Exploring the Anterior Pelvic Tilt

By Whitney Lowe, LMT

Lumbopelvic pain is a common complaint that is not always remedied with many standard low back pain treatments. For many people, some treatments have been helpful, but the condition still persists.

Frequently, the pain problem exists because an underlying postural or structural deviation has not been properly addressed. One such postural problem that might be considered is an anterior pelvic tilt, which can contribute to lumbopelvic pain in a number of ways.

The upright posture and locomotion of humans poses biomechanical balance challenges for the pelvis. The weight and force loads of the upper body are transmitted and distributed to the two lower extremities through the pelvis. When the pelvis is not aligned properly numerous biomechanical problems result, which can be painful and debilitating. Let's take a look at what constitutes an anterior pelvic tilt, some of its detrimental effects, and what role massage can play in helping to resolve it.

Background

For the sake of this discussion, the pelvis will be addressed as a whole, even though it is composed of two separate halves, called innominates. The left and right innominate can move independent of each other, but most postural distortions occur when the left and right halves are both out of alignment in the same direction.

An anterior pelvic tilt occurs when the pelvis rotates anteriorly in the sagittal plane. The sacrum is tightly wedged between the two innominates so when the pelvis tilts anteriorly, the sacrum moves with it. The sacrum is tightly bound to the L5 vertebra, which is bound to adjoining vertebra. When the sacrum tips forward, the lower lumbar vertebrae are subsequently tilted forward, creating an increase in the lumbar lordosis at the same time.

Figure 1: Anterior Pelvic Tilt ExaminationThere is a natural degree of anterior tilt in the pelvis that is necessary for proper movement and shock absorption. When the degree of tilt is too much, it is considered a dysfunctional anterior tilt. However, it is difficult to get an accurate determination of the exact degree of anterior tilt without a goniometer. Consequently, many clinicians use approximate alignment references to determine if the tilt is excessive.

However, just because it is challenging to define the anterior tilt, doesn't mean we should ignore it. Although massage therapists may not have the training to make accurate goniometer measurements, there are some simple tips for determining if a pelvic tilt could be a contributing factor to a clients pain. One way to evaluate the tilt with visual examination is to look at your client from the side. Place one finger on the posterior superior iliac spine (PSIS) and the other finger on the anterior superior iliac spine (ASIS). If the ASIS is more than a half inch lower (and slightly more in females), this would be considered a dysfunctional anterior tilt (Figure 1).

Detrimental Effects

A degree of lordotic curvature in the lumbar region is necessary for proper shock absorption in the spine. However, too much lordosis causes multiple problems. As the lordosis is increased, there is increased pressure on the facet joints of the spine (Figure 2). The increased facet joint compression can lead to pain, irritation and even early arthritic changes in the spine.

Figure 2: Increased pressure on the facet joints with exaggerated lumbar lordosis.An increased lordosis is frequently caused by excessive hypertonicity in the lumbar extensor muscles. Tightness in this muscle group is both a cause and an effect of the exaggerated anterior tilt. The lumbar extensor muscles are often tight in conjunction with the iliopsoas in a postural pattern known as the Lower Crossed Syndrome (Chaitow, Delany vol 1, 2000). A vicious cycle of muscle tightness and postural distortion ensues because muscle tightness contributes to the anterior tilt and is perpetually reinforced as a postural pattern. Myofascial trigger points in the lumbar extensors are also likely to develop as a result of the chronic tightness.

The increased lordosis may also decrease the opening of the intervertebral foramen which could lead to nerve root compression in the area. The risk of nerve root compression is increased if there are bone spurs or other obstructions along the edge of the foramen which encroach on the nerve with the exaggerated lordosis.

Another detrimental effect of the anterior tilt occurs at the Sacroiliac (SI) joint. There is only a slight degree of movement at the SI joint. For the most part, this joint is tightly bound so that the sacrum and ilia on both sides are almost locked into position with each other. The anterior pelvic tilt alters the force loads at the SI joint and is a frequent cause of SI joint pain and dysfunction.

Most of these potential effects are somewhat obvious, but another one that is not quite as clear is the increased risk of hamstring strains. When the pelvis tilts anteriorly, the ischial tuberosity rises in a superior direction, putting greater tensile stress on the hamstring muscle group. The elevated tensile load can lead to an increased incidence of hamstring strains, especially in active individuals.

Treatment

So, is there a role for massage therapy in addressing this problem? There is a role for soft-tissue treatment, but there is also controversy and misunderstanding in constructing the most helpful treatment plan.

One of the biggest mistakes that clinicians make in attempting to treat the anterior pelvic tilt is to over-simplify the treatment strategy. For example, if you look at a person with an exaggerated anterior tilt from the side, it would appear that the lumbar extensors are tight and the abdominal muscles are weak and elongated, which is true. The mistake comes in attempting to address this distortion by strengthening the abdominal muscles with standard abdominal muscle exercises like sit-ups or crunches performed with the feet rigidly held in position.

When the feet are held rigidly in place for a sit-up exercise, it is called a closed-kinetic chain exercise. Unfortunately, performing a sit-up in a closed kinetic chain position strongly recruits the iliopsoas muscle. Since tightness in the iliopsoas is a contributing factor with this condition, further strengthening is counter to the intended treatment goal.

The key goal in a treatment strategy for the anterior pelvic tilt is to reduce tightness in the lumbar extensor muscles and iliopsoas. In many cases, the abdominal muscles, which appear weak and overstretched, are not weak because they lack sufficient exercise, but are instead weak because they are being neurologically inhibited by the tight lumbar extensors (their antagonists). Reducing tightness in the lumbar extensors will often allow the abdominal muscles to resume a normal level of tonus. A variety of massage techniques can be directly aimed at the lumbar extensors to reduce their hypertonicity.

One of the biggest mistakes that massage therapists make when attempting to address an anterior pelvic tilt is to focus just on the soft-tissue treatment with the idea being that reducing the muscle tightness will restore the proper pelvic position. Unfortunately, that rarely occurs. Postural distortions like the anterior pelvic tilt have developed from chronic habitual reinforcement. Even if you perform excellent massage work on these muscles, the person is likely to quickly slip back into the postural distortion if certain habitual patterns are not addressed.

Dysfunctional postural patterns need to be changed by constant reinforcement of new and more correct postural adaptations. Certain treatment systems like Alexander Technique, yoga or Feldenkrais are aimed at improving awareness of posture and position in order to make changes and reduce dysfunctional positions. However, it isn't always imperative that the client adopt one of these practices.

Sometimes, it can be as simple as teaching new postural positions and encouraging the client to be aware of his or her own postural positions and to reinforce that change as much as possible. Having the client explore the ergonomics of his or her home and work activities is also important. Does their work set up inspire a slumped position at a desk? Do they stand a lot, could they put one foot up on a small block? Can they take more breaks for stretching and be shown good stretching solutions?

