基础动力学讲义
基础动力学讲义
基础动力学讲义
Day 1 Day 2
Left Anterior Interior Chain (AIC) Myokinematic Functional
Pattern and Pelvic Joint Dynamics Relationships
5255 R S REE
LINCOLN, NE 68504
402-467-4111
Posterior Exterior Chain (PEC) Internal Obliques/Transversus Abdominis, Paravertebrals, Quadratus Lumborum
External Obliques
www.posturalrestoration.com
Right Brachial Chain (R BC) R Lower Trapezius, R Triceps, L L HG Adductors (Pec Major), R
Triangularis Sterni, B Serratus Anterior, B Scapulothoracic IR (Pec Minor), R
Middle Trapezius Latissimus Dorsi
Individuals experiencing symptoms at the knee, hip, groin, sacral-iliac joint, back, top of shoulder, between the
shoulder blades, neck, face, or TMJ, will demonstrate inability to fully adduct, extend or flex their legs, on one or
both sides of their body. They usually have difficulty in rotating their trunk to one or both directions and are not
able to fully expand one or both sides of their apical chest wall upon deep inhalation. Cervical rotation,
mandibular patterns of movement, shoulder flexion, horizontal abduction and internal rotation limitations, on one
or both sides will also compliment the above findings. Postural asymmetry will be very noticeable, with one
shoulder lower than the other, and continual shift of their body directed to one side through their hips.
The pattern that is most often prevalent involves the left anterior interior chain, the right brachial chain and the
right posterior back muscles (PEC) of the body. The left pelvis is anteriorly tipped and forwardly rotated. This
directional, rotational influence on the low back and spine to the right, mandates compulsive compensatory
movement in one or more areas of the trunk, upper extremities and cervical-cranial-mandibular muscle. The
greatest impact is on rib alignment and position, therefore influencing breathing patterns and ability. It is very
possible that respiratory dysfunctions, associated for example with asthma or daily, occupational, repetitive, work
positions, can also influence pelvic balance and lead to a compensatory pattern of an anteriorly tipped and
forwardly rotated pelvis on the left.
Other common, objective findings secondary to compensatory physical attempts to remain balanced over this
unlevel pelvis include elevated anterior ribs on the left, lowered, depressed shoulder and chest on the right,
posterior rib hump on the right, overdeveloped lower right back muscle, curvature of the spine and asymmetry of
the head and face.
This particular pattern of neuromuscular imbalance is enhanced and generated usually at early ages of
development in the pre-adolescent and adolescent years. Since the fibers from our diaphragm that attach to the
front of the low spine and our diaphragm in general is stronger on the right, we all have a tendency to shift and
rotate our spine to the right sooner and more often than to the left. The liver also assists this directional pull on
the spine and pelvis because it keeps the right larger diaphragm better positioned for respiratory activity. We do
not have a liver on the left side. The left diaphragm leaflet is much smaller and does not have the advantage to
pull the ribs up and out upon inhalation, so there is a tendency to relax the left abdominal wall. Consequently,
these abdominal muscles on the left become weak.
This pattern complements our right dominance of extremity use, our daily shifting of weight to the right and
overcompensating patterns of activity above and below our pelvic floor. Airflow for example, will generally
move more easily into the left chest wall than into the right because of the rotational influence of the ribs, as
previously described. Lack of underlying structural support exists on the right that does not exist on the left due to
pericardium position. Rotation of the upper trunk to the left will generate less activity on the neck when in this
pattern because of this dynamic, respiratory, structural phenomena. However, rotation of the upper trunk to the
right limits air movement into the left chest wall. This created torque on soft tissue, secondary to movement on
an imbalanced foundational structure, usually results in chronic muscle overuse, inflammation and pain, such as
one would see in someone diagnosed with fibromyalgia or scoliosis.
The human body is not symmetrical. The neurological, respiratory, circulatory, muscular and vision
systems are not the same on the left side of the body as they are on the right, and vice versa. They have
different responsibilities, function, position and demands on them. This system asymmetry is a good
thing and an amazing design. The human body is balanced through the integration of system
imbalances. The torso, for example, is balanced with a liver on the right and a heart on the left.
Extremity dominance is balanced through reciprocal function; i.e. left arm moves with right leg and vice
versa.
Postural Restoration Institute® (PRI) credentialed professionals recognize these imbalances and typical
patterns associated with system disuse or weakness that develops because of dominant overuse. This
dominant overuse of one side of the body can develop from other system unilateral overuse. For
example, if the left smaller diaphragm is not held accountable for respiration as the right is, the body can
bec e i ed. The igh dia h ag i a a i a be e i i f e i a i , beca e f he i e
structural support of the right larger diaphragm leaflet. Therefore, the left abdominals are always
important to use during reciprocal function, such as walking, to keep the torso balanced.
Keeping the right chest opened during breathing is also challenging since there is no heart muscle inside
the right side of the chest. Standing mainly on the right lower extremity to offset the weight of the left
upper torso, assists in moving the pelvis forward on the left and the shoulder complex down on the right.
This asymmetry compliments the special functions of the two sides of the brain. Although the two sides
(hemispheres) of the brain share responsibilities for some functions, each hemisphere has its own
ecia ie . Each he i he e c he i e ide f he b d . The ef b ai ha e
responsibilities for speech and language and thus the right upper extremity becomes a dominant
extremity in communication, growth and development. PRI credentialed professionals recognize when
this normal pattern is not balanced sufficiently with left extremity neurologic and muscular activity.
When these normal imbalances are not regulated by reciprocal function during walking, breathing or
turning, a strong pattern emerges creating structural weaknesses, instabilities, and musculo-skeletal pain
syndromes. Balancing muscle activity around the sacrum (pelvis), the sternum (thorax) and the
sphenoid (middle of the head) through a PRI approach best positions multiple systems of the human
body for appropriate integrated asymmetrical function. PRI credentialed professionals incorporate
reciprocal f c i ed ce eadi g i h he ef e i a d igh a , a d e i a f ci
maximize airflow in and out of the right lung.
Vision, occupational demands, in-uterine position, etc. can all influence asymmetrical tendencies and
patterns. Humpback whales bottom-feed on their right side, lemurs tend to be lefties when it comes to
grabbing their grub, toads use their right forepaw more than their left, chimpanzees hold a branch up
with the left hand and pick the fruit with their right hand, and humans usually balance their center of
gravity over their right leg for functional ease and postural security. PRI credentialed professionals
recognize the more common integrated patterns of human stance, extremity use, respiratory function,
vestibular imbalance, mandibular orientation and foot dynamics; and balance these patterns, as much as
possible, through specific exercise programs that integrate correct respiration with left side or right side
inhibitory or facilitory function.
State of Disengagement
If e a i he dic i a i fi d defi i i ha a e, a ig ed i h
i g a ide i a a , di e, c e ; be gi g ei he i d ide. If a ea
chemist or pulmonologist it means neither acidic nor alkalinic. If you are a physicist it means having a
net electric charge of zero. If you are a painter it means, of or indicating a color that lacks hue or
achromatic. If you are a neutral politician you are on neither side and possess moderate views. If you
are an engineer, neutral means the machine is in a position in which a set of gears is disengaged.
If you are a PRI clinician, neutral means the human body posture is in a position in which a set of
muscles are disengaging so that a new strategic process of using these same polyarticular muscles can be
established. Those set of muscles are outlined in the summary section of the composite of PRI courses
as related to the Left AIC, Right BC and Right TMCC patterns. Once these muscles and corresponding
predictable faulty movement patterns are placed in a neutral or disengaged state, resumption of activity
can take place from a different start point or position. It is from this point reeducation of the
neuromuscular system, to build more efficient strategies and patterns of movement, can take place.
Transitional Zone
The ability to move from one end of a range of motion through a transitional zone, or mid-zone, to the
other end of the range of motion, and vice e a, c i e i g h gh i a d f
neutrality. It is important that the human experiences this mid-range position or can get into this
transitional zone of neutrality when the body attempts to shift, sway or swing using effortless
momentum.
People can develop tendencies or patterns built from sensory processing that promote more motion in
one direction and minimize motion in the other direction. These patterns include motion in all three
planes and include what happens on both the right and left sides of the body. The ability to decrease this
tri-planar bias of the body, which then allows a person to move into and through the mid-zone between
both ends of the movement spectrum, in each of the three planes, is required for neutrality to occur.
Moving into mid-stance or pronation on one lower extremity, as the other lower extremity is swinging
forward for weight of the body to be transitioned to the swinging leg at heel strike, is a good example of
decreased tri-planar balance on the mid-stance or pronated lower extremity. Human locomotion requires
uninterrupted alternating lower extremity exchange of weight support. Unbiased dynamic reciprocal
eigh di ib i a hee a d e a eed cc , f he h a a h gh a e a ,
transitional zone at the pelvis and at each midfoot, during mid-stance.
Unbiased Position
If at the time of re-examination, your patient is not neutral, further PRI intervention will not allow the
patie b d e e e c ei i i ic h h . Efficie e e de e d he b d
ability to reciprocally produce action marked by the regular recurrence from a start position that is in an
unbiased position.
This unpolarized or unbiased position is not usually taken into consideration when exercise programs are
designed or when evaluation occurs. In fact, the hypothetical neutral spinal position is rarely achieved,
achievable, nor maintained in activities of daily living. Our spines will never be optimally and
completely aligned at rest or during activity. However, we can achieve neutral zones where the body
functions most optimally.
Summary
Placing the sacrum, sternum and sphenoid in a desirable neutral position, from which movement begins
and ends, is not as challenging as it may seem, if one understands polyarticular triplanar organization
a d a cia ed a e f e i a i . The e a e a hi hica a ache ha e ea e a
i e e he de ad. B hese neutral spine principles do not take into consideration the
normal aberrations, asymmetries, and malalignments of the neuromuscular, cortical, reflexive, visceral
a d e ia e . The e a - e a a e a ei f ce c e atory
lateralization development. Once asymmetrical system integration is understood, optimal subconscious
competent function can occur without homo-lateral (ipsilateral) compensation, or hemi-lateral
symptomology.
PRI has outlined this asymmetrical system-integration and offered corresponding tests to determine if
he a ie i habi a ad i g e g he i g hei i e de i ab e e a ii .
These tests take into consideration: 1) the joints neutral position where minimal resistance is given by
he e iga e c e; 2) he c a i i f e ce C1 a d C2 a d he e i a e ; 3)
the diaphragm and rib interplay influence on sternal and spinal orientation; 4) the pelvic floor septal-
sagittal influence on the frontal plane; and 5) the visual-vestibular influence, in maintaining a center of
mass, on the head-on-body and body-on-head igh i g eac i ife e ba i .
These concepts will be useful to anybody and everybody who has an interest in tri-planar movement of
the human body and how homo-lateral (ipsilateral) muscle movement can affect and influence hemi-
lateral function.
Treatment considerations and the recommended PRI non-manual techniques, as related to the balanced,
a e ica a e ed h a , i a he begi e PRI c e a e dee i edia e fi d
success at reducing or inhibiting patterned position driven muscle. If you have taken one of our other
courses, you will recognize the strong correlation and integration of three polyarticular chains composed
f c e ha ca bec e e e e i e e i g a e c a eai f he fa i ie
of muscle. If you have taken this course before, you will hopefully enjoy this presentation even more
because of the familiarity with the flow of material, and the unique demonstration and participation by
e fe c e a e dee .
The PRI faculty recognize how important it is to establish a working vocabulary and clinical approach,
ea i h PRI f a i g a d d . Thi c e a e di i fa h f i g hei
e. I i ia i f he d ef e igh i e a a e he e i g he a e di . Thi
lateralized terminology is carried out under subtitles of facilitatory and inhibitory non-manual
techniques, also summarized in this appendix.
O ce agai , ha f a i g ad a age f hi i , a d if hi i fi c e
welcome to PRI! If you are a former PRI student, thank you for continuing on this path of integration!
Hopefully, your clients, patients and future students will be as grateful as I am.
