an FA exercise if it’s not just weight bearing that makes them different?

Any time the pelvis (acetabulum) moves on the femur then AF movement is taking place.  Anytime the femur is moving in the acetabulum then FA movement is taking place.  During gait both activities are occurring since the acetabulum (pelvis) is rotating around the femoral head as simultaneous femoral internal rotation is occurring with the femoral head moving internally (posteriorly) in the acetabulum.  Therefore any exercise in PRI that calls for movement of the femur in the acetabulum (no matter the WB status) is FA and anytime the acetabulum is called to move on the femur (no matter the WB status) is AF.

I have been having an issue with a patient who had ACL reconstruction on the right side who is a pronator.  They don’t have right glute max FA ER/AF ER.  Please let me know what you think about these patients if you have some time!

Your right knee ACL reconstruction patient that has a very “pronated” right foot poses some interesting challenges.  
The first issue is that he must be able to maintain support of his right calcaneus in the frontal plane when he shifts his weight over to the right into right mid-stance.  He is going to need a good stable shoe with a good stable base and a good heel counter (lateral support of heel motion).  He will also need adequate right arch support to help hold his mid-foot and heel in a near neutral position when he begins stance phase on the right side. 
This neutral controlled foot with a good arch will allow him to actively evert his right foot so he can inhibit his right adductor magnus and shift away from his right lateral hip into left AFIR and AFADD.  You will need to teach him to actively evert his right foot, but as he learns it, he will be learning to shift his right hip into AF ER and AF ABD.  This will kick in his right glute max and the posterior aspect of his right glute medius.  Besides the necessary left AF IR strength required of all Left AIC patterned patients, this right hip training will be a key to your success controlling the right knee joint.

When I took the Myokinematic Restoration class you said to email you about some information on Superior T4 syndrome.  You mentioned working your glute med’s for Superior T4’s.

Please read a handout I put together on Superior T4 syndrome.  Click HERE!

The reason I said the glute medius was such a big deal with the T4 patients is because of all the things that must be in place in order for the glute medius to be properly felt during single leg stance.  In other words, the Adductor Pull Back must have been well coordinated with proper breathing to clear out the right BC while it approximated the left femur up into the acetabulum.  In fact, your Adductor Pull Back should have restored full right HG IR to ensure that the left ZOA has been restored and the right BC has been inhibited.  The deliberate left hip approximation is a precursor for left posterior hip capsule stretching, which is often needed prior to the glute medius being able to properly work when doing single leg left AF and FA IR training.  Also of note, if the right thigh does not stay positioned ahead of the left thigh during single leg left AF IR training (like the Retro Stairs), then you are probably not maintaining the needed left AF IR state to keep the left glute medius active during single leg stance training.

I hope this helps clarify what I said about the glute medius.  And I hope the T4 document is helpful as well.  But remember, if the left hip does not do all of the above described items, your left hip comes out of place and the base of your spine will orient towards the right (something you’ll struggle to overcome with just upper half exercises).

-James Anderson, MPT, PRC

I was wondering if you might be of any assistance with a patient of mine. I have worked with this high school football player in the past who had an abdominal hernia and had surgery. He played football with no real concerns with this area and then started getting ready for triple jump in track when he started to feel the pain again. He finally went back to his physician and it was found that he had another hernia near the original. The MD wanted him to rest as he believed it would heal so he took 8 weeks off doing nothing. He still has the same pain. MD does not want to do anything until June 1 but this individual is to play college football next year and does not want to wait around. He is not sure if it will heal but does not know if surgery will be warranted. I have worked on his posture as he was rotated in his pelvis. What is your experience with these types of injuries and can you offer any assistance as what I might work with on him?