As clinicians, our goal is to understand each individual's biomechanical stresses as best we can so we can craft a reliable treatment strategy most likely to achieve beneficial results. At the same time, keep in mind that the presence of an anterior pelvic tilt is not a guarantee of any of the above adverse outcomes. There are people who have an anterior tilt that do not develop any issues. That is why it takes a thinking practitioner to determine when the pelvic tilt might be a contributing factor to a client's pain.

Massage Reduces Non-Specific Shoulder Pain and Improves Function

By Massage Therapy Foundation Contributor

Contributed by Derek R. Austin, PT DPT MS BCTMB CSCS; Jolie Haun, PhD EdS LMT; Pualani Gillespie, LMT MS RN BCTMB

While seemingly universal, pain and stiffness in the shoulders can be a significant cause of disability.

Often a pain that does not go away on its own, shoulder complaints tend to linger, sometimes for 12 months or longer. A recently published research analysis examined the question of whether massage and exercise are effective in treating shoulder pain and stiffness. This month's research review by the Massage Therapy Foundation explores the findings of a meta-analysis of 20 individual trials examining the effects of massage and exercise in people with non-specific shoulder pain.

"Non-specific shoulder pain" refers to shoulder pain without a clear pathology or physical signs. This broad category of potential non-specific causes of shoulder pain includes myofascial trigger points, bursitis, impingement syndrome, rotator cuff injuries and adhesive capsulitis. Paul ven den Dolder and his team from the Discipline of Physiotherapy at the University of Sydney in Australia published their research in the British Journal of Sports Medicine in August 2014. Physical therapists also use soft tissue massage, as well as exercise therapy to treat shoulder pain. The authors report that surveys have shown that physical therapists use massage and/or exercise to treat almost all of their patients with shoulder complaints.

While tight and painful shoulders are a common complaint in many massage therapy settings, this research article is the first systematic review of the effectiveness of massage for shoulder pain. Previous systematic reviews of the effectiveness of exercise for shoulder disorders have had differing conclusions. The authors aimed to review all of the research regarding the effectiveness of soft tissue massage and of exercise for non-specific shoulder pain compared to placebo, no treatment or other interventions.

Studies were included in the review if they were randomized controlled trials (RCTs) with participants who were adults with shoulder symptoms with the any of the diagnoses of "rotator cuff tendonitis, rotator cuff tendinopathy, rotator cuff tear, impingement syndrome, bursitis, adhesive capsulitis, periarthritis, 'frozen shoulder' [or] non-specific shoulder pain." Studies with participants with diagnoses of "infection, neoplasm, fracture, instability, dislocation, hemiplegia, postoperative or perioperative shoulder pain or inflammatory disease" were excluded. All studies had to include massage or exercise in isolation or with other therapies, as well as report patient outcomes such as disability, pain, and return to work. Two separate reviewers independently found studies by searching major databases including MEDLINE, EMBASE and PEDro. Then, they each assessed research quality and risk of bias for each of the identified studies. In total, the authors analyzed 20 discrete trials.

Based on data from these 20 trials, the authors conclude that soft tissue massage is effective for improving range of motion function and pain; exercise approaches improve pain immediately following treatment although the change may not be clinically worthwhile; and exercise does not improve reported range of motion function. The most important take-away for massage therapists treating clients with non-specific shoulder pain may be found in one study that showed the greatest treatment effect for massage. The authors wrote, "The greatest improvements with soft tissue massage [were found with] targeted treatment towards the lateral border of the scapula in end-range flexion, the posterior deltoid region in end-of-range horizontal flexion, anterior deltoid in end-of-range external rotation (measured as hand behind back) and pectoralis major in the stretch position. This demonstrated moderate improvements in active flexion and abduction ranges of motion, pain levels and functional scores." The researchers also conclude that there is evidence that soft tissue massage is effective for improving external rotation range of motion in patients with adhesive capsulitis. The authors emphasize that soft tissue massage techniques should be considered an important form of therapy, and they encourage future researchers to describe the massage techniques used in their studies in more detail.

While this meta-analysis was well-conducted and thorough, it is also limited by the generally low quality of the included studies. All of the studies that showed any effect for massage or exercise were low-quality RCTs. This research review is also limited by the fact that non-specific shoulder pain is an incredibly broad category. Thus, many possible massage and exercise treatment approaches may be indicated. Matching up the correct treatment to the correction presentation is difficult for practitioners and researchers alike. In the future, higher-quality research is needed to determine which techniques work best for which subgroups of patients.

This publication makes several contributions to research, practice, and the field of massage therapy. First, this systematic review of RCTs makes a significant contribution to the body of massage research providing supportive evidence that soft tissue massage is effective for improving range of motion, function and pain in people with shoulder pain. Second, these findings provide practitioners with the evidence needed to justify using massage techniques as an effective means of treatment for shoulder pain and stiffness. Finally, as research accumulates and supports evidence-based practice for treating common conditions such as shoulder pain, the field of massage will increase its presence in the practice of personal health and wellness.

Are you a massage therapy student who has an interesting case of your own? The deadline to submit to the MTF Student Case Report Contest is June 1, 2015. The Massage Therapy Foundation has sponsored Case Report Contests since 2006 to provide massage and bodywork practitioners and students a way to develop research skills and enhance their practice of evidence-based massage. Cash prizes are available to the winners of each contest, contingent on publication of the case report. If you or your students are interested in learning how to write and submit a case report of your own, check out the MTF's five-part case report webinar series to learn the how to write a winning case report.

To learn more about the effects of massage therapy, you can review the Massage Therapy Foundation review article archives, read accepted MTF Research Grant abstracts, or search PubMed for massage therapy studies. Visit www.massagetherapyfoundation.org.

Reference:

• van den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis. Br J Sports Med. 2014 Aug;48(16):1216-26. doi: 10.1136/bjsports-2011-090553. Epub 2012 Jul 26. PubMed PMID: 22844035.

Prone Position Syndrome

By David Lauterstein, RMT

How many times have you been receiving a massage and noticed after 40 minutes that you are still lying face down? Your sinuses have filled up. Your face and jaw are being deformed by the face cradle, leading to a related symptom, "cradle face." Your pelvis has been stuck in one awkward position for the much of the session.

If you're a knowledgeable receiver, you may already be wondering what will be left out of the massage, because, after 40 minutes prone, receiving mostly back and shoulder work, there is no way the lower body, front torso, arms, hands, head and neck can be adequately addressed. How many times has a therapist apologized for leaving something out because they "didn't have enough time" or they simply ignored it? How many times have you gotten off the massage table and found some symptoms worse from being prone too long or sore from certain areas overworked or underworked?