References:
1. Zaidi, ZF. Body asymmetries: Incidence, etiology and clinical implications. Australian Journal of Basic and
Applied Sciences, 2011; 5(9): 2157-2191.
2. Arun, CP. The importance of being asymmetric: the physiology of digesta propulsion on Earth and in space.
Ann NY Acad Sci, 2004; 1027: 74-84.
3. Wolpert, L. Development of the asymmetric human. European Review, 2005; 13(2): 97-103.
4. Vallortigara, G and Rogers, LJ. Survival with an asymmetrical brain: Advantages and disadvantages of
cerebral lateralization. Behavioral and Brain Sciences, 2005; 28: 575-633.
5. Lee, H. et al. The association between asymmetric hip mobility and neck pain in young adults. Journal of
Manipulative and Physiological Therapeutics, 2013; 23: 364-368.
6. Zink, JG and Lawson, WB. An osteopathic structural examination and functional interpretation of the soma.
Osteopathic Annals, 1979; 7(12): 433-440.
7. Sahrmann, S. Diagnosis and treatment of movement impairment syndromes. St. Louis: Mosby, 2002.
8. Boyle, KL. Clinical application of the right sidelying respiratory left adductor pull back exercise. The
International Journal of Sports Physical Therapy, 2013; 8(3): 349-358.
9. Krawiec, CJ et al. Static innominate asymmetry and leg length discrepancy in asympotomatic collegiate
athletes. Manual Therapy, 2003; 8(4): 207-213.
10. Levangie, PK. The association between static pelvic asymmetry and low back pain. Spine, 1999; 24: 1234-
1242.
11. Chibulka, MT et al. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low
back pain. Physical Therapy, 1988; 68: 1359-1363.
12. Hruska, R. Pelvic stability influences lower-extremity kinematics. Biomechanics, 1998 (June); 23-29.
MYOKINEMATICS
Defined: The study of motion, or lack of motion, produced by specific muscle force.
In other words, it is the study of muscle as it relates to movement.
1) When using a myokinematic focus, rehabilitative goals will include symmetrical muscle
flexibility, strength and length and how they affect motion.
2) Asymmetries in muscle strength and endurance must be balanced between agonists and
antagonists.
Anterior view of an
anterior and forward
positioned left innominate
with accompanying right
sacral torsion.
Posterior view of an
anterior and forward
positioned left innominate
with accompanying right
sacral torsion.
Note:
Raised left ischium
Right SI distraction
Rotation of sacrum, L5 and
L4 to the right
O a a
Closure of left obturator
foramen
Ligamentum Ligamentum
Iliofemorale Iliofemorale
Ligamentum Ligamentum
Pubefemorale Pubefemorale
Os Pubis Os Pubis
Femur Femur
Reprinted from The Malalignment Syndrome: Implications for Medicine and Sport. Wolf Schamberger.
Page 17 and 11. Copyright 2002, with permission from Elsevier.
1) Anterior Ligaments of Pelvis: The ventral S.I. ligaments are the weakest and are supported
anteriorly by the integrity of the pubic symphysis. (Netter 335)
b. Sacrospinous (from the lateral aspect of sacrum and coccyx to the spine of the ischium)
b. Sacrotuberous
Blends with the long head of biceps femoris
From the P.I.I.S., 4th and 5th transverse tubercles of the lateral sacrum and the lateral
coccyx to the inner ischial tuberosity (restricts sacral nutation)
A key function of the sacrotuberous (posterior) and sacrospinous ligament (anterior) is to
limit the amount of upward movement of the inferior sacrum
1) Piriformis
a. Proximal attachment - pelvic surface of the 2nd and 4th sacral segments, superior margin of
the greater sciatic notch and sacrotuberous ligament
b. Distal attachment - greater trochanter of the femur
c. Stabilizes sacrum, acts as a sacrum internal rotator, positions innominate via sacrum and
a a ac ,a b a a a ad ac ab
2) Coccygeus (ischiococcygeus)
a. Proximal attachment - ischial spine
b. Distal attachment - inferior end of the sacrum
c. Supports pelvic floor, draws coccyx forward during parturition or defecation
4) Gluteus maximus
a. Proximal attachment ilium behind posterior gluteal line and sacrotuberous ligament
b. Distal attachment iliotibial band and gluteal tuberosity of femur
c. Extends acetabulum (pelvis) on femur, extends and externally rotates femur on acetabulum,
a d c a a d ac ab , ac a ,
sacrum to femur, and femur to innominate and acetabulum, innominate to sacrum and femur
to sacrum
The sacral surface (of the SI Joint) is composed of hyaline cartilage and the iliac surface is
composed of fibrocartilage.
When the sacrum moves into nutation (increase lordosis) ligamentous tension increases and joint
compression increases.
C. Pubic Symphysis
1) Superior pubic
2) Arcuate inferior
The decussating tendinous fibers of the rectus abdominus and the external oblique
muscles also strengthen the pubic symphysis anteriorly.
D. L ga e M c e
1) Iliofemoral
The fibrous capsule is reinforced anteriorly by the strong Y-shaped iliofemoral ligaments (of
Bigelow). It attaches to the interior inferior iliac spine, the proximal acetabular rim, and the
intertrochanteric line distally. The iliofemoral ligament prevents hyperextension of the femoral-
acetabular (FA) joint during standing by forcing (twisting) the femoral head into the acetabulum.
Anterior View
Iliofemoral
Ligament
Posterior View
Iliofemoral
Ligament
2) Pubofemoral
The fibrous capsule reinforces inferiorly and anteriorly by the pubofemoral ligament. It arises
from the obturator crest of the pubic bone and passes laterally/inferiorly to merge with the
femoral-acetabular (FA) capsule. It also blends with the medial portion of the iliofemoral
ligament. It tightens during extension and abduction of the FA joint. Key function is checking
over-abduction of the hip.
Anterior View
Pubofemoral
Ligament
3) Ischiofemoral
The fibrous capsule is reinforced posteriorly by the ischiofemoral ligament. It arises from the
ischial part of acetabular rim and spirals superiorly/laterally to the neck of the femur just medial
the base of the greater trochanter. It tends to hold the femoral head medially into the acetabulum,
preventing hyperextension of the femoral-acetabular (FA) joint.
Posterior View
Ischiofemoral
Ligament
Hip at 90 (seated)
C. L ga e M c e
Femoral Rotators
EXTERNAL ROTATORS INTERNAL ROTATORS
ILIACUS (LESSER TROCHANTER), PSOAS (LESSER GLUTEUS MEDIUS (ANTERIOR FIBER GREATER
TROCHANTER) TROCHANTER)
GLUTEUS MAXIMUS (ILIOTIBIAL FASCIA, GLUTEAL GLUTEUS MINIMUS (ANTERIOR GREATER
TUBEROSITY) TROCHANTER)
PIRIFORMIS (GREATER TROCHANTER) TENSOR FASCIA LATAE (ILIOTIBIAL TRACT, GERDY S
TUBERCLE)
SUPERIOR GEMELLUS, OBTURATOR INTERNUS,
INFERIOR GEMELLUS, OBTURATOR EXTERNUS, ADDUCTOR MAGNUS (ISCHIOCONDYLAR-MEDIAL
QUADRATUS FEMORIS CONDYLE)
SEMIMEMBRANOSUS (MEDIAL TIBIAL CONDYLE)
SARTORIUS (GRACILIS AND SEMITENDINOSUS
SEMITENDINOSUS (MEDIAL TIBIAL CONDYLE)
TENDON)
PECTINEUS (PECTINEAL LINE) after 90o of hip flexion it
becomes an internal rotator
ADDUCTOR LONGUS (LINEA ASPERA)
FEMORAL STABILIZERS
HIP EXTENSORS
ADDUCTOR MAGNUS SEMIMEMBRANOSUS
*BICEP FEMORIS LONG HEAD/FIBULAR HEAD *SEMITENDINOSUS
GLUTEUS MAXIMUS
KNEE FLEXORS
GRACILIS BICEP FEMORIS SHORT HEAD
BICEPS FEMORIS LONG HEAD *SEMITENDINOSUS
POPLITEUS
HIP FLEXORS
ILIACUS/PSOAS TENSOR FASCIA LATAE
SARTORIUS
*RECTUS FEMORIS more active as an external
rotator with anterior pelvic rotation
KNEE EXTENSORS
VASTUS LATERALIS with valgus
GASTROC/SOLEUS with supination
*RECTUS FEMORIS more active as an external
rotator with anterior pelvic rotation
* Two Joint Muscle
Femoral Rotators
External Rotators
MUSCLE PROXIMAL ATTACHMENT DISTAL ATTACHMENT INNERV-
ATION
Sides of T12-L5 vertebrae and discs L1-L4
PSOAS MAJOR between them; transverse processes of Lesser trochanter of femur
all lumbar vertebrae
Sides of T12-L1 vertebrae and Pectineal line, iliopectineal eminence via L1, L2
PSOAS MINOR
intervertebral disc iliopectineal arch
Iliac crest, iliac fossa, ala of sacrum, Tendon of psoas major, lesser trochanter, and L1-L4
ILIACUS
and anterior sacroiliac ligaments distal femur
Ilium posterior to posterior gluteal line, Most fibers end in iliotibial tract that inserts into L5, S1, S2
GLUTEUS MAXIMUS dorsal surface of sacrum and coccyx, lateral condyle of tibia; some fibers insert on
and sacrotuberous ligament gluteal tuberosity of femur
Anterior surface of sacrum and L5, S1, S2
PIRIFORMIS Superior border of greater trochanter of femur
sacrotuberous ligament
Medial surface of greater trochanter (trochanteric L5, S1-S3
SUPERIOR GEMELLUS Ischial spine
fossa) of femur
Medial surface of greater trochanter (trochanteric L4, L5, S1,
INFERIOR GEMELLUS Ischial tuberosity
fossa) of femur S2
Pelvic surfaces of ilium and ischium; Medial surface of greater trochanter (trochanteric L5, S1-S3
OBTURATOR INTERNUS
Obturator membrane fossa) of femur
Margins of obturator foramen and L3, L4
OBTURATOR EXTERNUS Trochanteric fossa of femur
obturator membrane, arcuate tendon
Quadrate tubercle on intertrochanteric crest of L4, L5, S1,
QUADRATUS FEMORIS Lateral border of ischial tuberosity
femur and area inferior to it S2
Anterior superior iliac spine and S2-S4
SARTORIUS Superior part of medial surface of tibia
anterior part of iliac crest
Pectineal line of femur, just inferior to lesser L2-L4
PECTINEUS Superior ramus of pubis
trochanter
ADDUCTOR LONGUS Body of pubis inferior to pubic crest Middle third of linea aspera of femur L2-L4
Anterior inferior iliac spine and ilium Base of patella and by patellar ligament to tibial L2-L4
RECTUS FEMORIS
superior to acetabulum tuberosity
BICEP FEMORIS Long Head Ischial tuberosity L5, S1-S3
Lateral side of head of fibula; tendon is split at
Linea aspera and lateral supracondylar L5, S1, S2
BICEP FEMORIS Short Head this site by fibular collateral ligament of knee
line of femur
INTERNAL ROTATORS
MUSCLE PROXIMAL ATTACHMENT DISTAL ATTACHMENT INNERVATION
External surface of ilium between L4, L5, S1
GLUTEUS MEDIUS Lateral surface of greater trochanter of femur
anterior and posterior gluteal lines
External surface of ilium between Anterior surface of greater trochanter of L4, L5, S1
GLUTEUS MINIMUS
anterior and inferior gluteal lines femur
Anterior superior iliac spine and Iliotibial tract that attaches to lateral condyle L4, L5, S1
TENSOR FASCIA LATAE
anterior part of iliac crest of tibia
Adductor part: inferior ramus of Adductor part: gluteal tuberosity, linea L2-L5, S1
ADDUCTOR MAGNUS pubis, ramus of ischium aspera, medial supracondylar line
Ischiocondylar Portion
Hamstrings part: ischial tuberosity Hamstrings part: adductor tubercle of femur
SEMITENDINOSUS Medial surface of superior part of tibia L4-5, S1-2
Posterior part of medial condyle of tibia; L4, L5, S1, S2
Ischial tuberosity
SEMIMEMBRANOSUS reflected attachment forms oblique popliteal
ligament (to lateral femoral condyle)
FEMORAL STABILIZERS
MUSCLE PROXIMAL ATTACHMENT DISTAL ATTACHMENT INNERVATION
Adductor part: inferior ramus of Adductor part: gluteal tuberosity, linea aspera, L2-L5, S1
ADDUCTOR MAGNUS pubis, ramus of ischium medial supracondylar line
(Middle Fibers)
Hamstrings part: ischial tuberosity Hamstrings part: adductor tubercle of femur
BICEP FEMORIS Short Linea aspera and lateral Lateral side of head of fibula; tendon is split at L5, S1, S2
Head supracondylar line of femur this site by fibular collateral ligament of knee
Patients with a Left AIC pattern who are positioned in a state of right AF IR and left AF ER present with
the following myokinematic relationships:
The left innominate is positioned in a state of AF flexion, abduction, and external rotation with
compensatory femoral (FA) activity. All efforts to restore correct AF position and rehabilitate FA
activity on the left side should include extension, adduction and internal rotation.
