The Fragile Ironman – For the Clinician

I am a Fragile Ironman. In the previous blog, I discussed how my body has no business doing Ironman Triathlons (2.4 mile swim, 112 mile bike, 26.2 mile run) yet I still managed to pull off a few of them. My brain is such that it craves silly things like that, yet I didn’t when the gene lottery to have the most resilient body nor physiology.

Is it weird I have that same Speedo? PRI nerds – note the rib cage asymmetry. 

As mentioned in the previous blog, I am careful to assume whatever works for my body will work for the patients and athletes I work with. One of the greatest things about my profession is that it requires constant critical thinking and problem solving. Each person I work with is N = 1 and I really try to learn from each individual.

N of 1

With that said, I realize my story may provide inspiration or hope to some athletes out there. Swimming, biking, and running doesn’t have to be painful and injuries are not a necessity of the sport.

Doesn’t have to hurt!

Additionally, I appreciate I am in a somewhat unique situation of being a physical therapist who also competes in these crazy endurance endeavors. I really do practice what I preach so am that much more confident in what I preach. So, sharing a bit more specifically about what I do from a physical therapist and coach perspective, I may be able to help other clinicians out there.

Note: all are welcome to read, but this is geared to physical therapists. 

First off: I am a big nerd. I love learning about the body and learning things that assist me in helping more people. I have studied Postural Restoration Institue, SFMA/FMS, Kinesio tape, various soft tissue-assisted techniques, manual techniques, and much more. There is always a book on the bedside table and a podcast queued up on my phone about human behavior or physiology.

What about “how to mold a mighty mustache?” 

This is not meant to brag, rather, to inform that I am constantly searching for ways to help people and that I am open to many different intervention approaches. I am not a one trick pony. With that said, I do feel strongly about the Postural Restoration Institute’s (PRI) approach to evaluating and treating human movement dysfunction. While I would enjoy teaching for them someday, I am not paid by them nor have they endorsed this content. Hopefully this content will help PRI and non-PRI clinicians treat and asses their clients.

I feel strongly about PRI because, well, the methodology makes a lot of sense. And it works. Really well. Inquisitive young PTs and PT students, in my experience, are naturally drawn to PRI because is answers a lot of questions about why people hurt. Additionally, many clinicians seek out PRI because PRI is one of the only western institutions (that I know of) that integrates multiple body systems and appreciates the interaction on one another.

PRI breaks the mold

PRI does a fantastic job of appreciating natural human asymmetry as well as the effects of the sympathetic and parasympathetic tone on the body. (Check out this fantastic article by Julie Blandin and Zach Nott on PRI for the sports clinician for more info). If you are a PT, chiropractor, trainer, or physical preparation specialists, I encourage you to seek out a PRI class and have an open mind.

How can PRI help the endurance athlete?

  1. Endurance sports are amazingly repetitious. For instance, an average Ironman athlete will take over 2,000 strokes during a 2.4 mile swim. They will have around 30,000 revolutions of the pedal during the 112 mile bike, and 40,000-50,000 steps during the marathon. That’s a lot of repetition! Through PRI, we can appreciate the asymmetrical tendencies of the body and understand the dominant movement patterns that we will see with this repetition. So, even though it appears each leg is doing the same thing on the bike and run, we can understand that they actually do have different movements and stress on them. With each breath the athlete takes there is a slight asymmetrical force on the body that needs to be appreciated.
Get those reps in! 

2. Endurance sports are stressful on the body. Training creates stress on the body. The body (should) adapt to the stress and therefore adapt to be stronger, fitter, and faster. Improper training, lack of sleep and recovery, work/life stress, etc. can all lead to excessive stress on the body. This pushes the body to a more sympathetic (fight or flight) state. Understanding PRI concepts can help allow the athlete to reduce their sympathetic tone and thus allow for proper recovery and training by becoming less sympathetic.