Much of this can be traced to what I have named, "Prone Position Syndrome" or PPS for short. I'm being both funny and serious in bringing this up. This syndrome is obvious, but I've not often heard it identified as one of the major problems with massages these days. Why do therapists cause PPS so often? What are the causes and problems of PPS and what is the cure?

Problem 1

The first poblem is the lack of education regarding the importance of timing in a massage. What's the cure? Take a better history and determine a game plan for what body segments you will emphasize and approximately how much time you will spend on them. Get client agreement regarding your plan. Then monitor your timing as you go.

Problem 2

The belief that more is better – especially when it comes to working tense areas. The assumption that more force or that more repetitions will improve the session especially affects therapists' work with the back and posterior shoulder girdle. What's the cure? Realize less is often more! The thing that relaxes muscles' tensing is the nervous system. So honestly in massage we are not so much doing soft tissue manipulation (in spite of what most state laws say), instead we use manual suggestions to talk the nervous system into initiating the relaxation response. More repetitions do not do a better job of convincing the nervous system to relax – anymore than verbally telling the person to relax again and again and again.

Problem 3

Therapists are sometimes taught or get into the habit of always working at the same tempo, often doing all their strokes somewhat slowly. Frankly, if the massage is all slow, the client is often just put to sleep. When the client sleeps, there is no body-mind learning. The cure? Work that truly honors the nervous system, the mind and the body's needs – will vary in tempo. It is important to slow down in places of tension. It is equally important to speed up where things are relatively fine. I often think of Muhammed Ali's famous exhortation to "Float like a butterfly. Sting like a bee."

To repeat a stroke more than three or four times generally dishonors the client's nervous system. The nervous system GETS the message pretty quick! It doesn't need to be forced to relinquish its tension through brute force or excess repetitions. We need to remember that the client's awareness accompanies our touch and that a really good massage often will nonverbally impart important information to the client about their body and mind and emotions. I recently received a student session and I pointed out that the nervous system gets the message pretty quick and, if it's all slow, it's like assuming talking slow will improve communication.

Problem 4

Excess preoocupation with addressing the back, shoulders and neck and especially in the prone position. This often is a habit reinforced by frequent client requests to "just work on my back and shoulders." Clients do not realize that where their pain ends up is not necessarily where it's coming from. The most common example of this is back pain due to chronic forward flexion of the torso. As long as the front isn't lengthened, the back cannot let go. The cure?

Ida Rolf had an important saying, "Go where they're not." Explain to your clients, if they are willing listen, that you are happy to emphasize their backs and shoulders, but that often their back tension is related to posture and to stress elsewhere in the body. Therefore, in order to give them even more thorough and longer-lasting relief, in addition to giving the back, shoulders and neck lots of attention, your work will help them even more by addressing tension in the legs and feet which give critical support to the back; and addressing tension in abdomen and upper chest to help with the hunched over posture so many of us adopt at our desks and driving.

Problem 5

Boredom - the therapist just won't be bothered to individually plan the timing in the session. The cure? If you are bored in your work, you need to re-examine your attitudes and the environment you work in. Often in school, students say the subject they find most boring is business. But in graduate surveys, they often say if there was one subject they needed to pay more attention to it was business. If you are bored in your work, it is time re-examine your business plan; or, if you don't have one, it is high time create it. This can be fun and it certainly is necessary – look at Business Mastery by Cherie Sohnen-Moe or some other good business text written for massage therapists/health professionals.

Problem 6

Even more serious - lack of care. Sometimes one may be the sixth or seventh client of the day or the twenty-fifth of the week! The therapist, sadly enough, may just not care a whole lot at that point. The cure? Similar to boredom, lack of care may result from your attitudes or from being in an environment that is discouraging. Re-visit your business plan! Every business owner and/or employee needs to make sure that they keep on finding ways to activate their care for themselves and others in their work.

Problem 7

Not having the anatomical knowledge or technical skills to address the client's problems. The cure? Re-visit your anatomy and the most effective techniques you learned in school. Take continuing education that gives you efficient ways to address tension. Learn particularly how to pleasurably and effectively address the myofasical structures which keep the torso in chronic flexion – among them, especially rectus abdominis and pectoralis major.

In Summary

• Take a good history and pay attention to individualized timing.
• Less is more – the nervous system gets it without manual labor!
• Vary your tempo – otherwise your work becomes monotonous – for both of you!
• Remember the importance of the body parts other than just the back and shoulders.
• If you're bored or don't care, get clear what changes you need to make. And get a great massage so you get re-excited about what your clients are receiving!
• Enjoy revisiting your anatomy study. Find and take great workshops. Learn new techniques and make sure you include some for the all-important flip-side to the back – the front torso.

Together we can overcome this pervasive problem. Let us free ourselves and our clients from the dreaded effects of Prone Position Syndrome!

Causes of Pain and Dysfunction

Treating the Symptoms vs. Rehabilitating the Causes of Pain and Dysfunction

By Don McCann, MA, LMT, LMHC, CSETT

There is no shortage of clients in pain from musculoskeletal problems. All one has to do is look at the number of over-the-counter medication, chiropractors, physiatrists, orthopedic surgeons and neurologists to understand how great the need is for long-term solutions for musculoskeletal problems.

This raises the biggest challenge for massage therapists - how to achieve long-term rehabilitation from pain for their clients so they can resume their normal life activities pain free? If successful in achieving this, massage therapy can become the overall treatment of choice for those with musculoskeletal problems.

Finding the Cause

When clients come for massage treatment, much of their pain is a symptom of an underlying cause. If massage therapists spend most of their time treating the symptoms and not addressing the cause, they are likely to either create a client who is dependent on constant treatments just to stay out of pain or, as most clients do, eventually look elsewhere into more invasive and costly treatments from the medical profession that lead to even worse problems. So, our challenge is to first understand the origins of musculoskeletal pain and then to treat it by rehabilitating the causes of the pain. This leads to long-term resolution of the client's musculoskeletal problems. When massage therapists do this, they will be constantly in demand and could possibly earn the respect of the rest of the medical profession.

Within the musculoskeletal field, structural imbalance results in pain and dysfunction, whereas structural balance equates to pain free function. Therefore, the origins of musculoskeletal pain and dysfunction are actually easily observed in every client who seeks treatment for pain. This is usually the core distortion. Babies are born with it. The rotation of the iliums and the hip complex in infants and children is well documented by Dr. Terry R. Yochum and Dr. Lindsay J. Rowe in their description and images of normal acetabula angles in children from birth to three months and three to twelve months.