Yes, I’ve seen and treated a number of torsioned patients with resultant abdominal or inguinal hernias and these are some of the key treatment considerations:  
There is usually a pathology (ligamentous laxity) across their hips and possibly across their iliolumbar region that does not allow their pelvic floor, pelvis and abdominal wall to move out of their torsioned patterned state (R AF IR and AF ADD) into L AF IR and L AF ADD before they exert themselves.  In other words, they can’t shift fully into their L posterior capsule and get beyond the ischiofemoral ligament tightness (because they are so loose across the front of the hip) so the shifting and rotating forces that should be received via glide and roll into the L hip is transfered directly into the hernia site.
My recommendations are to first approximate and IR the L femur into the L acetabulum as strongly as possible (Right Sidelying Left Adductor Pull Back, or similar activity) prior to a passive and then active effort to stretch the L ischiofemoral ligament (usually started in L sidelying).  Attempts at stretching the posterior hip without fully “seating” the femoral head first can actually stretch them out of the hip and not into it.  
And then after the hip is fully seated and able to IR without compensation, FA IR with the IC adductor and anterior glute medius will be essential to hold the femoral head in the acetabulum during sidelying and eventually during L single leg dynamic stance activities.  If you can’t integrate these two muscles together during single leg IR stance then its a pretty good indication that you are not able to keep the femoral head properly positioned in the acetabulum during IR and that transverse and frontal forces will be directed back into the hernia site when they exert themselves.
Regardless of whether or not this athlete will need surgery or not, he will need the above muscle integration to treat the pathomechanics that put him at such high risk for hernia in the first place.

1. What, exactly, are we repositioning with the 90-90 repositioning techniques?
2. Why are patients ALWAYS in a posterior pelvic tilt when doing the exercises? 
3. What about patients who are already in a posterior pelvic tilt (i.e. no butt; they stand / exist in a posterior tilt)?

1.  You are repositioning the left coxal bone into extension, adduction and IR, called L AF IR, which actually repositions all 3 bones in the pelvic girdle (2 coxal bones and the sacrum).  Of course any change in position to the bones actually will change the position and relationships of all the associated joints and most importantly, all the associated muscles.

2.  Not always, but almost always in a posterior pelvic tilt.  If all patients started in a neutral sagittal plane position, you could view our positioning as heavily focused on posterior tilting.  But since most people are positioned forward on one or both sides, the posterior tilt emphasis is actually a strong effort to pull the pelvis back so the patient moves into a more neutral spine position and to counter the strong neuromuscular extension pattern called the AIC.

3.  Patients who stand in a posterior pelvic tilted position with their pelvis translated forward into a sway back kyphotic posture often have a different hamstring:hip flexor (length, tension, strength, tone) ratio because of the lengthening of the hip flexors and the positionally shorter hamstrings.  Note that they still could have a forward tilted pelvic position that appears to be in a posterior tilted state (with what may seem like AF EXT and AF IR), but the forward translation of the pelvic girdle is what really brought about the apparent position change. 

I recently attended the I&I course and, in reviewing the information with my PRI co-workers,realized that terminology and what appear to be contradicitons in the written material have confused us.
The first thing I’d like to clarify is terminology on scapular position and movement from the manual.

1) The manual uses both ‘protraction/retraction’ and ‘abduction/adduction’. Historically these terms are used interchangeably and refer to the movement of the scapula on the thorax in a medial/lateral direction, following the contour of the ribs. The manual seems to use ‘abd/add’ to describe a component of pro/retraction. Is this correct? Why do you use both as they don’t occur as two separate movements that the scapula can do?  You also describe a Type III as being ‘retracted’, then define that as an ‘appearance’ of retraction because the left rib cage is more ‘posterior’ than the right.  Do you mean because of a left rotation of the ribcage (spine) and if so, are all of the ribs rotated, or do you mean a position of rib ER, and if so, which ribs?

2)  Under the Treatment Guidelines for Type I: #2 is Integration of ipsilateral upper trunk rotaion with the LEFT low trap. Which side are you talking about? Ipsilateral to what, and rotation in which direction?) The exercises are then all for the RIGHT low trap and triceps, so I don’ know what he really means. Under #4, he again uses ipsilateral and contralateral and doesn’t indicate what the reference side is.

1)  Protraction and retraction refer to the movement along the ribs.  Abduction and adduction is movement of the scapula away from the spine and towards the spine.

