Today we talk about how to tell which of the facilitators you’ve found is higher on the causal hierarchy for an inhibited muscle; aka which one is closer to the root cause/compensation strategy.

So let’s say a patient comes into your office and is complaining of knee pain, and you see this horribly unstable valgus and a lot of pressure being put on that medial knee and the IT band. You have them climb onto the table and quickly show them that their peroneals were taking the TFL offline. They get up, move around, it holds and they have no pain. But are you done? Even if only one side is painful, so much of the time both of the knees are in similar states of instability driven in considerable part by the inhibited TFL’s. With a bilateral issue we look to that core and will often find that it’s likely the body was trying to drive the knees in to create stability to compensate for a failed core. We get the core on through whatever mechanism and boom, the knees are even better and we’ve fixed a higher order of problems, resulting in a much more stable and happy body.

The question at this point though, is again, are you done? The metaphor I use with patients in this situation is to tell them okay…we’ve found the direct cause of your problem…but was it the source? So does that mean it’s the hit man, or the crime boss that sent him after your knee? If we just get the former but not the latter, the source of the problem isn’t resolved and will pop up somewhere sometime later (sometimes the moment they get off the table in those pesky situations where your corrections just refuse to hold).

So let’s say you find an SI jam that’s turning off the TVA. Release the jam and the TVA is strong. Challenge and a bit weaker. Release more and now the TVA sticks with the challenge, awesome. But the question in my head is often “but what caused the SI jam?” Sometimes we can answer it easily, but most of the time it’s just part of a compression strategy to give axial stability so we have to look up the line…typically in things that cause or take away axial stability. The cases this week were as mentioned, usually the scalenes or levator pulling on the C2, etc. etc. But the thing is I want to see what the biggest ‘threat’ to the TVA is; the SI dysfunction or this pissed off neck muscle. This is the method I use to discern the top of the hierarchy, or at least the top out of the chain I’ve found, it may be higher still.

1: Gap the jammed SI and test TVA (after confirming that the SI jam was the TVA’s facilitator)
2: TVA tests strong, now go and turn on the scalene/levator
3: Test TVA and it blows out, definitely connected.
4: Release the scalene/levator and retest TVA, nice and strong.
5: To confirm the hierarchy, jammed the hell out of the SI and then hold in a gapped position and retest. If the test holds, the scalene/levator being released is more important to the TVA and it’s being cleared up will likely take care of that SI issue.
6: Look up the chain again! You’ve figured out which of these two issues is more important but in my example I had to check this all against the C2 itself and anything else I thought was above it. It may sound like a bit of work but I cleared up almost everything around the hips, the entirety of the core, adductors, much of the shoulder and neck inhibitions, as well as a bunch of painful facilitators, by taking a few minutes to find the top of the totem pole.

So if you compare two and one gives you a lock even when the other is challenged strongly, and in reverse the muscle blows out, you’ve found what’s higher on the hierarchy. Sometimes this will be the case for one muscle in the core…but the opposite in another, or in my example most issues were to the C2 or another original cause in the area, but sometimes it took releasing of the levator as well (C2 to TVA, levator to RA for example), but overall it really cuts down on homework for the patient and treats closer to the actual cause without having to guess. Most of the ‘noise’ down below, aka the SI jam, goes away the when the hierarchy is removed.

Filed under: The Practitioners Corner

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