The left ilium is rotated anteriorly resulting in a functional long leg. The right ilium is rotated posteriorly resulting in a functional short leg. This imbalance of the iliums and sacrum collapses further into rotation with life experiences until symptoms of pain become prominent. It is very easy when doing structural evaluation of a client to notice the twist in a standing client's body. There are many differences of opinion as to these actual rotations due to the methods of evaluation and interpretations of what is observed. If, however, you use functional kinesiology, the client is supine and asked to raise the right leg about 10 inches off the table. When the right leg is pressed down toward the table, there is significant strength. The same test done with the left leg will show significant weakness. "The rectus femoris is a powerful extensor of the knee, but is weak when the hip is flexed," along with the hip flexors. The anterior rotation of the left ilium (flexion) prevents the rectus femoris and hip flexors from being functionally strong. This is a consistent finding over 38 years of evaluation of clients with the core distortion and is just one of the many functional tests that verify the imbalances in the pelvis that is a major part of the core distortion found in the body.

Finding a Release

The discovery of the core distortion in the cranial motion reveals that the wings of the sphenoid are restricted in a pattern identical to the ASIS of the iliums, and that the ridge of the occiput is restricted in a pattern identical to that of the PSIS of the iliums. Working with the cranium to release the imbalances in the cranial motion as described previously, results in a balancing of the rotations of the iliums, an equalizing of the leg length and a leveling of the sacrum reducing curvatures of the spine. This is accomplished by releasing the soft tissue restrictions responsible for the imbalances in the cranial motion. Amazingly, this has been the missing link to restoring the balance and weight bearing support to the hip complex which includes the sacrum, ilium and SI joints.

The core distortion is involved in the entire musculoskeletal system including the cranium and its specific imbalances relating to TMJ imbalance and dysfunction. Therefore, if we start looking beyond just the areas of pain and look at the overall balance and function in the body, we find the source of most clients' pain. This covers TMJ, headaches, the entire spine and appendages into the feet such as plantar fasciitis and compartmental syndrome. As you can see, it involves the entire musculoskeletal system. With the imbalance of the iliums and sacrum, we get exaggerated curvatures of the spine putting excessive stress on the edges of the discs leading to early degeneration, thinning and even herniations and ruptures of the discs.

When evaluating the muscles and soft tissue using functional kinesiology, 50% of the muscles are operating at a 50% or less efficiency due to this imbalance, leaving them susceptible to injuries such as strain, tearing, adhesion and scar tissue build up. In addition, the shortening and over contraction of some of the muscles directly result in compression along the nerve pathways and many types of nerve pain.

The body in core distortion is also much more susceptible to injuries at the joints. The imbalance of the core distortion results in a dysfunction at the joints since at least half the muscles at the joints are severely weakened and cannot support the stabilization and balance under strain. No matter how effective your soft tissue therapy is, if the weaknesses at the joints due to the core distortion are not brought back to strength, then the causes for the injury or pain are still present and full rehabilitation has not been achieved. However, if the core distortion is released, the structure is brought back into balance including the joints and the soft tissue is brought back to full functional strength. This will produce long-term improvements. The symptoms of pain will disappear. The importance of releasing the core distortion back into balance and function to reduce and rehabilitate the conditions resulting in pain cannot be stressed enough. This is a long-term solution to the structural imbalance resulting in pain and dysfunction of at least 90% of musculoskeletal problems.

It is amazing that most of the medical field has not looked at the imbalances in the entire structure, but rather focuses on individual areas. Consequently, there is no awareness of the overall pattern of imbalance found with the core distortion. There are some chiropractic and osteopathic treatment models that do include working with the entire structure, but mainly by adjusting the joints and vertebrae. While the chiropractors adjust joints and bones, when the soft tissue is engaged in movement and structural stabilization, it moves the bones back into the patterns governed by the tension and weakness of the soft tissue. Whenever structural drawings are made of the musculoskeletal system, the imbalances of the core distortion are obvious. Massage therapists have an advantage as the soft tissue governs the organization alignment and function of the musculoskeletal system. It is possible to stand our clients up for full structural evaluation and see how the core distortion relates directly to their musculoskeletal pain. It is then possible to work with specialized soft tissue protocols to bring the core distortion back into balance, not only in the area of the symptoms (pain), but also throughout the structure so every part of the structure supports function and balance.

Consequently, the reoccurrence of the old dysfunction and pain is prevented. This is most effectively accomplished when the cranial imbalances caused by soft tissue restrictions of the cranium are released first, which bring the hip complex back into weight bearing support balancing the sacrum and equalizing the leg length. This creates a balanced weight bearing foundation for the spine reducing spinal curvatures and excessive pressures on the disc. The improved structural balance is seen at every joint and restores strength to the weakened muscles surrounding each joint.

Once a foundation for rehabilitation of the musculoskeletal system has been achieved by releasing the core distortion cranially, the body is trying to balance, there is weight bearing support at the hip complex and there is restored strength to the musculature governing every joint. At this point, further soft tissue work to release ischemia and trigger points, old myofascial holding patterns, adhesions, scar tissue and nerve compressions will be working with the body which is already moving into optimal balance and function. When this happens, structural balance results in pain free function. Even old injuries, damaged joints and discs can heal. Clients really are able to resume their normal life activities pain free.

The Forgotten Rotator Cuff Muscle

The Forgotten Rotator Cuff Muscle, Part 1

By Ben Benjamin, PhD

The teres minor is the weakest of the four rotator cuff muscles. It is the brother of the infraspinatus because they mostly do the same thing; lateral rotation. It gets a lot of use when you turn the steering wheel of your car or you reach high up on a shelf to get something. The teres minor works more at slightly different angles from the infraspinatus and assists in adducting the arm.

Try this. Put your hand on top of your head with your thumb facing down toward the floor and put your other hand on the ulna side of your wrist for resistance and then push up with the bottom hand. You are now engaging a number of muscles but more of the teres minor than with any other motion. The teres minor originates at the dorsal surface of the axillary border of the scapula, that's the lateral most border.

Its fibers run obliquely upward and laterally; the upper fibers end at the teres minor tendon which is inserted into the inferior facet of the greater tubercle of the humerus, that's the little bump at the most lateral edge of the greater tubercle. The tendon of the teres minor passes across the gleno-humeral joint, and joins with the posterior part of the joint capsule. The infraspinatus and teres minor attach to the head of the humerus; and form posterior part of the rotator cuff.

They help hold the humeral head into the glenoid cavity of the scapula. They work along with the posterior deltoid muscle to laterally rotate the humerus, as well as perform adduction and assist in extension of the arm behind you. Sometimes the teres minor is actually fused with the infraspinatus.

Now that you know a little bit about this muscle and how it functions, in my next article we will talk about how to assess and treat this little known, weak muscle.

Let's continue looking at the teres minor muscle – tendon unit; how to assess it and treat it.

The arm is overhead, the elbow bent at about 15 degrees, hand facing anteriorly above the forehead. The practitioner then gently grasps the clients wrist on the ulna side. The client pushes up as you apply an equal and opposite force down. Remember with resisted tests no movement through space should occur. It often takes very little pressure to induce the pain when a teres minor injury is present so start out with very little pressure.