In the manual it is stated like this:

Translatory motion
                Upward/downward (elevated/depressed)
                Abduction/Adduction
Protraction
                Forward movement of linear translation away form vertebral column, rotation of scapula around the end                                                                                                             of the clavicle (winging) and anterior movement of the lateral end of the clavicle

You can abduct and adduct your arm and scapula without protracting or retracting.  A type III scapula is in an abducted state, shoulder is usually slightly higher (Right BC Pattern) or in an abducted position, because of the spine orientation to the right in this pattern and because of upper trap, clavicular head of SCM and levator scap co-activity. 

Abduction and adduction do not have to occur with protraction and retraction.  The scapula would protract and abduct and retract and adduct at the same time if the “contour of the ribs” were the same on each side.  Which we are certain, they are not. 

Type III on the left are more in a posterior or backward position of linear translation toward the vertebral column that is further away from the spine than their counter part on the right – primarily because of a larger more expanded posterior mediastinum on the left and because of the right rib cages positional influence on positioning the right scapula in a more protracted state.  If the right thorax was normally inflating the right scapula would abduct on active protraction. 

2)  Type I’s are most often seen on the right side so ipsilateral is referring to the right side.  
        “Enhance ipsilateral apical expansion” – right side
        “Integrate ipsilateral upper trunk rotation with left low trap” – right trunk rotation with left low trap
        “Facilitate contralateral thoracic abduction and ipsilateral thoracic adduction with ipsilateral low trap” – left thoracic abduction with right thoracic adduction and right low trap

Every exercise we have in the shoulder program could be considered a right low trap/tricep activity.  In the list provided on page 80 under Type I treatment guidelines, we have went through and picked activities that would also engage the left low trap with the right low trap.  The reason it is labeled a “right low trap and tricep” is because all of them have a right low trap and right tricep component to them. 

I have been attempting to understand (etiology) and treat the condition of right ischial tendonitis.  In reading the Impingement and Instability manual, it describes left ischial tendonitis more difficult to manage because of the tendency of the Left AIC pattern and the left hip position putting the left hamstring (semitendinosus) on strain.  I have seen a few people now with only right side or initially bilateral and now only right side that I am struggling to get resolved.  When dealing with left side, I know it says that you want to take tension off of the right hamstring and develop left glute med and left quad together with right glute max.  Is it safe to say that with the right side you want to inhibit left hamstring and develop right quad and right glute med with left glute max?  How does the right ischial tendonitis develop…is it a right quad to right hamstring ratio deficit?  What exercise have you had success using?

You would not want to reverse the treatment for Left Ischial Tendonitis to treat Right Ischial Tendonitis.  Right Ischial Tendonitis is very common.  This would be considered a “Myokinematic Restoration issue”.  The tendon on the right side is being used for constant AF IR, it is long.  The glute max on the right is gone because they are relying on their hip flexors and hamstrings for support in the sagittal plane.

To reduce this pull on the right hamstring, you would want to shift them to the left (left AF IR).  The right glute max is a critical piece in this because the right glute max will help you gain frontal and transverse control on the right.

The exercises we would work on would be:

Left Sidelying IO/TA and Left Adductor with Right Glute Max
Standing Wall Supported Left Knee Flexion with Resisted Right Glute Max
Standing Supported Resisted Right AF ER with Right Glute Max

All three of these activities work on Left AF IR with Right Glute Max.

Based on PRI theory, what SI joint would move more in the sagittal plane?  And what SI joint would move more in the frontal plane (research says more sagittal plane motion of the right and more frontal/coronal plane motion on the left side)?

Really depends on the patient. We could argue for both but wouldn’t have enough evidence behind it to be objective.

It would make sense that in a Left AIC pattern the innominate moves anterior on the left and posterior on the right – possibly equally in the sagittal plane. And therefore, we see right SI pain patients do well with PRI. Compensation on the left usually is in the transverse plane to accommodate the need for more FA ER which usually results in overactive glute max muscle and left SI pain. Frontal plane orientations and compensation are difficult to assess without fluoroscopy because passive orientation isn’t a reflection of what is moving more or less. 

What is the neuromuscular deficit in individuals who cannot inhale through the nose while holding air in a balloon? What are some good cues to help them along?