Left AIC Positional Influences on Left Lumbo-Pelvic-Femoral Muscle Length and Strength
Flexors
Iliacus / Psoas (ER) short and strong secondary to flexion (positional) and external rotation
(compensatory). Overactive as a flexor and external rotator secondary to position (compromised
sagittal opposition from hamstrings, glute max and obliques).
Rectus Femoris (ER) short and strong secondary to flexion (positional) and external rotation
(compensatory).
TFL (IR) short and strong secondary to flexion (positional) and overactive as an internal rotator
secondary to compromised agonistic anterior glute med and IC adductor magnus.
Pectineus (IR >90° hip flexion) long and weak secondary to external rotation (compensatory).
Extensors
Biceps femoris (ER) long and weak secondary to flexion (positional).
Semi-ten and Semi-mem (IR) longer and weaker secondary to flexion (positional) and external
rotation (compensatory).
Glute Max (ER) extension fibers long, weak and out of position for optimal extension because of
flexion (positional) - i.e. anterior pelvic rotation. External rotator fibers are short and strong with
optimal leverage secondary to external rotation (compensatory).
Abductors
Posterior Glute Med (ER) short and strong secondary to abduction and external rotation
(compensatory).
Anterior Glute Med (IR) long and weak secondary to abduction and external rotation
(compensatory).
Adductors
Adductor Magnus and Longus (ER) long and weak secondary to abduction (compensatory) in
frontal plane, but short and strong in transverse plane.
Ischiocondylar Adductor Magnus (IR) longer and weaker secondary to abduction and external
rotation (compensatory).
Additional Rotators
Piriformis (ER) short and strong secondary to external rotation (compensatory).
Obturator Internus (ER) short, straight and weak secondary to flexion, i.e. anterior forward rotation
(positional) and external rotation (compensatory).
Vastus Lateralis (IR) long and weak secondary to external rotation (compensatory) with increased
postural demand on lateral soft tissue secondary to compromised position of hamstrings, glute max
and obliques.
The right innominate is positioned in a state of AF extension, adduction and internal rotation with
positional femoral activity. All efforts to restore correct AF position and rehabilitate AF and FA
activities on the right side should include flexion, abduction and external rotation.
Left AIC Positional Influences on Right Lumbo-Pelvic-Femoral Muscle Length and Strength
Flexors
Iliacus / Psoas (ER) long and weak secondary to extension and internal rotation (positional).
Rectus Femoris (ER) long and weak secondary to extension and internal rotation (positional).
TFL (IR) short or normal length secondary to extension and internal rotation (positional).
Pectineus (IR >90 hip flexion) short and strong secondary to internal rotation (positional).
Extensors
Biceps femoris (ER) long secondary to internal rotation (positional) and strong secondary to
extension (positional).
Semi-ten and Semi-mem (IR) short and strong secondary to extension and internal rotation
(positional).
Glute Max (ER) External rotator fibers are long, weak and out of position for optimal external
rotation secondary to internal rotation (positional). Extension fibers short and strong with optimal
leverage secondary to extension (positional).
Abductors
Posterior Glute Med (ER) long and weak secondary to adduction and internal rotation
(positional).
Anterior Glute Med (IR) long secondary to adduction (positional) but short and strong secondary
to internal rotation (positional).
Adductors
Adductor Magnus and Longus (ER) short and strong secondary to adduction (positional) in frontal
plane, but long and weak in transverse plane.
Ischiocondylar Adductor Magnus (IR) shorter and stronger secondary to adduction and internal
rotation (positional).
Additional Rotators
Piriformis (ER) long and weak secondary to internal rotation (positional).
Obturator Internus (ER) long, angled and weak secondary to extension, i.e. relative posterior
tilt/backward rotation (positional) and internal rotation (positional).
Vastus Lateralis (IR) short and strong secondary to internal rotation (positional) with increased
demand as an abductor and internal rotator (compensatory).
sacrum
R L L R
1 Piriformis
2 Iliacus
3 Gluteus maximus
hip bone
Lateral surface
Left Right
1 Gluteus medius
2 Gluteus minimus
3 Gluteus maximus
4 Piriformis
5 Adductor magnus
6 Obturator externus / internus
1 Iliacus
2 Obturator externus / internus
2
1 Iliacus
From behind
1 Adductor magnus
1 Adductor magnus
2 Obturator externus / internus
From below
2
FEMUR
From the front and medial side
4
2
3
3
Left
1 Piriformis
2 Gluteus minimus
3 Iliacus
4 Obturator externus / internus
5 Gluteus medius
Right
FEMUR
From behind, from lateral side and from above
From behind
1
1 7
2
Left
3 4
4
1 Gluteus medius
2 Obturator externus / internus
3 Iliacus
4 Adductor magnus
From above 5 Gluteus maximus
6 Piriformis
7 Gluteus minimus
Right
From behind
6
From above
1) Hamstrings (sagittal)
5) Adductors
Last Piton
6) Gravity
*These two muscles secure the acetabulum via attachment at lesser and greater trochanters with
a b a a d c a ac ac .
Figure 10: Clockwise rotation of the acetabulum on the Figure 11: Anticlockwise rotation of the acetabulum on the
femur results in the acetabulum internally rotating on the femur results in the acetabulum internally rotating on the
fixed right femur causing right acetabulum femoral internal fixed left femur causing left acetabulum femoral internal
a AF IR a d c c a ac ab a left AF IR and concomitant right acetabulum
a a AF ER ac ab a a a right AF ER ac ab nally
rotating on the fixed left femur. (J. Masek, 2014) rotating on the fixed right femur. (J. Masek, 2014)
Figures from: Masek, J. Femoroacetabular impingement mechanisms, diagnosis, and treatment options using postural
restoration®: part 1. Sportex. March 2015. Used with permission. https://co-kinetic.com/profile/18
1) Gluteus Maximus
2) Biceps Femoris
3) Obturators
1) TFL (FA)
1) Which pelvic and femoral rotators are inactive? Active? Long? Short?
3) One third of hip flexion movement is the consequence of pelvic posterior rotation or back
extension. This rotation always occurs within the first 8 degrees of hip flexion movement
(Bohannon 1985). Therefore, it is important to have working AF extensors and external rotators.
4) The most likely beginning of pathomyokinematics at the pelvis occurs with a long, inactive bicep
femoris (long head) on the left; a long, inactive, ischiochondylar adductor on the left; and a long,
weak, inferior, gluteus maximus on the right.
5) The most important movement of the hip is internal/external rotation, which activates receptors
of the posterior & anterior capsule. Abduction and adduction is also important because they
activate receptors of the inferior & superior portions of the capsule. Less than 3% of the capsular
receptors are found to be excited by flexion and extension of the hip in a cat that has similar
afferent responses and thresholds as a human. (Rossi A & Grigg P. Characteristics of hip joint
mechanoreceptors in a cat. Journal of Neurophysiology June 1982. Vol 47(6):1029-1042)
7) Internal rotation of the FA joint lifts levator ani and pelvic floor and stabilizes the low back
B. Pelvic Musculature
4) Iliacus 4) Coccygeus
5) Psoas 5) Pubococcygeus
D. Trunk Rotation
A positive test is indicated by a restriction from the anterior-inferior acetabular labral rim, transverse
ligament, and piriformis muscle or impact of the posterior inferior femoral neck on posterior inferior
rim of acetabulum that does not allow the femur to adduct; possibly secondary to an anteriorly
rotated, forward hemipelvis. Usually seen on the left in a Left AIC oriented patient.
*Positive Negative
A positive test is indicated when the tested lower extremity (usually the left) is restricted in hip
extension because of the forward orientation of the tested side compared to the other. If both femurs
do not approach the edge of the mat or table the patient is tested on, the innominates are rotated
forward bilaterally and the psoa c a ac . P ac a ac a
ac a a a . T lengthens the TFL and VL, which could lead to
hyperactivity restricting hip extension.
There is also a rotary component to this issue, especially seen with limitation in hip extension on one
side. Since the forward, anteriorly rotated pelvis accompanies sacral rotation to the contralateral side
(right rotation on a right oblique axis or left rotation on a left oblique axis) the iliofemoral ligament
will also limit extension when the femur is externally rotated by the therapist, through testing with
a a .
The femur in this case will not approach the patient support surface without femoral internal rotation
a d a ( . c c ) a a ad ad d
superior anterior condyloid labral rim of acetabulum.
Positive Negative
The patient li a a d d. Pa a a
while securing full knee extension. Stop moving the leg at the point where the opposite leg begins to
move toward the ceiling passively or when the leg has reached a point where the tension at the back of
the hip and leg is noted and limits comfortable movement.
A positive test is indicated by limited or unlimited/excessive passive hip flexion of one extremity or
both extremities. Less than 75-80° is considered limited. Greater than 100° is considered
unlimited/excessive.
Negative
D. Trunk Rotation
The patient is positioned supine with knees maximally flexed and together, and feet flat on the table.
Pa a a a d, ab
the other hand (placing it on the anterior lower ribs and sternum). A yardstick may be used to
measure the distance from the mat to the upper-most point of the superior knee, while maintaining
the opposite posterior thorax contact with the mat. Repeat the test in the other direction.
A positive test is indicated when the legs do not rotate in one direction as compared to the other. For
example, the legs are restricted in rotation to the left (ie. the legs do not rotate to the left as they do to
the right as measured through the use of an upright ruler). This means that trunk rotation is limited
more to the right secondary to probable left hip anterior rotation and sacral-lumbar orientation of the
spine to the right. Therefore, postural restoration should be initiated at the left lower extremity to
address left mechanical instability and maintain proper restored pelvi-femoral neuromechanics.
Most common goniometric findings of a Left AIC oriented patient in the seated position usually
reflect both osteokinematic and myokinematic (muscle position) influences. Therefore, in a non-
pathologic compensatory pattern of a Left AIC patient, where osteokinematic issues exist in a seated
position, Left FA IR will usually be decreased and Right FA ER will usually be decreased because
of the following reasoning:
*D c a d FA IR a c a d . Pa abd c d
in a Left AIC pattern or L AF ER position when placed in a seated state with legs directly in front of
a ac a .T hit ac ab
upon FA IR.
* Decreased right FA ER may also reflect the seated test position. A Left AIC patterned individual
with a Right AF IR positioned pelvis the right femur will be in an adducted state with the legs
d c a a d a .T impinge a ,
and medial acetabular rim upon FA ER.
Where osseous and capsular restrictions do not exist (following repositioning), a non-pathological
compensatory Left AIC patterned individual should have increased FA IR on the left and increased
FA ER on the right, to near normal values, compared to before repositioning.
If capsular and soft tissue issues exist after repositioning secondary to over-compensatory activity, a
non-pathology compensatory pattern can now become a patho compensatory pattern. See page 39
for treatment rationale.