In this next test, we combine lateral rotation with adduction (with the hand at the Elbow). Since the teres minor is both lateral rotator and an adductor of the shoulder, this test performs both at the same time. The client bends the elbow at 90 degrees and brings it a few inches away from the body. The practitioner places one hand on the distal dorsal forearm just proximal to the wrist and the other hand on the medial elbow. Now, ask the client to push laterally at their wrist as the try to bring their elbow toward their ribs into adduction.

When the teres minor is injured one or both of these two tests are painful. The overhead push test is most likely to be painful. Differentiating a teres minor from an infraspinatus injury is a very tricky piece of assessment. The first thing to notice is weakness as well as pain. When the body is injured, it's very difficult if not impossible to maintain strength, especially for a little muscle like the teres minor.

To get this injury, people are usually very athletically active. In most cases, the infraspinatus is the one that gets injured when lateral rotation is involved. In order to engage the teres minor you need to do something either very strenuous or something that pulls you to the medial aspect of your hand (that's toward your little finger).

One way to get this injury is by doing a handstand where you have to balance yourself using all parts of the shoulder in subtle ways. In order to balance yourself side to side you have to use the teres minor and if you lose your balance slightly you'll grip with this part of the rotator cuff complex.

So, if your client has pain in one or both of the tests described here, it is highly likely that there is a strain of the teres minor. In part three, we will look at palpation and treatment.

The Integration of Cranial Structural and Soft Tissue

By Don McCann, MA, LMT, LMHC, CSETT

Massage therapists around the world have taken to cranial work and have seen the vision of helping to facilitate homeostasis for their clients. Since massage therapists address musculoskeletal pain, it is only natural that new adaptations of cranial work have arisen and that rehabilitation from musculoskeletal pain has become a focus. 

Cranial/structural therapy is a cranial therapy that seeks not only a restriction-free cranial rhythm, but also the elimination of soft tissue restrictions in the cranium that can create structural distortions throughout the entire structure. This therapy not only releases restrictions within the normal cranial motion (which can be hydraulic or energetic or mechanical), but it also addresses additional soft tissue restrictions that hold the structural balance or imbalance of the body. Cranial sutures, like any joint in the body, are limited in range of motion by soft tissue restrictions in the reciprocal tension membrane, the tentorum, the dura or the fascia/musculature. Therefore, cranial/structural therapy includes soft tissue releases to achieve long lasting release of restrictions around the cranial sutures that will produce long lasting structural rehabilitation from musculoskeletal pain.

The chief cranial distortion we all have is the core distortion that directly affects the cranial motion and the SBS (Sphenobasilar Synchondrosis). Put simply, the soft tissue around the cranium connected to all the cranial bones, specifically the sphenoid and the occiput and their interrelationship with the other vault bones, has restrictions in the soft tissue that cause an imbalance in the cranial motion. This cranial imbalance is reflected in the pelvis with one ilium rotating anteriorly, the other posteriorly and the sacrum tipping from the lack of support of the anteriorly rotated ilium. This creates not only a long and short leg, but also a tipped unlevel sacrum at the base of the spine which results in exaggerated curvatures, some as severe as scoliosis. Imagine the excitement when it was discovered the distortion in the cranium was the same distortion found in the pelvis, and that when the distortion in the cranium was released and balanced, the rotation of the iliums was significantly bought into balance creating a weight bearing support for the sacrum and an immediate lessening of the distortion on the entire structure. Especially exciting was the reduced curvature of the spine and the leg lengths becoming equal.

One of the big challenges in treating clients with severe musculoskeletal issues such as disc conditions, migraine headaches, degenerating joints etc., has been trying to create long term structural support to maintain the improvements that move the body into balance to facilitate maximum healing and pain free function. This is even more important with the advent of stem cell injections as the structural imbalance would just damage the new tissue if left in the same imbalance, and results would be minimal. This is also the case with prolotherapy and bone tissue replacement. The good news is when the core distortion in the cranium is released and balanced, this new balance brings the pelvis into weight bearing support allowing the above mentioned therapies to be more effective. Even more important is that the need for those therapies is often eliminated. However, it is also necessary to integrate myofascial soft tissue releases for the rest of the body. This is especially true in the areas where the imbalance has created pain and degeneration.

When the core distortion is released from the soft tissue of the cranium, the pelvis returns to weight bearing support with the dramatic reduction of the degree of rotation of the iliums and leveling the of the sacrum. This starts an immediate process of the soft tissue unwinding out of its previous holding patterns throughout the body. This often results in a quick reduction of painful symptoms and prepares the body for more extensive myofascial therapy to release and balance the other soft tissue throughout the body. Prior to having the core distortion released the client's body had literally grown into the distorted pattern and much of the soft tissue is limited in the degree that it can unwind.

If a client had come for a session with back pain and a bulging disc, the unwinding from the cranial/structural core distortion releases would have taken some of the pressure off the disc as the spine straightened, but the client would probably still be in pain due to the compensation in soft tissue around the area.

If the curvature of the spine had so much pressure that it caused a bulging disc, then the soft tissue would have significant inflammation, fibering, shortening and splinting that could not unwind without specific hands-on soft tissue therapy. This would also be true not only in the area of the spine but around any joint in the body where pain and degeneration were a problem. This is a pain site-specific observation. However, if long term rehabilitation from pain is your goal then you need to look throughout the entire structure of the body, not just at the specific site of the pain. Releasing the core distortion from the cranium affects the pelvis and reduces the long leg/short leg discrepancy, but any distortion in any part of the body can have an effect on the site of the major collapse and pain.

Therefore, to fully rehabilitate the body so that it can maintain the improvements it is necessary to treat the entire structure of the body which has also been in core distortion for the lifetime of the client to achieve a balance that will support the area that had been in pain. If this is not done, the areas with the greatest imbalance will still be creating problems and painful symptoms in the client's body. In other words, the area that was most damaged will not be supported by the rest of the body, but will be still stressed by lack of support from other imbalanced areas of the body. A simple way of looking at this is any imbalance in the body affects the whole, and a weakened area will be most affected.

Thus, for maximum rehabilitation the concept of integrating the cranial/structural core distortion releases with soft tissue myofascial techniques to treat the tissues that had the most structural and direct effect on the area of pain is most effective. Initially, spending extra time on these areas and not trying to treat the whole body in the early sessions directly addresses and relieves the client's pain for which the client is grateful. Once this is achieved, it is then necessary to release the soft tissue throughout the rest of the body to support the increased balance in the area that was the original presenting pain. For the client who had a bulging lumbar disc, after the cranial distortion was released, the initial soft tissue treatments would work with the pelvis and leg distortions from the long leg/short leg discrepancy and the low back. Once the client had little or no pain in the area of the bulging disc, the rest of the structure would then be treated. Usually, next in importance would be the upper part of the spine with treatment of the head/neck/and shoulders area. This would be followed with a thoracic session to take the rest of the core distortion holding patterns out of the musculature releasing the curvatures in the thoracic spine which would allow the entire spine now to maintain a vastly improved pain free support. Additional soft tissue sessions would still be needed to release the remaining imbalances in the rest of the legs, feet and arms.

