Postural Restoration of an Ironman – A Week by Week Case Study

One of the things I’ve really wanted to do since doing my continuing education with Postural Restoration Institute was to openly share a complete exercise program I would create for someone using the PRI method as part of their training.  Enter, Coo (Catherine) O’Sullivan who is my main sidekick!  I am so excited about this for a few reasons: 1. She is one of my closest friends and we’ve worked together as trainers for over 11 years! (Coo, can you believe that?!!) 2.  She is an awesome trainer and gives everything to her clients and she deserves some LOVE too! 3. She completed her first FULL Ironman last year and she is incredibly gifted at all things endurance.  I want to see her continue to compete as long as she can because it’s amazing and she loves it. So we need to start digging in to all of her “issues”.  4. I know she will be compliant because she loves to exercise. Makes my job super easy!  5.  She’s got a lot of issues and lightbulbs are going off everywhere in my head! “Ah-ha moments”, “ding-ding-ding’s”, and “of course’s”, were just rolling off my tongue after her evaluation.

Here’s Coo during her Ironman last year.

She literally ran through the finish line smiling and waving her arms in the air!  AMAZING!

Here are the notes I took on her regarding her basic complaints and body issues.

Catherine is a competitive triathlete who completed an Ironman 6 months ago. She has right shoulder / neck pain she has been dealing with for 3 years. She says her c7 is tender to the touch all of the time. She also has a left hamstring strain she has been dealing with for some time. She has a 1 cm neuroma on her right foot and a 6mm neuroma on her left foot that caused her lots of pain during her last Ironman. She loves triathlons and wants to continue to compete without pain if possible.  

Below is her complete evaluation, which will only be useful for the PRI Fam 🤓 who are reading this right now.  Feel free to skip past the technical evaluation and I’ll break it down in a very understandable explanation.

Each week or two I will post my notes and the exercises I chose so you can get an understanding of how all this PRI stuff works and how I use it as a coach to help people strength train while addressing their asymmetries and compensations. If PRI is not something you are familiar with and you want to learn more because you think it may be useful to you as a coach here is the website and here is an article I wrote.

Click here for easy to understand version that skips the technical part.



This is an algorithm that PRI utilizes to help me see the big picture of Coo’s asymmetries and areas of weakness.  When I first look at this I try to summarize what I see in my brain and use that to decide what areas to focus on first.  These goals will likely change as we progress and get more specific, but to give a better understanding for those interested, here are my notes / initial thoughts below (For the record these notes are just very initial thoughts and, by no means, are all of these things addressed at once.  They just help me see from a broader lens so I can decide which exercises to start with):

Here are my PRI notes based on her full assessment.

Again, feel free to skip this part and move on to the non-professional / non-PRI explanation!

I did a full assessment using Myokinematic and Respiration assessments from PRI. Catherine was a PEC with limited FA internal rotation, more limitation on the right. She uses her TFL to actively internally rotate and has excessive hamstring flexibility. She is a bilateral BC. She has a lot of trouble breathing into her posterior mediastinum and it is slightly harder for her to get air into her right side. She uses her neck to breathe and expand through her chest to get air and may overuse her SCM and scalenes during inhalation. She has a narrow infrasternal angle. Her left ribs were lower than her right and she had a rib out on the right. There may be compensatory action from her right scalenes and SCM that is pulling her right rib cage upwards or she may have possible inferior T-8 syndrome which would cause greater flare of her right lower ribs.  

What the hell does all of that mean?!!

English Please!

Let me try to break it down as simply as possible in non PRI lingo.  Coo’s hips tilt forward. (Slightly more on the left side – this pic does not show the shift to the right side from the greater left tilt).  0139CD84-014C-4BCA-A34B-4B6431C517F3

For the record, Catherine does not look like this picture, this is waayyy exaggerated, but it gives you an idea of what happens to the lumbar (lower) spine when she is standing.  PRI always says not to trust your eyes but to trust the tests.  Because she is further tilted forward on the left she is slightly rotated to the right which causes her to put more weight onto her right leg.  Picture the statue of David below.


If we look up the kinetic chain we see that Coo’s rib cage is flared. Typically, based on the algorithm from PRI we would expect that she would have greater elevation on the left but she actually has slightly higher elevation on the right.  Overall Coo has elevated and externally rotated ribs on both sides.  The slightly more elevated right ribcage is unusual and may be a result of her clever compensations that get her through her amazing feats of endurance!  In addition both of her scapula (shoulder blades) are anteriorly tipped, protracted, and depressed.  Think winging scapula!  Here is what her ribs and scapula look like: (Again, I will state the obvious, Coo does not look at all like these individuals but I am giving extremes so you can see the big picture when we look at the much more subtle changes in Coo’s anatomy.)



Coo’s external rotation of her femur (thigh bone) in her acetabulum (hip socket) during sitting is adequate and she is relatively symmetrical but her internal rotation is slightly limited on her right leg

.  1E9FB21E-E6C8-4BC5-A02B-61895B5E219C

When placed supine with knees at 90 her internal rotation was much more limited. (I would like to retest her internal rotation in a prone hip extended position next time I meet with her.) She also uses her TFL (Tensor Fascia Latae) to actively internally rotate her femur in her hip socket on both sides.  When the TFL gets overactive and overused it can affect a LOT of other muscles.  I mean you might start breathing with your eyeballs?!  Basically it’s job is to flex the hip (lift the leg up), abduct (move the leg to the side) and internally rotate (rotate the leg inward).  That’s a big job, especially if you are working by yourself!  But wait, TFL is most certainly not in it alone, in fact it’s really not responsible for these actions on it’s own at all.  It’s supposed to be getting help from the glutes, hamstrings, adductors, and hip flexors and just come in a bit here and there to give a little assistance.  TFL is such an overachiever!


