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Empowered Performance Program

Assessment
Week 2 Notes

System Adaptability

A lens for identifying patterns of compensation when there is a change in “optimal flow”
of the entire system and a reduced ability to cope with unexpected disturbances.

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What is a compensatory pattern?

A position of the musculoskeletal system that we develop in order to continue breathing

and moving within an asymmetrical body.

Muscles having to shorten and tighten to overcome a specific “problem”.

Survival mechanism to maintain function.

*Trying to turn our rudder straight?” - Sacrum Sternum Sphenoid

Movement used habitually to achieve functional motor skills when a normal

movement pattern has not been established or is unavailable.

- Medical Dictionary of Health Professionals

Why do these patterns exist?

● From the outside we may look symmetrical: two eyes, two ears, two arms, two
legs, two feet...

● From the inside we are anything but symmetrical.

● Right Side - Liver, 3 lobes of lung, larger diaphragm with lower attachment.

● Left Side - Heart, 2 lobes of lung, smaller diaphragm.

“The greatest wisdom is seeing through appearances.”

Atisa - Buddhist religious leader.

Dysfunction vs. Functional Adaptation

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The Diaphragm

❖ We breathe 20,000 times a day.

❖ Breathing is moving.
❖ Inhalation
➢ Diaphragm contracts and pulls downward / flattens
➢ Muscles between the ribs contract to pull ribs upward.
➢ Air fills the lungs as space increases and pressure decreases.
❖ Exhalation
➢ Diaphragm relaxes and domes upward.
➢ Intercostals relax and ribs come down.
➢ Pressure increases and space decreases.
➢ Lungs contract and air is forced out.

“In order for the lungs to expand and contract, the thoracic cavity lengthens and
shortens due to the rise and fall of the diaphragm as the ribs elevate and depress to
produce an increase and decrease in anteroposterior diameter of the rib cage. Any
restrictions imposed by joint or soft tissue dysfunction will retard the efficiency of this
pumping process.”
- Chaitow, Leon. “Recognizing and Treating Breathing Disorders”

Fusion Pilates Video Link

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EP Active Range of Motion Assessment

● 6 tests that identify areas of compression in the axial skeleton.

○ ISA, Toe Touch, Squat, Overhead Reach, Apley’s Scratch Test, Standing
Rotation

● This helps us identify the relative joint positions of the appendicular skeleton.
○ Scapulothoracic, Glenohumeral, Lumbopelvic, Pelvic femoral

What Compression Looks Like

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Let’s Learn to Breathe

❖ Step 1: Lay down on your back with your knees bent and place one hand on your lower
ribs and the other hand just below on your belly.

❖ Step 2: Take a gentle inhale through your nose with your mouth closed.

❖ Step 3: Take a long sighing exhale out of your mouth making sure to get as much air out
as possible.

❖ Step 4: Repeat inhale and exhale and notice the ribs and belly rising and falling. Each
time you repeat try to get more air out and notice the contraction of your abdominals as
you exhale more and more.

❖ Step 5: Keep your abdominals tensioned after the next exhale and do not let floating
lower ribs elevate excessively as you take your next inhale. If you are doing it right it will
feel a bit difficult to get air.. This is okay, just get as much air as you can in and repeat 5
times.

❖ Step 6: Take a break and then repeat 5 times. Each time you inhale imagine expanding
your rib cage from the inside out by maintaining the pressure in your thorax and not
allowing your belly to come out.

❖ Step 7: Use this on all of your breathing exercises to maximize their effect.

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Next, We Need to Understand Our Position...

❖ Understanding the position that our rib cage, pelvis, scapula, and spine are in will
help us understand where we need to expand during breathing in order to restore
a position that will allow our thoracic and pelvic diaphragm to function optimally.
This will give us back our FLOW!!

❖ We will use our Active Range of Motion Testing to identify our position and
retest after our exercises to make sure we are on the right track!

❖ We can choose specific breathing positions that target the areas we need to
expand. The goal with these positions is to close off certain areas to allow
expansion in other areas so that our joints can move and our muscles can
function optimally. Think, “stretching from the inside.”

❖ We can also alter exercises and exercise selection based on our understanding
of position to help our bodies work optimally.

❖ This is how we become EMPOWERED!

Explanation of Assessment

INFRASTERNAL ANGLE (ISA)

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Normal Respiration

NARROW INFRASTERNAL ANGLE

In the narrow ISA a person’s ribs are generally straighter and longer anterior to posterior and
narrower laterally. This is a compensatory strategy to try to exhale. This results in potentially
weaker internal obliques and transverse abdominals. If the lower ribs are flared, the anterior
abdominal wall will be weak and we will need to learn how to curve those ribs back in without
further narrowing of the rib cage. Activation of the internal obliques and transverse abdominis
will allow the ribs to become more bent creating length laterally and promote anterior to
posterior compression. Increased strength in the abdominals will allow for greater potential to
reduce rib flare.

