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We received this great question last week from a clinician who has attended a PRI course. He brought up an interesting perspective…
During a conversation with a colleague a confusing issue came up. PRI stuff is interesting and one of the things that is most interesting to me is that they pretty much say “everyone has this presentation” (left anterior, tension in right hamstring, anterior tilt, etc…). If you have ever read Wolf Schamberger’s “Malalignment Syndrome”, he actually talks about the most common presentation being people anteriorly rotated on the right, posterior on the left - which is opposite to PRI’s thought process. Who is right? I think it is okay to notice trends (I have actually seen more people fall in the presentation from the Malalignment Syndrome - anterior rotation on right), but to group everyone into the same presentation is a bit strange.
It’s all a matter of perspective, which is what PRI challenges the most. Humans lateralize their center of gravity to the right more than to the left because of many objective reasons. If one establishes a neuromuscular pattern of stable, secure foundation through the right lower extremity, utilizing the right vastus lateralis, right hamstring, right adductors and right gluteus medius, you will find an anteriorly positioned or oriented innominate on the right. Subsequently, the left ASIS may “feel” more anteriorly rotated on the left and possibly the evaluator may “find” the right innominate more posteriorly rotated on the right. Inter-rater reliability in these situations, without further integrated objective testing is poor at best. In this case, in standing, the evaluator would find more lumbar-thoracic lordosis on the left.
If one becomes lordotic bilaterally, as often is seen with those who are tight and over-active with their posterior exterior chained paravertebrals (PEC patients) the right and left innominates move in an anteriorly rotated direction around the frontal axis going through both central acetabulums. Discussing axis of the sacral rotation complex, varies in every individual and has no validation in today’s research. This individual will now need to begin moving the left innominate out or externally rotated it around the vertical left SI axis to offset weight distribution to the right, resulting in:
Hyperactive right quadratus lumborum activity
Hyperactive left gluteus maximus and TFL
Hypermobility and possible laxity of left pubefemoral and iliofemoral ligament and soft tissue
Inhibition of left adductor and hamstrings
A left ASIS that feels “posteriorly” rotated compared to the “anteriorly” rotated right innominate
I am fairly certain, this compensatory activity associated with the human characteristic pattern of bilateral innominate anterior rotation (lumbar-thoracic lordosis) is what the “Wolf Schamberger’s Malalignment Syndrome” is all about.
Again, it’s all about perspective, position and pattern of the tester and the tested. Please realize that palpating ASIS’s and PSIS’s of those in sitting, standing, on one leg, supine, etc all result in various, ambiguous outcomes…a whole different discussion and set of circumstances.