Coo’s main area of pain during her Ironman were the Morton Neuromas in her feet.  They are what prevented her from having the most amazing ironman ever.  The run was very difficult and painful and she had to change her shoes multiple times to get through the pain.  Morton’s Neuroma is basically a thickening of the nerve between the metatarsals of the foot, typically between the 3rd and 4th metatarsal.


It’s very possible the neuromas formed because of excessive irritation from running with compensation on a high arched foot.  She has proper foot support but has very high arches which can cause compression on the nerve between the bones of her feet during stance phase of gain (when her foot hits the ground).  Also, her lack of control due to weakened glutes, hamstrings, and adductors, during stance phase of gait is likely adding more pressure on her forefoot.  Back to the anterior tilt and overachieving TFL!

I’ll sum it all up with this equation below.

Breathing and Diaphragm Dysfunction = Flared Rib Cage + Anterior Tilt + Overactive TFL + Weak Glutes, Hamstrings, and Adductors + High Arches + Extra Pressure on Stance Phase of Gait = Morton’s Neuroma’s (Ding! Ding! Ding!)

So where do we start!!

We have got to get Coo breathing before we do anything else!  “Breathing is Walking” and “Respiration wins every time” are two of the quotes by Mike Cantrell that ring loudly in my ears after my Postural Respiration Course in Atlanta and definitely apply in Coo’s case.

Enter Zone of Apposition – ZOA

For all the PRI nerds, Coo needs to take her bilateral brachial chain and restore a badass zone of apposition on both sides of her diaphragm.

In plain English this means that she is not great at getting her diaphragm in a good position to pump air.  See picture below.  The diaphragm needs to contract and relax just like any muscle and the body needs to be in the right alignment to allow that to happen.  If Coo’s hips are tilted forward and her ribs are flared it’s going to make it really tough for her diaphragm to do its job.  If the ZOA is lost then we start compensating.  Compensations are fine until there are just too many to handle.  The bones and muscles begins to change shape and function to help you get air and the cycle continues until you fix it or just decide not to move anymore because you are in so much pain.  So the goal is to restore breathing and diaphragm position by strengthening abdominal muscles and turning off neck and back extensors.  Once we have that restored we can start working on the appendages.


Exercise Prescription

I worked with Coo on how to breathe in general and also taught her basic balloon breathing to give her a better feel of what she should be feeling.  If you are interested the research behind balloon breathing, click here.  For our purposes we kept it pretty simple.  Coo can choose to breathe with or without the balloon depending on what she feels works best for her.

The basic breathing instructions I gave her are as follows:

1. Inhale gently through the nose for 4 seconds.

2. Exhale in the form of a sigh (think of making the ahhhh sound) for 8 seconds. As you exhale gently feel the contraction of your lower abdominals and obliques (think TVA and Internal Obliques)  Try to feel entire contraction from the left to right side.

3. Hold the air out while pushing your tongue onto the roof of your mouth behind your teeth for 3 seconds. Keep your abdominals engaged.

4. With abdominals engaged and tongue on the roof of your mouth, inhale gently through your nose trying not to allow the rib cage to lift up and pushing air into your back.

5. Repeat for 5 breaths.

Once we established proper breathing technique I gave her 3 exercises to focus on to help restore breathing into her posterior mediastinum.

Basically the goal of these exercises is to maintain abdominal contraction during inhalation and to push air into her back and not allow her to use her neck and chest muscles to breathe.  We want her to use her diaphragm to breathe and her neck, chest, and back to relax.

1. Seated or standing against the wall with both arms reaching, focus on breathing into back and contracting abdominals to draw pelvis posteriorly.

PRI Wall Short Seated Reach
PRI Wall Supported Squat – I had her do a bilateral reach with no hip shift.

2. A modified version of the Paraspinal Release with Left Hamstrings.  I made this bilateral and had her stay seated in a chair and just dig opposite heel while she reaches with opposite arm to get the same effect without her neck kicking in.


3. PRI All Four Left Posterior Mediastinum Expansion in Left Trunk Rotation.  All fours with left hand elevated.


Coo is instructed to do 5 sets of 5 breaths of each exercise 1-3 x per day.  I also recommended she do these after exercise or athletic events.


Below are my basic goals as of now and these are by no means all happening at once!  These are just the things that I would like to address at some point.  For now, I am just touching on goals 1-3.

Goals: 1. Restore breathing and increase posterior mediastinum expansion. 2. Increase ribcage mobility through alternating reach exercises and strengthen serratus to improve shoulder stability and reduce use of neck muscles for breathing. 3. Use TVA and IO’s to pull pelvis posteriorly. 4. Facilitate hamstrings to maintain neutral pelvis. 5. Strengthen hamstrings eccentrically to help late phase stance of gait. 6. Strengthen ischiocondlyar Adductor on left while stretching posterior hip capsule on left to decrease left hamstring strain. 7. Inhibit TFL on right and left so glutes can fire correctly. 8. Facilitate right glute max to prevent further valgus of right knee.

For Coo’s first week, I kept it simple and I am not having her do anything but the three exercises above.  She will, of course, still be running and biking and swimming to her hearts desire.  I plan on giving her some strength training and load as soon as we can get her breathing on point.

Here is Coo doing her exercises and of course smiling!



Stay tuned for a follow-up blog as we progress Coo into an optimal ZOA badass triathlete!

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