Once the cranial core distortion has been released, the structure of the body is trying to balance and release the holding patterns of the core distortion from all the soft tissue. It can only do so much on its own and needs a therapist's skilled hands to assist it. Since the soft tissue is now beginning to unwind out of the core distortion the therapist has an opportunity to work more effectively with the body as it tries to unwind into a new more supported balance with all levels of soft tissue releasing. Because the entire structure is trying to release at once it is possible to work all levels of connective tissue even in the first session.

Using this model it is possible and beneficial to work deeply to achieve maximum results even in the first session. An approach into the soft tissue that will first release fluid, ischemia and inflammation prepares the area for deeper work. Deeper strokes then allow the myofascial holding pattern to unwind and are most effective when providing direction to the unwinding in the same direction that the body is trying release. The soft tissue and the client are now prepared for deeper more specific strokes to release adhesions, scar tissue and lengthen connective tissue fibers.

As you can see, integrating cranial/structural therapy with soft tissue myofascial work can produce rapid long term results in rehabilitating clients with musculoskeletal pain. This new integration of advanced techniques may be the answer for many of your clients who keep returning with the same problems over and over. I have been developing this integration and using these techniques successfully for the last 25 years. Even the most complex cases who have given up hope after having been everywhere seeking treatment have been able to resume normal life activities pain free.

The Body's Load-Sharing Hub: The Thoracolumbar Fascia

By Leon Chaitow, ND, DO

Have you ever wondered why you swing your arms when walking? It's largely due to kinetic energy being stored and released in the thoracolumbar fascia (TLF), as forces from the lower body transfer upwards - and vice-versa.

Consider, for example, direct mechanical force-transmission from the lower extremity to the pelvis and the trunk, as load (tension) is transferred between the hamstrings, the sacro-tuberous ligament and gluteus maximus, and on to the contralateral latissimus dorsi, by means of forces transmitted via the superficial and deep layers of the TLF.

Because of their direct connections to the TLF, this transferred load also directly influences the behavior of the erector spinae muscles, as well as external and internal obliques, transversus abdominis and serratus posterior inferior ... and more. Any dysfunctional situations, in any of these (or anything they connect to and with), has the ability to alter the function of all the other listed muscles, with unpredictable symptoms emerging relating to either restriction, pain or motor control, or all of these.

The "load-transfer" process involves a virtual spring-loading of the amazing TLF junctional area, the hub, where forces from the lower body, upper body, abdominal area and the trunk are spread and shared. This virtual hub contains some remarkable features where distribution of load is even more concentrated – such as the Lumbar Interfascial Triangle (LIFT) - which is discussed later in this article.

Therapists Need To Know About The TLF

How might awareness of these links help your work to be more effective? Quite simply - manual therapists (and those working with movement/exercise methods) who understand the multiple connections formed, via the TLF, can focus their methods more appropriately.

For example, a painful knee can - in many cases - be shown to be connected to gluteus maximus dysfunction, which may itself be being negatively influenced by inappropriate load reaching it from the contralateral latissimus dorsi – which is itself being influenced by myofascial events in pectoral and cervical structures.

Stecco et al (2014) describe their findings following 12 successive dissections: "In all (12) subjects gluteus maximus presented a major insertion into the fascia lata, so large that the iliotibial tract could be considered a tendon of insertion of the gluteus maximus ... [explaining] ... transmission of the forces from the thoraco-lumbar fascia to the knee ... possibly explaining why hypertonicity of gluteus maximus could cause an iliotibial band friction syndrome (IBFS) or, more generally, knee pain."

Sliding And Gliding Between Fascial Layers

Each layer of dense fascia is separated from the layers above and below by a thin layer of loose connective tissue that permits the different deeper layers to slide on each other. This allows the multiple directions of force, generated by different muscular orientations, to be transmitted smoothly.

Where unexplained musculoskeletal dysfunction exists (restriction, or pain for example) it is possible that reduction in the sliding/gliding function between the different fascial layers that make up the TLF, might be causing it to fail in its efficient transmission of load/force.

When it is healthy and operating normally, this remarkable structure, (the TLF) structurally and functionally connects the legs to the arms, the abdominal muscles to the low back muscles, the hamstrings to the neck, the gluteal muscles to the arms – simultaneously transferring forces in multiple directions, while also allowing sliding and gliding functions between its various layers of deep and superficial fascia and muscle. It therefore deserves the focused attention of all manual therapists – for when it is not functioning well due to trauma, inflammation, overuse, misuse, disuse and or age - a variety of symptoms can emerge – ranging from back pain to poor motor-control and balance problems.

Schematic representation of TLF and many of it's muscular and ligamentous attachments.Helene Langevin and her colleagues (2011) have shown that reduction of fascia's gliding potential in the thoracolumbar area (described technically as "reduced thoracolumbar shear strain"),is strongly associated with increased thickness of some fascial layers in the TLF, and in males in particular, this seems to predispose to low back pain. This gender-bias between a free sliding motion of fascia in the TLF, the thickness (or "densification") of some connective tissue layers, and low back pain, remains unexplained. Note: Some of the main reasons for fascial dysfunction are discussed later in this article.

As previously mentioned, the thoracolumbar fascia (TLF) integrates forces deriving from connective tissues, as well as numerous active muscular structures that attach to the fascial layers, including aponeurotic and fascial structures that separate paraspinal muscles from the muscles of the posterior abdominal wall.

The superficial posterior layer of the TLF is mainly an aponeuroses of latissimus dorsi and serratus posterior inferior, while deep to this is sheath that encapsulates the paraspinal muscles that support the lumbosacral spine.

Where this sheath meets the aponeurosis of transversus abdominus, it forms a seam-like ridge (known as as a raphe [pronounced "rafe" – see illustration of the TLF]. This dense septum is the junction of the structures anterior and posterior to the spine - where the Lumbar Interfascial Triangle (LIFT) is formed.

The LIFT is a remarkable structure (a "roundhouse" in Tom Myers terminology) that helps to distribute load from the abdominal and extremity muscles into, across, and from, the TLF.

Inferiorly, all the layers of the TLF fuse, to merge with the posterior superior iliac spine, and the sacrotuberous ligament, (which links directly to the hamstring group) - assisting in support of the lower lumbar spine and sacroiliac joint, and sharing load with the lower extremity.

Load reaching the LIFT from the abdominal muscles, latissimus dorsi, the lower extremity and pelvic muscles, are therefore appropriately distributed, in order to assist in stabilizing the spine, trunk and pelvis.