Narrow ISA Breathing Strategy

For the narrow ISA we would like to promote contraction of the internal obliques and TVA to help
drive lateral expansion (more curve) in the ribs. A long sighing exhale that is soft and gentle is
optimal.

**Here is a great example of using too hard of a breath and it actually closing the ISA on a
narrow. Please note she is 34 weeks pregnant in this video. You can see how the ISA narrows
despite the flare.
Ellen Petosa Breathing Video

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WIDE INFRASTERNAL ANGLE

In the wide infrasternal angle a person’s ribs are generally wider laterally and narrower anterior
to posterior. This results in potentially weaker external obliques. Additionally, if the ribs are
flared (externally rotated) the anterior abdominal wall will be weak. Activation of the external
obliques will allow the ribs to become straighter and promote anterior to posterior expansion.
The strengthened abdominal wall will allow for greater potential to internally rotate and reduce
rib flare.

Wide ISA Breathing Strategy

For the wide ISA we would like to promote concentric action of the external obliques during
exhalation to help drive the ribs straighter anterior to posterior. A forceful exhale is optimal.

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*In both scenarios we need controlled eccentric facilitation of abdominals (Inhalation) to create
pressure in the anterior abdominal wall to prevent overuse of compensatory breathing muscles
(aka: neck, low back). A fully intact and competent abdominal wall will allow expansion of the rib
cage via pump handle, bucket handle and posterior mediastinum for full diaphragmatic
contraction. This orientation will allow for expansion of the thoraco-lumbo-abdominal cavity that
allows for a lessening of concentric activity in undesired muscles. (No belly breathing)

General Population Explanation - The position of your rib cage allows for some muscles
to work more than others. If your rib cage is wide (measurement greater than 90 degrees)
the outermost muscles on the sides of the abdomen are not very active. We can use a
specific forced exhale to help those muscles to turn on. If your ribcage is narrow
(measurement less than 90 degrees) the deeper muscles on the sides and even deeper
muscles that run across the abdomen are not very active. We can use a long sighing
exhale to help those muscles turn on. When we change which muscles are being used
we can allow the rib cage to function better, making it easier to breathe and move.
(Remember: Breathing is Walking). Better use of our entire abdominal wall will allow us
to better perform all exercises while reducing pain from overusing the wrong muscles.

For the ISA we are looking at the measurement between the bottom of both sides of the ribs
with our index fingers touching the bottom of the sternum. If the distance is greater than 90 you
are wide and less than 90 you are narrow. For the wide ISA we are going to utilize a hard exhale
and for the narrow a long soft sighing exhale. In both strategies we want to get as much air out
as possible and maintain abdominal tension as we inhale to keep the ribs down.

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Wide ISA

Narrow ISA

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MAKE SURE TO MEASURE CORRECTLY

THE ISA TELLS US ABOUT THE IPA (INFRAPUBIC ANGLE

*We will learn more about this in the coming weeks.

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TOE TOUCH

EXCESSIVE
If a person has excessive toe touch, we can make an inference that the hip extension muscles
may be over-lengthened. In this scenario it is important that we drive the facilitation of the
hamstrings (Biceps Femoris, semimembranosus, semitendinosus, and extension fibers of
gluteus max) to help pull the inferior aspect of the pelvis (Ischium) downward to allow more
posterior orientation of the pelvis and concentric shortening of the hamstrings.

LIMITED
If a person has limited hamstring length as indicated by not being able to reach fingertips almost
or all the way to the floor we can make the assumption that their hamstrings are not over
lengthened, but their pelvis is anteriorly oriented, thus creating the limitation. In this scenario it
may be more beneficial to create facilitation of the abdominal wall first to allow for lower
posterior thorax expansion and eccentric lengthening of the spinal extensors. The abdominal
wall is the lowest hanging fruit in this scenario. Once we have restored the position of the trunk
we can work on hamstring facilitation. Additionally, we may find it useful to combine exercises
that make it easier to achieve posterior expansion (inverted and rock back positions) with
hamstrings.

FULL
If a person has relatively normal hamstring length as indicated by a toe touch we can make a
broad assumption that their hamstrings are possibly slightly overstretched or not overstretched
which would mean their pelvis is in a relatively neutral position / or slightly more anteriorly
oriented and / or rotated position. In this case, if we are attempting to simplify our methods a
general approach could be taken and any strategy could be utilized to see positive changes on
tests.