Seems stressful 

3. Asymmetrical patterns of human  movement and dominant muscle groups tend to over-work with endurance training. These are described by PRI. Appreciating this with a strength program to counter-act those patterns will aide in improving performance and staying healthy.

Working on his asymmetry, no doubt. 

Go learn about PRI already people!

So what do I do?


Quick big picture outline:

  • Pre-workout routine of primarily PRI activities and occasionally PRI-influenced dynamic techniques.
  • Post-workout inhibitory techniques.
  • 3x/week strength program focusing on unilateral alternating techniques and emphasizing hamstrings, glutes, abs, serratus anterior, triceps, and low traps.

(Note the modern, color pictures)


I like to start the pre-workout routine with a balloon technique. Many clinicians like to move away from the balloon for their patients, as do I when they understand the purpose (and it makes the techniques a bit less cumbersome). However, for me it just feels good. It helps activate my obliques, improves my ribcage mobility, and it acts to center my focus on my body and on the day’s objective.

Quick note on the balloon aspect of the technique: The balloon helps achieve a state of exhalation. Exhalation is associated with parasympathetic tone. Inhalation is sympathetic tone. Increasing your state of inhalation will create a state of physical and neurological sympathetic tone. Swimming, biking, running all promote excessive inhalation. They promote a more sympathetic state. Combine that with over training, improper recovery, sub-optimal nutrition, life stress, etc., a triathlete can easily find his or her way in an excessively sympathetic state (and then over training, irritability, adrenal fatigue, and so on). Best way to counteract this? Get in a state of exhalation. Blowing up a balloon with a complete exhale and pause will assist your body to be in a more parasympathetic state physiologically and neurologically. This not only helps your bio-mechanics but also your ability to recover and adapt from your workouts.

Mackenzi-Breathing short sit balloon
Making it a party! 

A balloon technique (I like the short seated balloon the most, but may also do a PRI squat with balloon, wall reach with balloon, or standing alternating wall reach with balloon) will often be followed by a few integrative techniques that combine multiple muscles to inhibit L AIC / R BC and encourage R AIC / L BC tone (PRI terms…essentially to inhibit common asymmetrical patterns and promote proper reciprocating, alternating movement).

  • I prefer standing techniques that I can combine a right trunk rotation movement. Some of my favorites include the standing supported wall squat series, various hip approximation maneuvers, and left af ir right abduction techniques. Much of this depends on how I feel and what I feel I need to inhibit or facilitate.
  • Dynamic routine focuses on breathing mechanics (full exhale, inhale to expand posterior mediastinum) during the movements and alternating movements. These may include 3-4 of the following: gorilla lunges, spiderman lunges (lunge with rotation), alternating deadlift movement while “sinking” in to stance hip (AF IR and adduction), retro walk, bear crawl, inchworm, walking alternating elbow to knee crossovers, and lateral walks with trunk flexion.
  • This is usually completed in our basement (we have a mini-gym area) so I usually always make my way back up the steps backwards (retro-step…a money technique!).



Post-workout routine is largely focused on inhibitory techniques. It is likely inevitable that I will over-engage my calves, quads, hip flexors, and back muscles during a workout (especially running) due to the nature of the movement. For PRI people…essentially my PEC muscles. All athletes (especially runners) are unknowingly trying to be a PEC individual. Some of us have achieved it, others are getting there.

Full squat back stretch

So, I want my post-workout routine to be heavily anti-PEC tone. This routine will often include 2-3 of the following: All 4 belly lift, short seated reach, full squat back stretch, more all 4 belly lift, and a lat hang. I will also include some right intercostal inhibitory techniques such as right sidelying left arm reach with left adductor or standing right QL and right intercostal inhibition.

All 4 Belly lift

After that my body is feeling pretty good and ready to take on the day!

Strength Routine

I admit it. I am an endurance athlete to the core. Like most runners and triathletes, I would rather my time be spent running or on a bike. And sometimes swimming.