Strain Transmission During Stretching

Research has now explained more about how muscular forces are transferred – largely via fascia – to surrounding and distant tissues. For example, Franlklyn-Miller and colleagues (2009) have shown that when the hamstring group of muscles are stretched – as in straight-leg raising – whatever the degree of force being used in that stretch is multiplied greatly – so that 240% of that load reaches the iliotibial band, and 145% of the load transfers to the same-side low back, via the TLF.

The evidence is quite clear therefore – that the use of the word isolated in conjunction with the word stretching is difficult to justify. We need to learn more about which tissues are affected when stretching or compression is used – where load transfers to – and from - and where dysfunction might be coming from when we identify it!

Clinical Relevance The clinical relevance emerging from awareness of the TFL and LIFT and their multiple attachments, relates to their junctional coordinating functions, as pathways of force transmission, to and from different areas of the body, meet. The transfer of load from knee to hamstring to gluteus maximus to hip to TLF and on to latissimus dorsi etc etc - example, described above, suggests that influences at a distance need to be considered when seeking the causes and maintaining features of any pain or restriction – and that therapeutic attention to these areas may have multiple effects.

The TLF As a Sensory Center

The thoracolumbar fascia is a richly innervated, with marked differences in the distribution of the nerve endings, over various fascial layers: The superficial fascia contains a dense presence of sensory mechanoreceptors (such as Pacini receptors and Ruffini endings). Substance P-positive free nerve endings—assumed to be nociceptive—are exclusively found in these layers. "The finding that most sensory fibers are located in the outer layer of the fascia, and the subcutaneous tissue, may explain why some manual therapies that are directed at the fascia and the subcutaneous tissue (e.g. fascial release) are often painful."

How Fascial Problems Start

Fascial dysfunction may result from slowly evolving trauma (disuse, overuse and misuse), or sudden injury (abuse) leading to inflammation and inadequate remodeling (such as excessive scarring or development of fibrosis):

• Densification may occur involving distortion of myofascial relationships, reducing sliding facilities and altering muscle balance and proprioception.
• As a result of such changes, chronic tissue loading forms global soft tissue holding patterns.
• When fascia is excessively mechanically stressed, inflamed or immobile, collagen and matrix deposition becomes disorganized, resulting in fibrosis and adhesions.
• Fascia is also greatly affected by the aging process – as well as by inactivity, possibly related to illness or concurrent pain.

The more manual therapists know about and understand structures such as the TLF the more they will be able to understand their patient's symptoms, and be able to help them towards recovery from pain and restriction.

New Book on Fascial Dysfunction

In my new book, Fascial Dysfunction: Manual Therapy Approaches, I have explored and explained fascia's multiple roles in the body, as well as the ways fascial dysfunction starts and develops – based on translation of the avalanche of scientific research that is emerging.

In addition, the book contains guides to assessment protocols (including a chapter by Tom Myers), as well as chapters that examine a wide range of fascia-focused treatment approaches - involving contributions from approximately 20 leading experts.

In a future article, I will focus attention on which manual approaches have demonstrated evidence of efficacy.

References

1. Barker PJ, Briggs CA.1999 Attachments of the posterior layer of lumbar fascia Spine 1757-1764.
2. Benetazzo L1, Bizzego A, De Caro R, Frigo G, Guidolin D, Stecco C. 2011 3D reconstruction of the crural and thoracolumbar fasciae. Surg Radiol Anat. Dec;33(10):855-62.
3. Franklyn-Miller A et al 2009 IN: Fascial Research II: Basic Science and Implications for Conventional and Complementary Health Care Munich: Elsevier GmbH.
4. Hammer W 1999 Thoracolumbar Fascia and Back Pain. Dynamic Chiropractic 17(16):1-3.
5. Kirk & Chieffi, M . Variation with age in elasticity of skin and subcutaneous tissue in human individuals. J. Gerontol. 17:373–380.
6. Langevin H 2008.. In: Audette, Bailey (Eds.) Integrative Pain Medicine. Humana.
7. Langevin H.M. et al 2011. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskeletal Disorders 2011, 12:203.
8. Myers T 2009 Anatomy Trains, 2nd edition Edinburgh: Churchill Livingstone.
9. Macchi V et al., 2010. Histotopographic study of fibroadipose connective cheek system. Cells Tissues Organs 191(1):47–56.
10. Stecco C, Porzionato A, Lancerotto L, et al 2008 Histological study of the deep fasciae of the limbs. Journal of Bodywork and Movement Therapies 3: 225–230.
11. Stecco L Stecco C 2009 Fascial Manipulation: Practical Part. Piccini Italy.
12. Stecco A et al 2014 The anatomical and functional relation between gluteus maximus and fascia lata Journal of Bodywork & Movement Therapies (IN PRESS).
13. Tesarz J et al Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience. 2011 Oct 27;194:302-308.
14. Willard F Vleeming A Schuenke M Danneels L Schleip R 2012 The thoraco-lumbar fascia: anatomy, function and clinical considerations Journal of Anatomy 221(6)507–536.

The Perils of Perfect Posture

The Perils of Perfect Posture, Part I

By Erik Dalton, PhD

Throughout history, human posture has been scrutinized for symbolic values ranging from socioeconomic status to psychological babble. In schools, teachers often reprimanded students to sit up straight.

Young girls innocently walked with books balanced perfectly on the top of their heads during "charm school" classes. Aesthetically, even the dancer has come to represent the epitome of graceful posture and balance, with the ethereal vision of the lithe ballerina artlessly stretching to the sky. Meanwhile, the rest of us may never forget the words of well-intentioned parents, "Now, stand up straight or people will think you have something to hide." Society's undying commitment to its tradition for proper postural codes remains alive today, in circles that not only envelop the military private, but also the young debutante in white.

But as we begin to casually observe the people around us, the question must arise: Is perfect posture really a reasonable goal for the average American living in a flexion-addicted society?

Clinical evidence overwhelmingly supports the fact that prolonged sitting or sleeping in flexed positions neurologically shortens and tightens the body's hip flexors, particularly the iliopsoas muscles. As the antagonist gluteus maximus muscles gradually become reciprocally inhibited and weak, a primary muscle imbalance pattern ensues. Could more harm fall upon someone in this condition? Simply put, yes. As he rises from his chair, the shortened iliopsoas and rectus femoris muscles drag the hips and lumbar spine forward. Thus, the unsettling "before" snapshot: A swayback posture and protruding belly ... paving the way to a disappointing first impression.

However, prolonged slumped sitting can also promote an even greater pain-generating problem. While slouching or leaning forward, such as when we tirelessly perform computer or couch potato work, our swayback curve gradually begins to reverse itself by overstretching the posterior low back ligaments and joint capsules. Gravity loudly demands its pound of flesh, and this newly formed "reversed lordosis" gets an extra boost in its battle with the flexion-addicted swayback.