IR
RIGHT
ER
W a 90 , IR ca b c c d a d d c d b c a
ligament and/or the inferior capsule.
W a 90 , ER ca b c c d a d reduced by either the iliofemoral ligament and/or
the superior capsule.
L IR ( R ) R IR ( L )
L ER ( R ) R ER ( L )
* AF & FA ADD/IR IC adductor for hip * Inferior capsule or anterior capsule stretch.
approximation to stabilize pubefemoral AF ER glute max to position lengthened
ligament/inferior capsule. right obturator for hole control.
* AF & FA IR anterior glute med to stabilize AF & FA ABD posterior glute med to stabilize
iliofemoral ligament/inferior capsule. superior ischialfemoral ligament/capsule.
Posterior superior capsule stretch.
LEFT RIGHT
1 2 3 4 5 1 2 3 4 5
FA IR
Glute Med TFL Glute Med TFL
FA ER 1 2 3 4 5 1 2 3 4 5
+ L ADT + L EDT
* - L EDT (Iliofemoral / pubefemoral laxity)
Limited R TR
*Non-Limited R TR (Right iliolumbar laxity)
L SLR
Note: Proximal attachment site of hamstring group is more forward and elevated
secondary to anterior rotation of innominate.
* L SLR (Long, neuromuscularly weak, hypotonic, overly stretched
i ac i e ha i gg ha bec e e ed a he somatosensory
cortical level secondary to tactile extinction of LE)
L IR (FA ROM)
Note: Ove ac TFL, FA ER a d c tight posterior capsule
secondary to left AF ER osseous position.
R ER (FA ROM)
Note: Overactive right adductors, r FA IR a d a ad
anterior medial acetabular cotyloid rim upon FA ER secondary to right AF IR osseous
position.
+ R ADT + L ADT
Note: Posterior Exterior Chained or PEC
+ L EDT + L ADT
+ R EDT + R ADT
L AF IR = R AF ER
R AF IR = L AF ER
KEY:
L = Left R = Right B = Bilateral + = Positive Test – = Negative Test
ADT = Adduction Drop Test SLR = Straight Leg Raise AF IR = Acetabular Femoral Internal Rotation
EDT = Extension Drop Test ↑ = Increased AF ER = Acetabular Femoral External Rotation
TR = Trunk Rotation Test ↓ = Decreased FA IR = Femoral Acetabular Internal Rotation
( ) = Patho Compensatory Issues FA ER = Femoral Acetabular External Rotation
FA ROM = Femoral Acetabular Range of Motion
Positive Left
Extension Drop Test (unable to extend left femur to neutral)
Hruska Adduction Lift Test < Level 2 Right Hruska Adduction Lift
Test (patient lying on their left side)
Hruska Abduction Lift Test < Level 2 Right Hruska Abduction Lift
Test (patient lying on their left side)
D c a d FA IR a c a d . Pa abd c d
in a Left AIC pattern or L AF ER position when placed in a seated state with legs directly in front of
a ac a .T hit ac ab
upon FA IR.
Decreased right FA ER may also reflect the seated test position. A Left AIC patterned individual
with a Right AF IR positioned pelvis the right femur will be in an adducted state with the legs
d c a a d a .T impinge a ,
and medial acetabular rim upon FA ER.
Copyright 2000-2017 Postural Restoration Institute® 42
Myokinematic Restoration An Integrated Approach To Treatment of Patterned Lumbo-Pelvic-Femoral Pathomechanics
Position
1) Patient sidelying back rounded
2) Uppermost lower extremity resting on therapists shoulder (neutral hip, extended knee)
3) Lower leg in flexed position
4) Maintain pelvis in a neutral position (do not allow upper pelvis to rotate forward or
backward)
Mechanics
1) Step 1: ask patient to raise ankle of flexed lower leg to upper knee
2) Step 2: have patient raise flexed lower knee while keeping ankle to the knee
3) Step 3: patient will then raise lower hip while maintaining the above positions
4) Discontinue test at the step patient is unable to perform
Grading Criteria
LEVEL 0
LEVEL 1
LEVEL 2
LEVEL 3
Ability to maintain above position while lifting
lower hip off table slightly
LEVEL 4
LEVEL 5
I ab c a a d
proprioceptive skills to shift hips
Position
1) Patient sidelying with upper leg extended and aligned with hip and shoulder.
2) Adjust position of knees to wall, so that top knee is above the level of the ipsilateral
shoulder.
3) Lower leg is flexed with lower toes positioned on the wall directly under the top foot and
ac d 4 6 b .
4) Top palm should be placed flat on surface in front of chest and upper hand under head.
Grading Criteria
LEVEL 0
LEVEL 1
LEVEL 2
Ab a b nee without
moving top pelvis backwards.
LEVEL 3
LEVEL 4
LEVEL 5
In a non patho-compensatory Left AIC pattern, you will more than likely see decreased left leg
length, compared to the right.
If you see increased left leg length, compared to the right, this is usually associated with a patho-
compensatory Left AIC pattern.
References:
1) Cooperstein R, Lew M. The relationship between pelvic torsion and anatomical leg length inequality: a
review of the literature. Journal of Chiropractic Medicine. 2009;8:107-118.
2) Cummings G, Scholz JP, Barnes K. The effect of imposed leg length difference on pelvic bone symmetry.
Spine. 1993;18(3):368-373.
3) Juhl JH, Ippolito Cremin TM, Russell G. Prevalence of frontal plane pelvic postural asymmetry part 1.
JAOA. 2004;104(10):411-421.
4) Karski T, Karski J. The biomechanical aetiology of the so-called idiopathic scoliosis. The role of gait and
a di g a ea e he igh leg i he de el e f he def i . Surgical Science. 2014;5:33-38.
5) Klein KK, Buckley JC. Asymmetries of growth in the pelvis and legs of growing children. ACTJ.
1968;22(2):53-55.
6) Nourbakhsh MR, Arab AM. Relationship between mechanical factors and incidence of low back pain.
JOSPT. 2002;32(9):447-460
7) Rothbart BA. Relationship of functional leg-length discrepancy to abnormal pronation. Journal of the
American Podiatric Medical Association. 2006;96(6):499-504.
Treatment considerations
NO YES
Reposition
NO
YES NO
NO YES NO
YES NO
2) Hip Bursitis
5) Pubalgia
6) Hamstring Pulls
a b c
a b c d
a b c
a b c d
a b c d
a b c d
5) Vulvodynia
6) Dyspareunia
a b c
a b c d
a b c d
a b c d
a b c
a b c d
a. Standing Left AF IR with Resisted Left Arm Pull Down and Right FA Abduction (pg 62)
b. Right Lateral Walking (pg 63)
c. Left Stance Reciprocal Step Through (pg 64)
a b c
a b c
a b c d
a b c d
a b c d
e f
a b
a b c
d e f
Notes:
Appendix
Myokinematic Restoration Repositioning Techniques ................................................................2
Protonics® Neuromuscular System .............................................................................................4
Left AF IR Positioning Program ..................................................................................................6
Left AF IR Recommendations & Desirable Position of Activity ................................................11
PRI Right AIC Alternating Reciprocal Gait Recommendations .................................................15
Myokinematic Restoration Non-Manual Techniques
Left Hamstring ...................................................................................................................... 16
Left Ischiocondylar Adductor ............................................................................................... 25
Right Gluteus Maximus ........................................................................................................ 31
Left Gluteus Medius ............................................................................................................. 39
References ....................................................................................................................................101
Medically Informed Consent (Example)......................................................................................112
PRI Evaluation Form ...................................................................................................................113
Copyright © 2000-2017 Postural Restoration Institute® 1
Appendix Myokinematic Restoration
Repositioning
It is suggested that these activities be performed in the order as listed below. Place the system on the
LEFT leg and set the system to a ___. Perform 15 repetitions of each. Repeat 3-4 times a day.
Step Over
Place Protonics on left leg with setting at ___. Stand facing a 4 / 6 / 8 inch block. Pull back left leg at the
knee as you place your left foot on the top of the block. Step up and lift right foot to top of block. Then
slowly lower right foot to floor. Step down with your left leg. Step back up to the top of the block, going
backwards, with left leg. Lift right foot to the top of the block. Lower right foot behind block. Step
down with left leg. Repeat ___ times.
Lateral Step Up
Place Protonics on left leg with setting at ___. Advance sideways up the stairs leading with left leg.
Remember to pull back left leg at the knee before advancing up to the next step. Keep left foot behind the
right. Keep feet parallel to each other or stay neutral at the hip. Try to place both feet flat on respective
steps prior to hip movement. Advance sideways down the stairs with right leg. Perform ___ flights (10
to 12 steps in a flight of stairs), up and down, ___times a day.
Retraining / Walking
Following two exercise sessions a day, wear the Protonics system at a resistance level of ___ during
activities of daily living for a period of 1 to 2 hours.
The Protonics® system is intended for use during occupational and home environmental
activity for retraining. Therefore, it is not recommended for use during long walks,
recreational running, retraining periods longer than 2 hours, or more than 8 hours of total
retraining during a 24-hour period.
When in a seated
position keep your trunk
rounded and your knees
at or above hip level.
For increased comfort,
place a small bolster
underneath your left
thigh and shift your left
knee back.
Sleeping Standing
Reaching
While reaching for something we suggest that you first place your right
foot in front of you and shift back onto your left hip.
Keep your right shoulder behind your left and attempt to reach with your
left hand.
Getting On a Bicycle
If you are mounting the right side of the bike we suggest you hike your left leg up above the level
of your right and then begin to swing your left leg over the seat of the bike.
To position yourself in the seat, we suggest that you bring your left foot off the ground first and
position your left foot in or on the left pedal.
As you are placing your foot on the pedal, begin to bring your bottom back on the seat.
If you are mounting the left side of the bike it is recommended that you lift your right knee in
front of you creating a 90-90 position with your trunk and your thigh.
Now bring your right leg over the bar in the middle and plant your right foot down on the ground.
To position yourself in the seat, we suggest that you bring your left foot off the ground first and
position your left foot in or on the left pedal.
As you are placing your foot on the pedal, begin to bring your bottom back on the seat.
When getting in a car on the drivers side, we suggest that you first slightly shift your left knee behind your
right.
Keeping your left foot on the ground, begin to bring your right leg into the car as you keep your trunk slightly
oriented to the left.
Now bring your left leg into the car next to the right.
When driving, we encourage you to keep your left foot planted firmly on the floor board of the car and your
left knee shifted behind your right. It is best if your seat remains in an upright position.
When getting into a car on the passengers side, we suggest that you first slightly shift your left hip back.
Keeping your right foot planted on the ground begin to bring your left foot into the car as you also begin
to orient your trunk to the left.
When riding, we recommend that you keep your left knee shifted behind your right. It is best if your
seat remains in an upright position.
When positioning yourself on the right side of the bed, we suggest that you first sit on the edge of the
bed, and shift your left knee behind your right.
Begin to lie down on your back as you simultaneously swing your legs up to the bed.
Now roll to the left keeping your knees bent.
When positioning yourself on the right side of the bed, we suggest that you first sit on the edge of
the bed and shift your left knee behind your right.
Begin to lie down on your left side as you simultaneously swing your legs up to the bed.
Now roll to the right keeping your knees bent.
Left AF IR RECOMMENDATIONS
2. Retro Stairs
1) L AF IR / L FA IR L AF IR / R FA IR L AF IR / *R FAER
2) R AF ER / R FA IR R AF ER / *L FA IR R AF ER / L FA ER
3) L AF ER / L FA IR L AF ER / *R FA IR L AF ER / R FA ER
4) R AF IR / R FA IR R AF IR / L FA IR R AF IR / *L FA ER
1. Lead with the left arm and the right leg when moving forward. Remember to move both
the left arm with the right leg and the right arm with the left leg.
2. Hit each heel as you strike the ground and try to push off with your great toes on each
side as your foot leaves the ground.