General Population Explanation - Your ability to touch or not touch your toes can help us
understand what is happening with the muscles on the back of your legs and the position
of your pelvis. Generally we see one of two scenarios, you cannot touch your toes or you
can touch way beyond your toes and put your palms on the floor. In either scenario your
hamstrings may feel “tight” because they are being pulled at all times because of the
position of your pelvis. If you have an excessive toe touch then your hamstrings are
overstretched and we need to get them stronger to help pull your pelvis back to a more
optimal position. If you can’t touch your toes then your hamstrings are not overstretched
but the position of your pelvis and trunk are limiting your movement. In this scenario we
want to restore your trunk position first and then restore the position of your pelvis.

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For the toe touch, stand with your feet together and knees straight but not hyperextended.
Reach down towards the floor and stop when you feel tension.

VIDEO OF TOE TOUCH

Testing Points:

● Feet stay together

● Knees straight but not locked

Additional Observations:

● Curvature of the spine - Look for areas of compression and expansion.

● Foot Position
● Knees - Look for hypermobility
● Asymmetry of Posterior Thorax

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Additional observations from behind

OVERHEAD REACH

LIMITED (RIGHT, LEFT OR BOTH)

For the Movement Professionals:

If a person has limited overhead reach the scapula is relatively in a position of
adduction, elevation (orientation on thorax), external rotation, and downward rotation on
a rib cage that is compressed posteriorly. In this position subscapularis, latissimus dorsi,
rhomboids, infraspinatus and levator are concentrically oriented and pull the scapula
back allowing opening of the chest wall. A concave scapula on a flat rib cage makes it
harder for the scapula to glide along the rib cage. You may also expect a reduction in
shoulder external rotation if they are also compressed in the middle of their posterior
thorax. To restore position and movement of the scapula we would want to supinate the
forearm and protract the shoulder while keeping the anterior lower ribs internally rotated
and not allowing them to flare. The protraction and supination will allow for posterior
expansion, lengthening of the concentric muscles and contraction of serratus to drive
the posterior rib cage back and also drive abduction, internal, and upward rotation of the
scapula. In addition we will restore rotation of the thorax.

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General Population Explanation - Your ability to reach overhead is a reflection of the

ability of your shoulder blade to move upwards and rotate forward. Because of the
position and shape of the ribcage certain muscles become more active and shortened
and others become less active and lengthened. We can restore the position of the rib
cage and shoulder blade using a forward supinated reach in our breathing exercises.

For the overhead reach test, stand next to a wall, a foot length away and do not allow arching of
the low back by keeping back flat against the wall. As you raise your arms up, do not allow the
elbows to flare out to the side or excessively bend. Raise the arms overhead and notice any
limitations.

(Picture shows limited left, full right)

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VIDEO OF OVERHEAD RAISE

Testing Points
● Thumbs should point up towards the ceiling.
● Keep arms shoulder width.
● Test stops when arms begin to open to the side.
● Back stays flat on the wall and ribs down.

Additional Observations:

● Arms travel away from midline

● Back leaves wall or ribs flare
● Moving head forward
● Shrugging shoulders upwards

Optional Testing:

● Supinated reach
● Seated against the wall

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APLEY’S SCRATCH TEST FOR INTERNAL ROTATION

LIMITED (RIGHT, LEFT OR BOTH)

For the Movement Professionals:
The Apley’s test for IR measures glenohumeral extension, internal rotation, and scapular
adduction. If a person has limited reach towards the opposite inferior angle of the scapula the
scapula is in a relatively abducted, internally rotated, and upwardly rotated position on a rib
cage that may be anteriorly compressed and posteriorly expanded or compressed. In this
position the Rhomboids, Infraspinatus, Levator, Subscapularis, and Serratus, may be
eccentrically oriented, while the pectoralis minor and sterno clavicular portion of pec major are
concentrically oriented and the chest wall is closed off and compressed. To restore position and
movement of the scapula and rib cage we would want to expand the anterior rib cage and
eccentrically orient the pectoralis minor muscle and possibly the biceps, and latissimus dorsi if
contributing to lateral flexion. If using a 90 90 or hook lying position we would want to relax the
arm out to the side on the ground or reach straight forward with a neutral arm (not supinated)
and focus on breathing into the chest wall. If using a prone position we would want to keep the
palm facing down and / or reach forward and to the diagonal slightly. (As the arm goes overhead
in greater flexion we also get a posterior rotation of the clavicle which may help restore position
of the upper chest wall.) Choose the inverted position if limited in flexion and internal rotation, to
allow for easier expansion front to back as the guts push down into the upper thorax making it
easier to expand.

General Population Explanation - Your ability to reach behind your back and touch the
opposite shoulder blade is a reflection of the ability of your shoulder blade to move

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backwards and towards midline. Because of the position and shape of the ribcage certain
muscles become more active and shortened and others become less active and
lengthened. We can restore the position of the rib cage and shoulder blade using
breathing exercises that expand the chest wall.

For the Apley’s Scratch Test, stand up tall but do not allow low back to arch and ribs to flare.
Reach one arm behind your back and see if you can touch the bottom of your shoulder blade.
Repeat on the other side.