When I took on the Ironman distance, I read that it helps to put in the time in the weight room to get strong. In fact, some pro (forgot the name and article reference) said the last mile of an Ironman was like squatting 300 pounds with each step. A bit of an exaggeration, but it scared me enough to start to think about lifting heavy things.  A marathon after 112 miles of bike requires quite a bit of strength on top of the crazy. And swimming hard for 2.4 miles requires a good amount of upper body strength.

I realized, however, that I just can’t get on an Olympic lifting program. My body type is such that it tends to bulk up when I lift and I didn’t necessarily see the carry-over with much of the lifts. Heavy squats and deadlifts can be good, but not for everyone. And I would argue there are much better techniques to keep us healthy and improve performance for our sport.

I’ll be honest. I am not a big fan of physical therapists, coaches, trainers, etc. giving a blanket statement that endurance athletes should partake in a lifting program to stay healthy. 100% disagree <collective gasp felt by the endurance and PT community>. Rather, Endurance athletes should partake in the correct strength program for their individual mechanics and sport while maintaining proper form to stay healthy. What is exactly proper form is hotly debated yet crucial. This depends much on the athlete and how they move. Certain movements and positions will help the athlete achieve good form (actually….it puts them in positions that it is hard to screw it up).

Appreciating the natural human asymmetrical patterns and acknowledging the fact that certain muscle groups will over-work with my triathlon-ing helped me create a program to not only get stronger to help performance, but to help my body become more resilient to the stress of training. The strength program needed to be composed of techniques to emphasize my hamstrings, glutes, abs, serratus, and triceps. They needed to be done in positions that my calves, quads, and back wouldn’t over-work. It would also be nice if they were alternating, as doing things that are alternating (left-right-left-right so on) are much more natural for our body (crawling, walking, running….all alternating movements).

Many of my athletes know I am a fan of alternating movements emphasizing hamstrings, glutes, and abs. The following are my top strength exercises and what I do on a regular basis.