Some neuromuscular deficits in individuals who cannot inhale through their nose include:
1.  Restricted air flow through sinus cavity (deviated septum, sinus polyps, etc.)
2.  Restricted airway (sleep apnea, forward head posture, cervical instability, mandible position, etc.)
3.  Poor abdominal co-contraction during inspiration (poor ZOA and thorax position)
4.  Poor diaphragmatic power-strength
I encourage them to start with the balloon by pinching the neck off the balloon while inhaling and then gradually move into respiration (6 seconds out through the mouth and 3 seconds in through the nose) as neuromuscular and respiratory strategy improves…again provided they don’t have a cold, sinus congestion, airway compromises, etc.

I have a referral into the clinic for a 60 year old female with continuing right facial pain after having a dental cleaning.  It has become more frequent and intense over the past month.  Everything dentally has been cleared and she has been cleared by the ENT.  My immediate thought is Trigeminal Neuralgia but this has not been formally diagnosed.  Other than the things we have been shown through the Postural Respiration course are the other things I should look for or use for someone like this?

A pivotal treatment consideration for this patient is her ability to rotate her C3-C7 cervical spine to the left.  If it rotates well to the right and is limited to the left then your spinal position is strongly oriented right and requires that her cranium counter rotate to visualize the frontal plane via right TMCC activity.
You will need to get her into left AF IR and secure her left hip with both frontal and transverse plane musculature.  And after you secure her left hip, her right glute max will be needed in the transverse plane to redirect her pelvic and spinal orientation to the left.  Her left ZOA and left IO’s and TA’s will be a key to anchoring the spine left prior to thoracic-scapular and scapular-thoracic right low trap work.  This would be my first course of action to get her neck to rotate to the left.  If she is very overactive in her right anterior neck, she may have developed into Superior T4 Syndrome, but the spinal orientation issues are still going to need to be addressed.  Manual BC treatments are likely in this case.
If you can neutralize her neck with the Myokinematic Restoration and Postural Respiration principles described above, she would probably do well with some cranial stability afforded by the lateral pterygoids.  Teach her to “cluck” and to blow a balloon and other related activities with her tongue on the roof of her mouth.  In fact, it would be good if she could move her jaw both ways with her tongue elevated to the roof of her mouth (jaw to the right will likely be the challenge) while she shifts and rotates her body in gait-like fashion.

I have a question on the most recent clip regarding cervical axial rotation and decending vs. acsending issues.  Listening to Jen’s patient case study sounded very familiar as I have a patient struggling with right sided neck pain and headaches who is slowly getting better but not over the hump. Neutral BC except we have trouble keeping keep axial rotation to the left.  So I tried the modified exercises with her today.  With each one I could not get her to feel her left SCM and in fact all she felt was her right neck working to the point of creating some discomfort that she hadn’t had in awhile.  Is there a better cue to use to engage her left SCM or was she just not stable enough proximally (have just started upright right serratus work with her) to be able to keep her right neck off?

Ask your patient to sit upright first and find and feel or search for her left SCM by moving her chin down toward her right chest and slightly sidebend to the left.  Compare this activity to the other side…or consider starting with the other side first to help with associated movement that is denied on the left.  Then try the sidelying left SCM recommendations.  If this fails consider supine activation (see Florence Kendall recommendations).  You’re also correct in your thinking; regarding right SA, lower trap, and tricep instability.  This may be the chief issue.

Describe the intent of the bolster for the Left Sidelying Right Glute Max, Left Sidelying Knee Toward Knee and Right Sidelying Adductor Pull Back exercises.  Is the bolster under the feet for sidelying exercises there to increase the ROM that the hips have to go through…..Left Sidelying Right Glute Max to increase right hip ER ROM?  Left Sidelying Knee to Knee to increase right hip ER and left hip IR (help activate left anterior glute med and IC adductor magnus more via shortening it w/ hip IR positioning)?  What about bolster in between both legs for Adductor Pull Back….that puts left hip into more IR.

The bolster under the ankles, when the patient is in left sidelying, is to help align the medial malleolus with the pube. It also gives the patient the sensation or proprioceptive input to “turn” the right knee up (right FA ER) and “turn” the left knee up for left FA IR. It places the left ischiocondylar adductor and the right FA ER’s in better transverse plane position. The bolster between the ankles when in right sideyling helps increase left FA IR with left adductors (left ischicondylar adductors).