3. Wear shoes that have good arch support and find and feel your right arch with each step
you take on the right side.
4. Occasionally take a smaller step with the left leg than the right or a larger step with the
right leg than the left. Remember this would include moving the left arm forward more
than the right or the right arm backward more than the left.
5. Walk and weave. Move from the left side of the sidewalk to the right and vice versa.
6. If you feel the need to walk clockwise, remember to focus on feeling the right shoe arch
and take a greater swing with the left arm as the right leg moves forward and your body
weight shifts over the left leg.
7. If you feel the need to walk counter-clockwise, remember to heel strike and push off with
the great toe on the left side. As the right knee comes up, when the left foot is on the
ground, move the left elbow to the right knee slightly more and raise the right knee
slightly higher than you would on the other side.
Trunk
Trunk
Hips
Hips
R L
L R
R = Exhalation
L = Inhalation
Standing Supported Right Knee Flexion with Weighted Left Proximal Hamstring
(Left Hamstring – Standing #7)
1. Stand against a desk or counter, and place your right foot on a 2-inch block and a
3-5 lb. ankle weight around your left ankle.
2. Place your hands on the surface in front of you and round your back.
3. Maintaining contact with your right shoe arch, begin to straighten your right knee as you raise your
left foot off the floor.
4. Keeping your left leg straight, hike your left hip up above the level of your right. Your left foot will
be higher than your right. You should feel your left inner thigh engage.
5. Keeping your left hip hiked, bring your left thigh back and bend your left knee. You should feel the
back of your left thigh engage.
6. Maintaining the above position, squat down by bending your right knee. You should feel the muscles
on the front of your right thigh and right outer hip (buttock) engage.
7. Staying in the right squat position and keeping your left hip hiked and thigh pulled back, straighten
and bend your left knee 10 times. You should feel the muscles on the back of your left thigh engage.
8. Relax and repeat 2 more times.
Standing Supported Right Knee Flexion with Weighted Left Hamstring and Right Trunk
Rotation
(Left Hamstring – Standing #19)
1. Place your right foot on a 2-inch block and a 3-5 lb. ankle weight around your left ankle.
2. Place a dowel or stick in your left hand, and round your back as you reach back with your right hand.
3. Maintaining contact with your right shoe arch, begin to straighten your right knee as you raise your
left foot off the floor.
4. Keeping your left leg straight, hike your left hip up above the level of your right. Your left foot will
be higher than your right. You should feel your left inner thigh engage.
5. Keeping your left hip hiked, bring your left thigh back and bend your left knee. You should feel the
muscles on the back of your left thigh engage.
6. Without letting your left hip drop, turn your left lower leg out to the side. You should feel the
muscles on your left outside hip (buttock) engage.
7. Maintaining the above position, squat down by bending your right knee. You should feel the muscles
on the front of your right thigh and right outside hip (buttock) engage.
8. Hold this position while you take 4-5 deep breaths, in through your nose and out through your mouth.
9. Relax and repeat 4 more times.
(R AF ER / FA ER L FA IR) (R AF IR / FA ER L FA IR)
Shift right knee forward and repeat above. Shift right knee back and repeat above.
Left Sidelying IO/TA and Left Adductor with Right Glute Max
(R AF ER / FA ER L FA IR FA ADD)
(Left Ischiocondylar Adductor – Sidelying #23)
1. Lie on your left side with your left leg straight.
2. Place a 2-3 inch towel under your left side and 1-2 pillows under your head so that your neck is
slightly sidebent to the right.
3. Bend your right leg and cross it over your left leg.
4. Place your right foot slightly ahead of your left knee and drop the inside of your right foot toward the
mat so that you can feel the arch of your foot push into your shoe.
5. Push your left hip down into the mat so that your right hip moves toward the wall. You should feel
your left abdominals engage as you lift up away from the towel roll. With your right hand you can
feel your left abdominals engage. Do not engage your neck.
6. Keeping your right arch in contact with the mat, shift your right knee and hip forward and turn your
right knee out. You should feel your right outside hip (buttock) engage.
7. Keeping your left hip down and right knee turned out, turn your left leg in so that your toes are
towards the ceiling and pick your entire leg up. You should feel your left inner thigh engage.
8. Hold this position while you take 4-5 deep breaths, in through your nose and out through your mouth.
9. Relax and repeat 4 more times.
Left Sidelying Supported Left Flexed FA Adduction with Right Extended FA Abduction (L
AF IR / FA IR R FA IR FA ABD)
(Left Ischiocondylar Adductor – Sidelying #35)
1. Lie on your left side with your right leg straight and your left leg bent at a 60-degree angle. Your
right shoulder, hip, knee and ankle will be lined up.
2. Place 2-3 pillows under your head so that your head is slightly sidebent to the right.
3. Place your left foot on a 2-3 inch bolster with your foot pressing into the wall and a small bolster
underneath your left side.
4. Sligh l ai e o lef knee off of he floo b ning o high in o b hing your left foot
into the wall and using it as a pivot point. You should feel your left inner thigh and left outer hip
(buttock) engage.
5. Keep your left knee raised from the floor and turn your right leg in.
6. Attempt to take your right foot off of the wall. You should feel your right outside hip (buttock)
engage.
7. Hold this position while you take 4-5 deep breaths, in through the nose and out through the mouth.
8. Relax and repeat 4 more times.
Standing Supported Right Glute Max with Left Hip Approximation and Left FA IR
(Left Ischiocondylar Adductor – Standing #11)
1. Stand against a desk or counter and place your right foot on a 2-inch block.
2. Place your hands on the surface in front of you and round your back.
3. Maintaining contact with your right shoe arch, begin to straighten your right knee as you raise your
left foot off the floor.
4. Keeping your left leg straight, hike your left hip up above the level of your right. Your left foot will
be higher than your right. You should feel your left inner thigh engage.
5. Sidebend to the left and bend your left knee. You should feel your left abdominals and the back of
your left thigh engage.
6. Maintaining this position, slowly bring your left lower leg out to the side and back in 10 times feeling
your left outer hip (buttock) engage. You should also continue to feel your left inner thigh, back of
your left thigh and right outer hip (buttock) muscles engaged.
7. Relax and repeat 2 more times.
Left Sidelying Left Adductor with Resisted Right Glute Max (L AF IR / R FA ER)
(Right Gluteus Maximus – Sidelying #13)
1. Lie on your left side with your feet on the wall, hips and knees at a 90-degree angle. Place a 4-6
inch bolster under your ankles. Place a pillow under your head and keep your back and neck
relaxed.
2. Place tubing around both thighs.
3. Press your feet into the wall and shift your right knee forward ahead of your left knee.
4. Keep your right knee shifted forward and slowly raise your right leg by turning your thigh
outward. You should feel the outside of your right hip (buttock) engage.
5. Note: If you now do not feel the muscles of your left inner thigh, raise your left knee slightly off
the mat.
6. Hold this position while you take 4-5 deep breaths, in through your nose and out through your
mouth.
7. Relax and repeat 4 more times.
Left Sidelying Supported Right Glute Max with Right Hip Extension and Right FA ER
(R AF NR / FA ER)
(Right Gluteus Maximus – Sidelying #16)
1. Lie on your left side with your left hip and knee bent at a 90-degree angle resting in front of you.
Place a pillow(s) under your right lower leg.
2. Reach your right hand forward towards your left knee so that your right hip moves forward over
your left hip.
3. Keep your right knee bent at a 90-degree angle and press your right foot/arch into the wall.
4. Keeping your right foot/arch on the wall, rotate your right thigh out by lifting your right knee
towards the ceiling. You should feel your right outside hip (buttock) engage.
5. Hold this position while you take 4-5 deep breaths, in through the nose and out through the
mouth.
6. Relax and repeat 4 more times.
Left Sidelying Supported Right Glute Max with Hip Extension and FA Abduction
(R AF NR / FA EXT ER)
(Right Gluteus Maximus – Sidelying #20)
1. Lie on your left side with your left hip and knee bent at a 90-degree angle.
2. Keep your right hip neutral (aligned with your body) and place your right lower leg on several
pillows or an appropriate size bolster. Your right knee will also be at a 90-degree angle.
3. Press your left foot into the wall and press your right knee into the wall.
4. Maintain the above position and rotate your right thigh out towards the ceiling. Lift your right
thigh up towards the ceiling. You should feel your right outside hip (buttock) engage. Your right
ankle should not move off the bolster.
5. Hold position as you take 4-5 deep breaths, in through your nose and out through your mouth.
6. Relax and repeat 4 more times.
Standing Wall Supported Left Knee Flexion with Resisted Right Glute Max
(L AF IR / R FA ER)
(Right Gluteus Maximus – Standing #15)
1. Stand with your feet shoulder width apart and tubing
around your knees.
2. Place your right foot flat on the wall behind you.
3. Shift your right knee down and sidebend your trunk to the
left.
4. Maintaining the above position, press your right foot/arch
into the wall and rotate your right knee out against the
resistance of the band. You should feel the muscles on the
outside of your right hip (buttock) engage.
5. Keeping your right knee turned out, begin to squat down
by bending your left knee. Place your right hand on the
wall for stability. You should feel the muscles on the front
of your left thigh and left outer hip (buttock) engage.
6. Hold this position while you take 4-5 deep breaths, in
through your nose and out through your mouth.
7. Relax and repeat 4 more times.
Left Sidelying Left Flexed FA Adduction with Right Extended FA Abduction and Left
Abdominal Co-Activation (L AF IR / FA IR R FA ABD)
(Left Gluteus Medius – Sidelying #23)
1. Lie on your left side and place a 2-3 inch bolster under your left abdominal wall and 1-2 pillows
under your head so that your neck is slightly sidebent to the right.
2. Place a crate or a stool that is about 13 inches in height under your right ankle and bend your left
knee. Your right ankle, hip and shoulder will be lined up.
3. Inhale through your nose and as you exhale through your mouth, reach down toward the wall with
your right leg.
4. Push your left hip down firmly into the mat and try to arch your left abdominal wall. You should feel
your left abdominal wall engage as you lift up away from the towel roll.
5. With your left abdominal wall engaged and your right leg reaching down, push the outside border of
your left foot down into the mat and “turn your left knee up. You should feel your left inner thigh
and left outer hip (buttock) engage.
6. With your left inner thigh engaged, attempt to pick your right foot off of the stool with your foot
turned out to the side. You should feel your right outer hip (buttock) engage.
7. Hold this position while you take 4-5 deep breaths, in through your nose and out through your mouth.
8. Relax and repeat 4 more times.
Supine Hooklying Supported Resisted Right Glute Max with Left Glute Med
(R AF IR / FA ADD L FA FLEX FA IR)
(Left Gluteus Medius – Supine #6)
1. Lie on your back with your feet on a 2-inch block and your knees bent.
2. Place a ball between your knees and a band around your ankles.
3. Inhale through your nose and as you exhale through your mouth, perform a pelvic tilt so that your
tailbone is raised slightly off the mat. Keep your back flat on the mat.
4. Shift your left knee down towards you so that your left knee is slightly below your right, and press
your left knee into the ball. You should feel your left inner thigh engage.
5. Now lift your left foot off of the block. You should feel the back of your right leg and outside hip
(buttock) engage.
6. With your left foot off of the block, turn your left lower leg out to the side. You should feel your left
outer hip (buttock) engage.
7. Hold this position while you take 4-5 deep breaths, in through your nose and out through your mouth.
8. Relax and repeat 4 more times.
Standing Resisted Trunk Around with Left AF IR and Right Trunk Rotation
(L AF IR / R TR FA FLEX)
(Left Gluteus Medius – Standing #21)
1. Stand with tubing in your left hand, facing
away from the door.
2. Shift your left hip back, and slightly bend both
knees. You should feel your left outer hip
(buttock) engage.
3. Keeping your left hip back and weight through
your left mid-foot/heel, begin to orient your
trunk to the right by reaching across the
midline of your body with your left hand. You
should feel your left abdominal wall engage.