lauren gorilla lunge
Gorilla Walking Lunge
  1. Walking Gorilla Lunge – Oh yeah, if any of my athletes made it this far they knew this would be on the list
    1. Take a big step out, contacting the ground heel-first.
    2. Round forward and reach for your front ankle.
    3. Push through your front heel and mid-foot as you come out of the lunge position and in to the next step. Use the glute and hamstring of the front leg to do this and try not to arch your back. Keep the “ribs down” during the movement so that the hinging comes entirely from the hip and not your lumbar spine. I usually do this with dumbbells in each hand.
  2. Reverse Gorilla Lunge (ideally on a slider)
    1. Take a step back (or slide your leg back if on a slider) and drop your back knee to the ground. As you do this, round forward and  reach for your ankle.
    2. Push through your front heel and mid foot to return to upright, using your front glute and hamstring. Try not to arch your back. The front foot should feel like it is “pushing the ground behind you” to properly engage the hamstring.
    3. Side comment on this one: This is a great technique to teach runners how they need to “push” the ground behind them with the big movers – hamstrings and glutes – and not “reach” or and pull the ground towards them. A great advanced technique for a runner with calf/achilles/plantar fascia/metatarsal issues, patella tendonitis or Osgood issues, are heel or toe strikers, or who tend to over-stride. Really good exercise for runners, but you need to teach it well and the patient needs to understand the purpose of the motion. If they don’t understand (clinician’s fault, not the patient’s), you could make things worse for them. A single leg RDL primer is another good one to teach this.
  3. Single Leg Alternating Gorilla Deadlift
    1. Weight in opposite hand of stance leg.
    2. Round forward, hinging at the hip, to reach just ahead of your toes.
    3. Think about pushing the ground behind you with your heel to return to upright. This should help engage the hamstring properly. You should not be on your toes nor should you be feeling your quad more than your hamstring.
  4. Lateral Gorilla Lunge
    1. Similar to the Gorilla Lunge but to the side. Take a big step out to the side, round forward and reach for your heel.
    2. Push back through the arch and heel of the lunging leg, using your glute.
  5. Exercise Ball Bridge with pull-back
    1. One of my favorites to teach cyclists how to get a quality full-circle pedal stroke. Lie on your back with your legs straight out on an exercise ball.
    2. Exhale to set your ribs down, in, and back.
    3. Perform a glute squeeze and bridge your bottom of the floor, using your glutes and not your back.
    4. Pull the ball back towards your bottom, using your hamstrings. Keep your back relaxed and ribs down the whole time.
    5. Slowly return the ball to the start position.
  6. Alternating dumbbell rows in a belly lift position
    1. This one works on your abs, mid- and low-traps, serratus, and improves your mobility through your rib cage and thoracic spine. One of my favorite upper body techniques.
    2. Start on your hands and knees with your hands on dumbbells. Push the ground away from you as you tuck your tail. Exhale to set your abs.
    3. Straighten your legs back, keeping your back rounded and abs on.
    4. Pull one dumbell up in to a “row” position, feeling your mid and low traps complete the motion. The other arm will be simultaneously pushing to activate your serratus. Alternate back and forth, focusing on the exhale to keep the abs engaged.
  7. Belly lift exercise ball pull-ins
    1. Hands on the ground or pushup bars, legs outstretched on a ball. “Push” the ground away from you as you exhale to engage your abs and serratus. Keep your “tail tucked” or maintain a posterior tilt. Your low back muscles should not engage.
    2. Pull the ball in, keeping your abs engaged and your lower ribs down, in, and back. Go side to side to challenge different parts of your ab wall. Continue to “push” the ground away from you at your shoulders as you focus on the exhale to set your abs and ribs.
  8. Inverted Row with hamstrings and posterior pelvic tilt
    1. This is a challenging to do correctly and to not engage your back, so be careful with this one.
    2. I have a dip bar station in the basement, so I use those. Legs up on a ball. Dig your heels in to the ball and use your hamstrings to complete a posterior pelvic tilt. Exhale to feel your abs pull your ribs down, in, and back.
    3. Keeping your posterior tilt and rib position, complete the row motion emphasizing full scapula retraction and protraction and not arching your back. Focus on the exhale throughout the movement.
lauren good plank
Most techniques performed with ribs down, in, and back with slight posterior pelvic tilt like above. 
lauren bad plank
Want to avoid back arched, ribs up and forward, and anterior pelvic tilt with most of the techniques. 

Clinician Takeaways

This blog has gotten long enough….bullet-point time!


  • Go learn about PRI if you have not already! Not the end-all-be-all but very powerful and you are missing out on helping a lot of people if you have not introduced yourself to it.
  • Look at your athletes/patients/clients as a whole system, not just one muscle/bone/ligament. Figure out what muscles their sport will over-develop and what needs to be emphasized based on their mechanics and sport.
  • Create a pre-workout routine for them to activate or engage muscles that they need to oppose their dominant muscle patterns. Most will need some form of PRI technique that appreciates their natural asymmetries. What that technique is will vary a lot based on the individual.
  • Your athletes need a post-workout routine to de-tone muscles that over-work during their activity (typically PEC muscles).
  • Strength training is not good for everyone. The correct strength training that appreciates how an individual moves, takes in to account their sport and movement patterns, and is done with the best form for their body is good for everyone.
  • Go practice what you preach!!! Never ask a patient/client to perform an activity you have not tried. If you are asking people to do 3-4 techniques a day to stay healthy, you better be doing at least that yourself. Patients loose trust in clinicians who are all talk and no action themselves. As a profession we need to lead by example by having active, healthy lifestyles.
Training best experienced with friends. 

There you have it. That is a brief summary of my recipe as a full time physical therapist/ part time athlete to stay healthy and compete in events I have no business even completing based on my injury history. Would love to hear other stories on what athletes/clinicians/coaches are doing to stay healthy and stay on top of their game. Leave a comment below or email me at and I can share them on future blogs.




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