VIDEO OF APLEY’S TEST

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Additional Observations:

● Excessive winging
● Arching low back
● Position of the hands (can you see the palms)
● Shoulders roll forward

Optional Testing:

● 90 degree IR
● 0 degrees is Ober’s or Adduction Drop Test of Shoulder

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STANDING ROTATION

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LIMITED (RIGHT OR LEFT)

We can use a person's ability to rotate to the right and left as a proxy measure for evaluating the
biased rotation of the thorax and pelvis. If a person is more rotated to one side or the other, it
changes the dynamics of all joints distal to the ribcage and causes concentric and eccentric
muscle activity that results in compensatory patterns. A greater leftward rotation is likely to be
indicative of a flared left rib, adducted left scapula, abducted right scapula, and right rotation of
transverse processes in relationship to the rib cage. In this scenario the motion is usually
coming from the lower back and you will notice more compression in the lumbar when turning to
the left and potentially swaying to the right with the hips. Often a true limitation in left rotation is
caused by an ilium that is in more of an externally rotated position, which decreases the ability
to rotate over the femur and limits left rotation of the pelvis to the left. Although this can be
common it is not always true.

A greater rightward rotation may be because the pelvis can move better to the right. A limitation
in rightward rotation could be because the pelvis and thorax are already turned so far to the
right there's nowhere left to go. Having said this, I like to use this as a demonstration to clients
of the reorientation of the thorax following breathing. In addition, we can look for pelvis motion
side to side as well as what is happening at the feet. This is a broad test that allows us to see
many things from a wider lens and make correlations to the other tests.

*Expanding the thoraco-abdominal region where necessary should reduce limitations in

standing rotation to one or both sides.

General Population Explanation: As our ribs become compressed front to back or side to
side due to improper breathing and compensations we may become limited in rotation to
one side or both. This limitation can result in secondary compensations above and below
to try to accomplish tasks that require us to reach behind us, reach across, and look side
to side or behind us. The result is overuse of muscles of the neck and lower back and
many more throughout the body. We can use this as a pre and post test to determine if
our breathing position is creating a beneficial change.

For the standing rotation test, start with your feet together and arms across your chest. Rotate
as far to the right as you can, looking over your shoulder, and then repeat on the left.
Sometimes it can be hard to feel differences. If this is the case, take a video of yourself from
behind and go back and watch the video to determine limitations. (Note: these pictures are not a
demonstration of my limitations. If you watch the video you will see that I am limited to the left in

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the pelvis and slightly more limited to the left in the thorax. We will talk more about this as the
weeks go on)

VIDEO OF STANDING ROTATION

Testing Points:
● Keep your feet together.
● Don’t force the pelvis to stay still.

Additional Observations:
● Feet
○ supination / pronation
○ position
● Arching low back
● Asymmetrical compression
● Scapula height
● Neck ROM
● Weight shifting

Optional Testing:
● Seated

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TOE TOUCH TO SQUAT

We can use a person's squat to determine how compressed or expanded a person is.
Typically with a wide ISA we see a limited squat due to a pelvis that can’t externally rotate and a
sacrum that can’t counternuate and a thorax that can’t posteriorly orient. Generally, but not
always, these people have more sacral nutation and a limited toe touch, but narrow ISA’s can
also be limited because of compression higher up that limits the squat. When squatting these
people will tend to hinge forward rather than standing straight up and keeping the head and
ribcage stacked over the pelvis. Typically with a narrow ISA we see a pelvis that can externally
rotate and a sacrum that is able to counternutate. Generally, I find these individuals to have
more laxity throughout the entire body, over lengthened hamstrings, and a harder time nutating.
When squatting, especially with load, they may have a difficult time getting out of the bottom of
the squat due to the overall eccentric orientation.

General Population Explanation: As our ribs flare and our hips tip forward our body will
have to alter some other area to be able to achieve a full squat. Generally, a person will
hinge forward and use hamstrings and low back (these are usually the people with a
limited toe touch), or a person will drop all the way down to the floor because their
hamstrings and other tissues are over lengthened (these are the people who have
excessive toe touch ability). We can use this as a pre and post test to determine if our
breathing position is creating a beneficial change.

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For the toe touch to squat, stand with your feet together and allow your knees to bend, reach
down and grab your toes (it is fine to bend the knees as much as you need to). Slowly squat
down and stop when you get to a place where you can no longer squat or you feel you might fall
over. If you are unsure if you are below 90 and you seem to be right at 90 then record it as
above 90.

VIDEO OF TOE TOUCH TO SQUAT

Testing Points:
● Keep feet and knees together
● Bend down and grab toes.

Additional Observations:

● Curvature of the spine - Look for areas of compression and expansion.

● Foot Position
● Heels coming off the floor
● Asymmetry of Posterior Thorax

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● Shifting side to side

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