4. Keeping your trunk turned to the right, raise
your right foot off of the ground. You should
feel the muscles on the front of your left thigh,
left outer hip (buttock) and left abdominals
engage.
5. Balance in this position while you take 4-5
deep breaths, in through your nose and out through your mouth.
6. Relax and repeat 4 more times.
INHALATION
EXHALATION
Seated Supported Left AF IR with Right Psoas and Iliacus and Right FA ER
(Right QL and Left Psoas Inhibition - Seated #2)
1. Sit in a chair and place your feet flat on the floor. Your knees should be at or above the level of your
hips (you may need to place a block under your feet).
2. R d back a d ll el i back feeli g i b e.
3. Begin by shifting your left knee back so that it is behind your right. You should feel your left inner
thigh engage.
4. Slightly orient and sidebend your trunk to the left. You should feel your left abdominal wall engage.
5. Pick your right foot slightly off the floor and turn your right ankle inward (your thigh will turn
outward). You should feel the muscles on the front of your right hip engage.
6. With your left hand, reach towards your right knee, orienting your trunk to the right as you gently
press your left hand into your right knee.
7. Hold this position while you take 4-5 deep breaths, in through your nose and out through your mouth.
8. Relax and repeat 4 more times.
Inhale Exhale
Left Sidelying Left Ischial Femoral Ligamentous Stretch with Left FA Adduction
(Left Posterior Capsule Inhibition - Sidelying #10)
1. Lie on your left side with your right leg straight and your left
leg bent at a 60-degree angle.
2. Place a small bolster underneath your left knee and your left
abdominal wall.
3. Place your left foot flat on the wall and your right foot on the
wall. Turn your right foot/ankle out so that your right arch is
resting on the wall.
4. Keep right ankle, hip, and shoulder lined up.
5. Rotate your right hip forward until you feel a stretch in your
left outer hip (buttock). Your pant zipper will be toward your
left leg.
6. Keeping your right hip forward, lift your left knee off the
bolster. You should feel your left inner thigh engage.
7. Hold this position for 4 to 5 breaths, in through your nose and
out through your mouth.
8. Relax and repeat 4 more times.
Modified All Four Inferior Glute Max, Adductor Magnus and Quadratus Femoris Stretch
(Right Inferior Gluteus Maximus Inhibition – All Four #3)
1. Position yourself on your hands and knees.
2. Bend your right knee and cross your leg in front of your left thigh so that your right ankle is in front
of your left knee.
3. Lower yourself onto your forearms and straighten your left leg.
4. Keeping your back rounded, continue to reach back with your left leg until you feel a stretch on the
outside of your right hip (buttock).
5. Hold this position while you take 4-5 deep breaths, in through your nose and out through your mouth.
6. Relax and repeat 4 more times.
*INCORRECT*
Do not roll your trunk to the
right or let your upper body
come all the way down.
S Bar Reach
(Plantar Flexor Inhibition – Standing #2)
1. Position yourself behind a door frame, and place the bar on the outside of the frame as pictured
above.
2. Keep your feet shoulder width apart and pointing straight ahead.
3. Round out your back as you tuck your bottom under you.
4. Keep your weight through your heels and hold onto the bar as you slowly squat down keeping your
back rounded. Squat as much as you can without letting your heels come off the floor.
5. Hold this position for 4-5 deep breaths in through your nose and out through your mouth. Attempt to
fill or expand your upper back chest wall with air on each inhalation.
6. On the final exhale, slowly stand up by pushing through your heels and keeping your back rounded.
7. Relax and repeat 4 more times.
Soleus Stretch
1. Stand against a high counter or table top with your right leg in front of
you and your left leg behind you.
2. Slightly bend both your knees.
3. Keeping your left heel on the floor, bend both your knees further until
you feel a stretch on the upper part of your left calf muscle.
4. Hold this position while you take 4-5 deep breaths, in through your nose
and out through your mouth.
5. Relax and repeat 4 more times.
Integration
Standing Left AF IR with Resisted Left Arm Pull Down and Right FA Abduction
(Integration – Standing #13)
1. Anchor a piece of tubing in the top of a door and hold onto the other end with your left hand.
2. Place a 2-inch block under your left foot.
3. Shift your left hip back and slightly bend your left knee. Keep your weight through your left mid-
foot/heel. You should feel the front of your left thigh and your left outer hip (buttock) engage.
4. Reach down towards the ground with your left hand as you sidebend your trunk to the left. You
should feel the muscles on your left abdominal wall engage.
5. Maintaining the above position, slightly bring your right foot out to the side as you turn your right
ankle out so that your right arch is toward the floor. You should feel the muscles on the outside of
your right hip (buttock) engage.
6. Hold this position while you take 4-5 breaths, in through your nose and out through your mouth.
7. Relax and repeat 4 more times.
*If you are unable to feel your right outer hip (buttock) on step #5, place your right arch down onto
the floor and maintain the left squat position, feeling your left outer hip (buttock), front of your left
thigh and left inner thigh engage. With your right arch resting on the floor, you should also feel a
stretch in your right inner thigh.
Option B
1. Stand as in picture #3 with your left foot on a 2-4 inch block. Be sure to look straight ahead during
this activity.
2. Shift your left hip back, and pull your left knee in slightly. You should feel the muscles on your left
inner thigh and left outer hip (buttock) engage.
3. Sidebend your trunk to the left, feeling your left abdominal wall engage.
4. Keeping your left outer hip (buttock) muscle engaged, slowly bring your left arm and right leg
forward as your right arm goes back. Tap the ground with your right foot.
5. Pause, then slowly bring your right leg and left arm back as you bring your right arm forward. Tap
the ground with your right foot.
6. Continue this sequence 10 times keeping your left outer hip (buttock) muscle engaged.
7. Relax and repeat 2 more times.
1 2 3
Retro Walking
(L AF IR / R FA EXT R FA IR AF IR / L FA EXT FA IR)
(Integration – Standing #104)
1. Stand with your feet shoulder width apart and place tubing around your ankles. This activity can also
be performed without a resistance band/tubing.
2. Round out your back.
3. Place your right foot forward and left arm forward, while your right arm is behind you.
4. Shift your left hip back and bend your left knee, keeping your weight through your left mid-foot/heel.
Sidebend your trunk to the left. You should feel your left outer hip (buttock) and left abdominals
engage.
5. Keeping your back rounded and left hip back, slowly bring your right leg out to the side and back
(making a half circle) with your right toes pointed straight ahead, as your right arm moves forward
and left arm back. Hold this position 3 seconds before placing your right foot on the floor. You
should feel your left outer hip (buttock), front of your left thigh and right outer hip (buttock) engage.
6. Place your right foot on the ground.
7. Shift your right hip back and bend your right knee, keeping your weight through your right mid-
foot/heel. Sidebend your trunk to the right. You should feel your right outer hip (buttock) and right
abdominals engage.
8. Keeping your back rounded and right hip back, bring your left leg out to the side and back (making a
half circle) with your left toes pointed straight ahead, as your left arm moves forward and right arm
back. Hold this position 3 seconds before placing your left foot on the floor. You should feel your
right outer hip (buttock), front of your right thigh and left outer hip (buttock) engage.
9. Repeat 4-6 steps backwards with each leg while inhaling through your nose and exhaling through
your mouth.
10. Relax and repeat the sequence 4 more times.
ON
Starting Position
1
2. Exhale and shift your weight to your right leg as you bring your left leg behind
you and your left arm reaching towards your right toes. Lower your body closer
to the ground when shifting to the right leg by bending your right knee further
than before. Keep your back rounded as you try to balance on your right leg.
Picture #2 should reflect the end position of this movement. Once in
this position take another breath in.
3. Exhale and shift your weight to the left leg as you bring your right leg behind you
and your right arm reaching towards your left toes. Lower yourself even further
to the ground than in step #2 by bending your left knee closer to the ground.
Keep your back rounded as you balance on your left leg.
Picture #3 should reflect the end position of this movement. Once in
this position take another breath in. ON ON
2 3
LOWER QUADRANT
MYOKINEMATIC RESTORATION PROBLEM SOLVING
1. Inactive left hamstring, anteriorly rotated, forwardly tipped left hemipelvis
2. Limited right apical expansion secondary to inactive left abdominal obliques
3. Restricted left posterior hip capsule acceptance of femoral head
4. Weak left hip: gluteus medius and ischiocondylar adductor (L FA IR)
5. Weak left hip: gluteus medius (L FA IR)
6. Weak right hip: gluteus maximus (R FA ER)
7. Weak concomitant left adductor and right abductor
8. Inactive left abdominal oblique
9. Tight, restrictive, short, strong right adductor
10. Weak right hip: gluteus medius (R FA IR) with concomitant gluteus maximus
11. Restrictive right rectus femoris
12. Restrictive right psoas Limiting right hip extension after reposition
13. Restrictive right pectineus
14. Inability to shift hips to the left secondary to restricted left posterior capsule and tight left gluteus
maximus
15. Inability to rotate lumbar spine to the left secondary to weak right psoas and iliacus
(1) 90-90 Supported Hip Lift with Hemibridge (Left Hamstring – Supine #6)
1. Lie on your back with your feet flat on a wall and your knees and hips
bent at a 90-degree angle.
2. Inhale through your nose and as you exhale through your mouth,
perform a pelvic tilt so that your tailbone is raised slightly off the mat.
Keep your low back flat on the mat. Do not press your feet flat into the
wall instead dig down with your heels.
3. Maintain the pelvic tilt with your left leg on the wall and straighten
your right leg.
4. Slowly take your straight right leg on and off the wall as you breathe in
through your nose and out through your mouth. You should feel the
muscles behind your left thigh engage.
5. Perform 3 sets of 10 repetitions.
(2) 90-90 Hip Lift with Balloon (Left Hamstring – Supine #8)
1. Lie on your back with your feet flat on a wall and your knees
and hips bent at a 90-degree angle.
2. Place a 4-6 inch ball between your knees.
3. Place your right arm above your head and a balloon in your
left hand.
4. Inhale through your nose and exhale through your mouth,
performing a pelvic tilt so that your tailbone is raised slightly
off the mat. Keep your back flat on the mat. Do not press your
feet flat into the wall instead dig down with your heels. You
should feel the muscles on the back of your thighs engage.
5. Inhale through your nose and slowly blow out into the balloon.
6. Pause three seconds with your tongue on the roof of your mouth to prevent airflow out of the balloon.
7. Without pinching the neck of the balloon and keeping your tongue on the roof of your mouth, take
another breath in through your nose.
8. Slowly blow out again as you stabilize the balloon with your hand.
9. Do not strain your neck or cheeks as you blow.
10. After the fourth breath in, pinch the balloon neck and remove it from your mouth. Let the air out of
the balloon.
11. Relax and repeat the sequence 4 more times.
(7) Left Sideyling Supported Left Flexed FA Adduction with Right Extended FA
Abduction (Left Gluteus Medius – Sidelying #25)
1. Lie on your left side with your right leg straight and your left leg bent at a 60-degree angle. Your
right shoulder, hip, knee and ankle will be lined up.
2. Place 2-3 pillows under your head so that your head is slightly sidebent to the right.
3. Place your left foot on a 2-3 inch bolster with your foot pressing into the wall and a small bolster
underneath your left side.
4. Slightly raise your left knee off of the floor by turning your thigh in or by pushing your left foot
into the wall and using it as a pivot point. You should feel your left inner thigh and left outer hip
(buttock) engage.
5. Keep your left knee raised from the floor and turn your right leg in.
6. Attempt to take your right foot off of the wall. You should feel your right outside hip (buttock)
engage.
7. Hold this position while you take 4-5 deep breaths, in through the nose and out through the mouth.
8. Relax and repeat 4 more times.
(10) Left Sidelying Supported Right Glute Max with Right Hip Extension and Right FA IR
(Right Gluteus Maximus – Sidelying #17)
1. Lie on your left side with your left hip and knee bent at a 90-degree angle and rest it in front of you.
Place firm pillows or a bolster under your right lower leg. (Right ankle should be higher than your
right hip).
2. Reach your right hand forward towards your left knee so that your right hip moves forward over your
left hip.
3. Keep your right knee bent at a 90-degree angle and press your right foot/arch into the wall.
4. While maintaining pressure of your right foot into the wall, rotate your right thigh in by gently
pressing your right knee into the pillows or bolster. You should feel your right outside hip (buttock)
engage.
5. Hold this position while you take 4-5 deep breaths, in through your nose and out through your mouth.
6. Relax and repeat 4 more times.
(13) Left Sidelying Supported Right Glute Max with Right Hip Extension and Right FA
ER (Right Gluteus Maximus – Sidelying #16)
1. Lie on your left side with your left hip and knee bent at a 90-degree angle resting in front of you.
Place a pillow(s) under your right lower leg.
2. Reach your right hand forward towards your left knee so that your right hip moves forward over your
left hip.
3. Keep your right knee bent at a 90-degree angle and press your right foot/arch into the wall.
4. Keeping your right foot/arch on the wall, rotate your right thigh out by lifting your right knee
towards the ceiling. You should feel your right outside hip (buttock) engage.
5. Hold this position while you take 4-5 deep breaths, in through the nose and out through the mouth.
6. Relax and repeat 4 more times.
(15) Seated Supported Left AF IR with Right Psoas and Iliacus and Right FA ER
(Right Quadratus Lumborum and Left Psoas Inhibition – Seated #2)
1. Sit in a chair and place your feet flat on the floor. Your knees should be at or above the level of your
hips (you may need to place a block under your feet).
2. Round out your back and roll your pelvis back feeling your sit bones.
3. Begin by shifting your left knee back so that it is behind your right. You should feel your left inner
thigh engage.
4. Slightly orient and sidebend your trunk to the left. You should feel your left abdominal wall engage.
5. Pick your right foot slightly off the floor and turn your right ankle inward (your thigh will turn
outward). You should feel the muscles on the front of your right hip engage.
6. With your left hand, reach towards your right knee, orienting your trunk to the right as you gently
press your left hand into your right knee.
7. Hold this position while you take 4-5 deep breaths, in through your nose and out through your mouth.
8. Relax and repeat 4 more times.
3) Lateral rotators (iliopsoas, pectineus, adductor magnus) of the hip joint may become
medial rotators from a position of extreme medial rotation of the femur or extreme
hip flexion. – Kapandji
4) Lateral rotation of femur and tibia at midstance, terminal stance, and preswing (toe
off) is limited in extreme hip flexion.
5) S a c a ce e ca c ea e e -lordo e ef , ea ef
extensors, and dystonic left lower quadrant stabilizers.
6) P b e ac f c ea ed e - d :
Adaptive shortening of iliotibial band and iliopsoas
Increased tonic activity of tensor fascia latae and vastus lateralis at midstance,
terminal stance, preswing, initial swing, and midswing, in addition to
beginning stance and terminal swing phases
Increased vastus lateralis activity throughout all phases of gait
Increased iliopsoas at midswing, terminal swing, initial contact and loading, in
addition to stance and preswing phases
(Note: 1/3 of hip flexion movement results from posterior pelvic rotation. –
Elia 1996)
Overall decrease of gluteal activity
Decreased medial hamstring activity:
- From 18 to 28 percent of the stance phase (initial contact)
- From 40 to 58 percent of swing phase (midswing)
- In the last 20 percent of swing phase (terminal swing)
Increased anterior translation force of the proximal tibia without co-activation
of hamstrings and pelvic control
Overuse of plantar flexors, gastrocnemius, and soleus for hip extension
assistance
If, over time, encoding is allowed to take place during static and dynamic activity, these
facilitators of proprioception assume that the patterns associated with a forward, anteriorly
rotated pelvis (AIC) are normal. Encoding of this faulty pattern is normalized and
neuromuscular adaptation begins.
When a prolonged increase in muscle length occurs the muscle spindles develop a higher
threshold for detecting changes in length and rate of change. With a left AIC, this occurs at the
left hamstring (because of the anterior tilt of the hemipelvis). In this lengthened position an
increase demand on motor efferent neurons develops in order to produce coordinated, smooth
movements (i.e. control).
The Golgi tendon organs, at the myotendinous junction of the left hamstring, become more
responsive to eccentric muscle action; while on the right it is more concentric. Activation causes
inhibition of synergists and antagonists (quadriceps) on the ipsilateral side and opposite reflex
action on the contralateral side.
The Ruffini endings in the fibrous layer (zona obicularis) of the right FA joint capsule are more
responsive to direction and speed of capsular stretch then on the left. This is because the
sensitivity of position changes, amplitude, and velocity of a joint is greatest where the
intracapsular fluid pressure is high. The Pancinian corpuscle become more active in joints where
stance phase or closed kinetic activity is high by responding rapidly to high velocity changes
(acceleration and deceleration) in joint position. Therefore, the Pancinian corpuscles are more
active in the right peripheral extremity joints (knee a d a e) a d e e ec e ca e
fibrous layers.
This increase in neural input on the right Golgi-Mazzoni corpuscles, found along the inner
surface of the FA capsule, and the respective Golgi ligament endings give the individual a better
sense of positional awareness and control. Therefore, patients with a left AIC often demonstrate
a right lower extremity dominance by increasing their right stance phase time during function
(increased right COG). This altered neuromuscular control (secondary to torsional
pathomechanics of the pelvis and weakness in the left hamstrings and gluteals) leads to muscle
inhibitions, weakness, and compensatory patterns involving other muscles. The CNS receives
this faulty sensory input from both FA joints and alters the neuromuscular function in other
segments of the kinetic chain so that daily activity can continue. In other words, this is an
example of how reflexive patterns of adaptation become a daily occurrence and over time can be
c de ed a b e e rological system (state of homeostasis).
Disturbances in joint position, perception, movement reflexes, and postural balance will be
evident in the clinical, myokinematic exam. Altered proprioception and abnormal
arthrokinematics increase over-compensatory activity of synergistic muscles around the joint to
minimize the stress, dyskinesia, injury, etc. This compensatory overuse of synergistic stabilizers
leads to compression and congruence breakdown of the joint, as well as malfunction of the
proximal stabilizers.
For one to establish normal FA, myosseous, rotary control during sagittal plane activity, feed
forward activation of the left hamstring (key repositioning muscle) needs to simultaneously
concur during left FA rotation. Rehabilitation and restoration activity must conclude with closed
kinetic chain activity.
Many continue to use rehabilitative strategies that accept high tone as an acceptable adaptive
strategy for muscle recruiting. The long-term consequences of premature muscle activation
(psoas), articular compressive degeneration (right FA joint), disuse atrophy (left gluteals), altered
joint reaction/balance, and delayed motor control lead to stronger faulty movement patterns and
reflexive adaptations.
Most joint afferent receptors are active only near the end of the range of motion thus probably
c b e ef e e a d a c ec a f e f e d fee .
Autonomic
Sympathetic hypogastric plexus
Parasympathetic sacral ganglia
Voluntary
Pudendal nerve
Obturator nerve
Femoral nerve
1. Thomas Test
The patient is positioned in supine with each lower extremity (LE) extended. The LE
contralateral to the LE being tested is then flexed at the hip and knee, to bring the
thigh to the point that the lumber curve is flattened. According to Thomas, if a hip
extension limitation is present, the person will be unable to keep the tested LE fully
straightened.
The patient is positioned in supine with both thighs on the table. Both hips and knees
are flexed to the chest. Passively lower one leg over the edge of the table while
helping the patient hold the untested knee close enough to the chest to maintain the
low back against the table. Do not allow hip abduction to occur past zero degrees on
the tested extremity while passively dropping the FA joint into extension.
A positive test is indicated when the tested lower extremity (usually the left) is
restricted in hip extension because of the forward orientation of the tested side
compared to the other. If both femurs do not approach the edge of the mat or table the
patient is tested on, the innominates are rotated forward bilaterally and the psoas
ce ae ac . P ac e fe e a ac a ac e a e
femur in external rotation. This tightens the TFL and VL and restricts hip extension.
There is also a rotary component to this issue, especially seen with limitation in hip
extension on one side. Since the forward, anteriorly rotated pelvis accompanies sacral
rotation to the contralateral side (right rotation on a right oblique axis or left rotation
on a left oblique axis) the iliofemoral ligament will also limit extension when the
femur is externally rotated by the therapist, through testing with the femur in a
e a .
The femur in this case will not approach the patient support surface without femoral
e a a a d a ( e. c c ) f a e e fe a
head moving forward under the superior anterior condyloid labral rim of acetabulum.
By flexing and extending the knee of the tested LE, one can determine if the test is
positive because of rectus length (one joint muscle structure vs. the two joint muscle
structures).
1. Ortolani
When the hip is flexed to a right angle and then abducted, the lateral aspect of the
thigh normally will reach or nearly touch the examining table and will form an angle
of almost 180 degrees if the other thigh is placed in a similar position at the same
time. If posterior subluxation of one or both hips is present (too much FA IR after
repositioning or with a neutral pelvis), abduction is distinctly limited, and the thigh
will come only within 45 degrees or less of the examining table. Telescoping or up-
and-down movement of the femur in relation to the pelvis may be demonstrated if the
hip is dislocating. The examiner may alternately push upward and downward on the
thigh with the fingers of one hand behind the greater trochanter while the thumb is on
e ASIS a d e e a e a e ee anteriorly.
Hip and knee on the side to be tested are flexed so that the heel lies beside or on top
of the opposite extended knee. The hip being examined is abducted and externally
rotated as far as possible. The presence of pain, muscle spasm, or limited ROM in the
tested hip is positive and suggests abnormality in that hip. Pain may be elicited in the
opposite SI joint, which requires differentiating from the positive response.
3. S a i g Hi Ma e e
LEVEL 0
As stated in the PRI Myokinematic Restoration course manual, the inability to raise the lower
a e ff e a ab e c de ed a 0 c e. T ab ef ec b a ea e
malpositioned obturator of the flexed lower extremity. However, for a variety of reasons
(outlined below) some patients cannot successfully assume the Hruska Adduction Lift Test
position. A common pitfall is to allow the patient to go ahead with attempted execution of step
one of the test while not being in the correct position for the test. If a patient cannot assume the
test position, then that must be reflected in the exam since the exam itself is an assessment of
myokinematic function. Obviously, good functional start position or mobility can be challenged
in some way due to influences of the left or right AIC (the very things being examined). This
level of immobility, therefore, must be understood and documented. Consequently, if a patient
cannot assume the test position then the test should be halted and a score of 0 should be assigned
before ever attempting to engage the obturator (Level 1 of the test).
Restriction of the posterior capsule or abutment of the femoral head against the posterior/inferior
f e ace ab , ca e c ed e e f e fe e ace ab ce
independent, rotational motion of the acetabulum on the femur and the femur on the acetabulum
ee . T c ed e e e b ed a e e a f e e f ff f e
mat or table. It is possible that the a e a e b c ed tion at the FA joint due
to recruitment of agonistic muscles like ipsilateral adductor magnus, piriformis and other femoral
external rotators. Therefore, the examiner must carefully look for foot elevation movement and
then see if the patient can lower the foot down to the table while maintaining the proper position
for the test. This would indicate that the patient can inhibit those agonists and a capsular
e c a be e e . If , e e c e a 0 bef e e e be e e .
Another reason the patient might flex at the FA joint on the extended LE is to avoid excessive
lumbar extension which can occur if the patient has difficulty extending the FA joint to neutral.
If the patient has difficulty extending the top lower extremity at the FA joint, the inability to shift
completely into left AF IR is likely. Once again this is most commonly due to limitations in the
contralateral FA joint. Rather than extending the FA joint the patient simply compensates by
flexing the innominate (AF flexion) and extending the lumbar spine. The test should be halted
a da c e f 0 d be ad e ed f ac de a ed a d ca be
corrected.
LEVEL 1
To achieve a functional score of 1, the patient has to elevate the lower ankle to the upper knee.
This step in the test aids the examiner in determining if the patient has weakness of the obturator
and other ER muscles of the flexed LE. It also discerns weakness of AF stabilizers of the same
extremity since those AF stabilizers must be at least minimally active in order for the patient to
externally rotate the femur during the test without significantly changing pelvis position or
compensation from the psoas.
There are few difficulties encountered with regard to execution of this portion of the test.
LEVEL 2
At this point during the test, the client is asked to raise the lower knee off of the exam table.
This portion of the test is used to determine if the patient has the ability to utilize AF and FA
muscles while shifted into left AF IR. Multiple issues come into play while the patient is
attempting Level 2.
hip extension during adduction and internal rotation of the bottom femur]) also can become a
factor. Erector spinae can also come into play by aiding forward (sagittal plane) rotation of the
pelvis with accompanying thoracic-lumbar extension. These compensatory activities can all be
detected by the examiner as excessive pressure on the examiners shoulder.
Further, if the patient is unable to maintain engagement of the ipsilateral internal obliques and
transversus abdominis muscles during the Le e 2 f ee a ,a e e a
rotate the femur will result in loss of frontal plane control of the abdominal wall. When this
control i , e a e bea d ee a e de ec aaea e
extremity for stabilization. If the patient repeatedly presses down the top extremity into the
e a e de a d c ec e e e e ac ca be obtained during an
attempt at Le e 2 f e e , e e d be a ed a d a c e f 1 d be
administered.
Again, the purpose for the HAdLT is to aid the examiner in understanding if the patient is ready
for progression. If a patient is progressed through a PRI regimen too rapidly then failure with the
rehab program will be the likely outcome. If in doubt, it is always better to grade a patient too
low rather than too high on the test. Scoring too high can result in frustration on the part of the
patient and the clinician as both expect greater outcomes in the following visits only to be
disappointed when these outcomes are not achieved. All of this can be avoided simply by being
more careful and conservative in scoring the test.
Mentioned throughout this document is that the patient should have opportunities to correct poor
positioning or improper effort during the test. There is nothing wrong with helping the patient
with understanding specifically what it is you require of them during the test. Indeed, this will
aid you as you progress the patient through a non-manual regimen, since the patient will better
understand what it is that you require of them from the test perspective. Hopefully they can then
apply that understanding to the exercises prescribed.
When in doubt about position or patient ability to execute portions of the test, one may need to
review the Hruska Abduction Lift Test to recognize, correct alignment for the Hruska Adduction
Lift Test. This would aid in fully understanding what is required of the HAdLT. Further, the
Hruska Abduction and Adduction Lift Tests are complimentary to each other and can aid you in
more accurately determining true functional scores.
Expected test results in identifying a patho-compensatory Left AIC pattern in the left hip (laxity
of the iliofemoral and pubofemoral ligament):
The treatment hierarchy begins by repositioning the pelvis in the sagittal and transverse planes
via the left hamstrings and/or ischiocondylar (IC) adductor.
After repositioning the pelvis in the sagittal plane with the bicep femoris, special attention
should be paid to approximate and seat the left femoral head into the acetabulum and then
continuing AF IR and FA IR stabilization activities with the left gluteus medius non-manual
techniques.
Common compensations:
Patient does not remain in AF IR during FA adduction. Tightness in the
e / e ca e f e ef ca a a e ab a a e
shifted back position and they will shift forward upon adduction in the frontal plane.
Patient will extend their backs and potentially feel their left TFL during attempt at AF IR
as they compensate in the sagittal plane.
Patient will begin exercise in too much right thoracic abduction at the start of the
exercise. Position patient with right arm overhead and move right hip closer to the wall
or left hip toward shoulder to encourage left thoracic abduction. This must be maintained
during the entire exercise.
Pa e d e b ea e a e, ead f a a e e e e
femur back.
Any of these compensations may indicate a posterior capsule stretch is necessary before seeking
further progression through the hierarchy.
Once patient achieves left AF IR on a repositioned pelvis, it is now time to recruit a left anterior
gluteus medius to roll the FA joint into the acetabulum and secure it with progression of
concomitant retraining of the left IC adductor and the left anterior gluteus medius in both the
frontal and transverse planes.
This exercise allows the clinician to also determine if the left hip is positioned properly on
the acetabulum following the adductor pull back exercise.
Common compensations:
The patient is unable to maintain a position of T-L flexion in the sagittal plane (the
patient arches their back on AF IR approximation).
The patient feels the left TFL or vastus lateralis.
The patient feels the left glute max.
The patient does not feel anything.
If the patient fails to feel the anterior fibers of the left gluteus medius, it is another indication of
tightness in the posterior superior left hip capsule that prevents the femoral head from rotating
properly into the acetabulum. This indicates an active or passive stretch should be performed
before proceeding through the algorithm to ensure non compensatory roll and glide onto the
acetabulum during FA IR.
Re-testing the Hruska Adduction Lift Test and seated goniometric measurements at this point
will assist the clinician in determining whether they need this step.
If these capsule and ligaments restrictions exist, a patient cannot fully achieve AF IR and
maintaining left gluteus medius activation will not be possible.
Once the soft tissue restrictions have been addressed, proper neuromuscular retraining of the
left gluteus medius and ischiocondylar adductor to stabilize dual hole control can commence.
Continued rechecking of the Hruska Adduction Lift Test will assure that you have properly
maintained the left hip on the acetabulum without compensations during your treatment
progression.
Once you achieve a 3/5 right Hruska Adduction Lift Test you can begin upright activities (a
patient may begin at a 2/5, but make sure to use wall support and/or table support to prevent
functional failure).
It is important to recognize the need for the anterior gluteus medius muscle to stabilize the
over lengthened lateral bar of the iliofemoral ligament in these patients. Without a strong left
anterior gluteus medius, these patients will continue to compensate into FA ER, when they
appear neutral during upright activities. The resultant compensations for this pelvic position
can be altered all the way up to Right Brachial and Right Temporomandibular Cervical Chain
resulting in neck hyperactivity.
The left sidelying PRI non-manual techniques should include attention to FA adduction and
IR with the IC adductor with concomitant activity of the left anterior gluteus medius. If a
patient does not feel their anterior gluteus medius, it is indicative to back up and retest the
Hruska Adduction Lift Test and or seated goniometric measurements.
As you move through your rehab program, into steps 4 and 5 and attain bilateral hole control
and step 6 standing dynamics, you must maintain the activity of the left IC adductor and left
anterior gluteus medius to ensure a successful PRI treatment plan. Without securing a left
hip into left AF IR, a Left AIC pattern will be fed and outcomes will be limited.
Poor femoralpatellar
congruence
PIRIFORMIS SYNDROME
Examination Considerations:
Positive Left Adduction Drop Test Positive Left Adduction Drop Test
Decreased Seated Left FA IR Decreased Seated Right FA ER
2 or Lower Right Adduction Lift Test 2 or Lower Right Abduction Lift Test
2 or Lower Right Abduction Lift Test Decreased Seated Right FA ER Strength
GOALS:
(Toward the end of treatment, if seated (Toward the end of treatment, if seated Right
FA ER Left FA IR strength remains weak, strength remains weak, then attempt
then work on Left Glute Med strengthening.) Left Sidelying Resisted Right Glute Max.)
ILIO-SACRAL STRAIN
Right IS Strain Left IS Strain
Focus on Right Glute Max & R AF & FA ER Focus on Left Ischiocondylar Adductor and
activity with concomitant L AF IR Left FA IR (after achieving Left AF IR)
1. Left Sidelying Right Glute Max 1. Right Sidelying Respiratory Resisted Left
(appendix page 32) Adductor Pull Back
(appendix page 26)
Notes:
Poor co-activation of left ischiocondylar adductor (FA IR) and right gluteus maximus (FA ER).
Examination Considerations:
1) Adduction Drop Test
Intervention:
Left hip adduction integrated program to increase AF adduction (active and passive) on the left
and AF abduction and ER on the right.
1) Left Sidelying IO/TA and Left Adductor with Right Glute Max
(appendix page 28)
Clinically, this presenter finds a correlation between symphysis pubis pain and excessive internal
rotation at one FA joint and excessive external rotation of the other. Repeated minor trauma
from excessive, repetitive biomechanical shearing leads to compensatory patterns of lumbar
lordosis or hemilordosis (anterior pelvic rotation on one side). Pain is often aggravated by
pivoting on one leg, kicking a ball, sprinting, climbing stairs, or sitting up.
Notes:
Poor concomitant facilitation of adductors with contralateral abdominal obliques and transverse
abdominis
Examination Considerations:
Hruska Adduction Lift Test
Seated FA IR and ER
Intervention:
Increased integration of LEFT AF IR with LEFT internal obliques and RIGHT external obliques;
Increased integration of RIGHT AF IR with RIGHT internal obliques and LEFT external
obliques
The tibia and femur rotate medially on initial contact, and loading response phases of gait. Then
they laterally rotate at midstance, terminal stance, and pre-swing. Initial, mid, and terminal
swings require medial rotation. Transverse rotation or torque through the tibia increases with
excessive femoral external rotation weakness, excessive femoral internal rotation, and strong
plantar flexors at heel strike through midstance. Torque across the tibia increases when there is a
premature active supination in an attempt to assist with stabilizing the ipsilateral anteriorly
rotated hip.
Notes:
Excessive femoral and tibial IR, poor hip extension influencing anterior pelvic rotation and
obligatory FA IR, overuse of ipsilateral supinators
Examination Considerations:
Gait Analysis, SLR Test, Extension Drop Test, Ankle Dorsiflexion
Intervention:
Reciprocal swing of upper extremity with contralateral lower extremity; retro walking with
concomitant FA IR, appropriate stretching of hip flexors and back extensor
Muscles with a high percentage of type II (fast twitch) fibers are more likely to be injured
because of the implications of faster contraction of muscle. Hamstrings are primarily composed
of fast twitch fiber. No research can be found to support the suggestion that fast twitch fibers in a
muscle that is in a long resting state takes on slow twitch fiber characteristics.
Bicep Femoris (ER) strains occur on the ipsilateral side of an anteriorly rotated hemi-pelvis. This
pelvic position results in delayed hip extension during early heel strike or late swing phase.
Excessive demands are placed on the lengthened hamstring as it attempts to eccentrically control
internal rotation. These strains can also occur contralateral to the side of the anteriorly rotated
hemi-pelvis secondary to concomitant femoral internal rotation.
Semitendinosus (IR), Semimembranosus (IR), and Adductor Magnus (IR) strains occur on the
ipsilateral side of an anteriorly rotated hemi-pelvis. This is secondary to the medial hamstrings
acting as an antagonist to an overactive psoas that concomitantly externally rotates the femur
during midstance, terminal swing, and preswing. These individuals usually have an overly
stretched anterior capsule (Adduction Drop Test is positive, Extension Drop Test is negative and
ca a a c c ).
EXAMINATION CONSIDERATIONS
1) How much FA internal and external rotation do they have? TFL or Gluteus Medius?
4) Do they have equal strength upon resisted knee flexion in sitting with the femur positioned
internally in the acetabulum and with the femur positioned externally in the acetabulum?
INTERVENTION
2) Determine status of anterior acetabular femoral capsule. If stretched or lax you will need to
increase IR strength from gluteus medius and ischiocondylar adductor; not the tensor fascia
latae.
Restore position
Restore position
HAMSTRING CONSIDERATIONS
Control of knee is reduced with poor hip extension (gluteals, hamstrings, obliques) Eccentric
quadriceps activation upon deceleration creates a large magnitude of anterior translation force at
the proximal tibia without co-activation of the hamstrings and pelvic control.
Initial Swing Hamstrings act concentrically at the knee to produce knee flexion
Late Swing Hamstrings act eccentrically to control knee extension and to re-extend the hip
Decreased dynamic hip extension promotes overuse of plantar flexors, gastrocnemius and soleus.
Contraction of hamstrings leads to posterior translation of the tibia and its tuberosity and
concomitant flexion of the patella.
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