As we repeatedly stand, sit and slouch throughout a typical 8- to 10- hour workday, our low back curve is forced to repetitively translate anteriorly to posteriorly. The inevitable strain from local lumbar hypermobility soon begins to ravage the vulnerable sensory receptors in the body's joints, ligaments and intervertebral discs. Noxious afferent stimuli bombards the central nervous system causing the brain to react by triggering layers of muscle spasm to protect the unstable spine from further insult. Digging out the deep spasm and fascial contractures is usually a sad waste of time and energy unless the underlying joint dysfunction is first appropriately treated. Approaches to restore optimal posture and relieve chronic pain should include specific techniques designed to co-activate hyperactive sensory receptors such as mechanoreceptors, nociceptors and chemoreceptors in joints and ligaments, while activating muscle spindles to tonify inhibited weak tissues.

Ligaments, Muscles and Strain Patterns

While the overstretched ligaments valiantly strive to maintain spinal stability, the unrelenting force of gravity pounds the posterior facet joints and flattens the lumbar discs. The brain then begins its selective recruitment of specific muscles to provide ancillary support to the unstable spine. The problem worsens since contractile tissues designed to move bones are now required to work as spinal stabilizers. Sustained isometric muscular contraction neurologically weakens the lumbar myofascia due to the sudden influx of lactic acid and other toxic waste products. As the shortened tissue tugs unevenly on the spine, the joints' axis of rotation is altered. Predictable strain patterns and postural compensations reverberate throughout the thorax, neck and head. Forward head postures and slumped shoulders are two favorite dance partners of the pained swaybacks in this rapidly growing social circle of "flexaholics."

Postural muscles, such as the iliopsoas, quadratus lumborum, rectus femoris, and hamstrings, are structurally designed to resist fatigue in the presence of prolonged gravitational exposure. So why are distorted postures and chronic pain problems dominating our practices? The easy answer: overuse, underuse and just plain old abuse.

These three primary culprits create muscle imbalances that reduce the body's capacity to resist stress. As with everything in life, the body exists on a plane of give and take. Therefore, when postural muscles tighten, the antagonist groups are overstretched and weakened, allowing asymmetric patterns to develop. Soon the anti-gravity function of the body's myofascial system sends an alarm to deeper structures, such as spinal ligaments, joint capsules and intervertebral discs, to brace for the overbearing compressional loads. The homeostatic threshold has been violated.

The body must now prepare to battle the devastating, self-perpetuating pain/spasm/pain cycle manual therapists confront each workday.

If considering the medley of countless occupations that require the typical 12-pound head to be held in a bent forward position, with arms positioned in front of the body, why is it any shock that neck, shoulder and arm pain run rampant in today's society? Consider the typical profiles of individuals fitting this definition. This endless list runs the gamut from dentists, car mechanics, stockbrokers, hairdressers, etc. - even bodyworkers.

Long hours of passive sitting at the computer, or leaning over therapy tables, create stretch weakness in the rhomboids and lower trapezius. This repetitive physical practice contributes to forward dragging of the shoulder girdle due to the pectorals propensity for domination. Tight latissimus dorsi and subscapularis muscles unite with the clavicular head of pectoralis major to internally rotate the humerus. With the scapulae protracted and the arms internally rotated, the neck reluctantly moves forward on the shoulders often forming the unattractive "dowager's hump". Unfortunately, as the spinal facet joints slide open, the cervical curve loses its lordosis and transforms to a typical straight cervical curve. To prevent the person from only looking at the ground, the brain recruits the suboccipitals and other capital extensor muscles to cock the head back into hyperextension. As the occiput hyperextends and slides forward on the atlas vertebra, the posterior occipital atlantal membrane is squashed along with local neural and vascular structures.

Sadly, tonic reflexes and dural attachments originating at the O-A joint dictate postural muscle tone throughout the entire trunk. Stubborn head, neck, brachial, and scapular pain refuses to leave when in an agitated state. These painful and chronic conditions frustratingly persevere until the therapist chooses to systematically balance the shoulder girdle on the rib cage, the neck on the shoulders, and the head on the neck.

To better understand the consequences of forward head postures and slumped shoulders, try these two experiments:

Exercise #1

• Assume a comfortable sitting or standing posture.
• Tuck the chin toward the chest. Allow the shoulders to come back into an ideal postural position.
• Slowly turn the head as far to the right and left as comfortably possible. Take notice of the available range of cervical motion.
• Assume the forward head posture. Rotate the head as far left and right as possible.

Most people experience a 25 percent to 50 percent decrease in range of motion while in the forward head position. This exercise helps illustrate the physical limitations of people suffering forward head postures and demonstrates the negative impact these sensitive neck structures must endure during normal activities, such as driving, shopping, dancing, etc., Spondylosis, degenerative disc disease and osteoporosis are but a few names that describe what physically transpires when this structural alignment problem is not corrected in a timely manner. The farther the head slides forward on the sagittal plane, the more devastating the long-term effects. The posterior longitudinal ligament likes to tear away from the discs and vertebral bodies from C4 to C6 causing internal pressure to fill the cracks with calcium or bone spurs (osteophytes) - the resounding reason why bone spurs originating from forward head postures have become the most common cause of chronic neck pain.

Exercise #2

• Assume a comfortable sitting or standing posture.
• Tuck the chin toward the chest. Allow the shoulders to come back into an ideal postural position.
• Close the eyes. Raise the arms from your sides as high as comfortably possible.
• In the same postural position, raise the arms to the front as high as possible.
• Assume a slumped shouldered/forward head posture. As in the first exercise, again raise your arms to your side and to the front as high as possible.

Both exercises lead to a compromising conclusion: Always begin upper-quadrant postural alignment by balancing the shoulder girdle on the rib cage, neck on the shoulders, and the head on the neck,before tackling specific extremity pain problems, such as supraspinatus tendonitis or thoracic outlet syndrome.

Supraspinatus tendonitis pain is generally the result of forward head postures and slumped shoulders ... not the cause. When the humerus internally rotates from a slumped posture, the supraspinatus attachment at the greater tubercle of the humerus also rolls forward. Then when called upon to lift a heavy suitcase, the supraspinatus tendon cries for help as the shoulders are retracted. Pain shoots down the arm as the tendon flips back over the humeral head, and soon the fibers begin to tear.

Part II

Postural Harm to the Viscera

Prolonged sitting can contribute to a significant loss of cervical and lumbar curve, while increasing thoracic kyphosis.

Just like the newborn, the result is one big C-curve, with all the facet joints sliding open - beginning at the sacrum and curving all the way up to the occiput. With the shoulders drawn forward and the chest flattened, the abdomen protrudes below the belly button, resulting in altered breathing patterns. Tension increases on the pericardium and its neurovascular contents, because the diaphragm is now lowered. Individuals who suffer from this condition may seek help from their physician for complaints of heart palpitations or respiratory infections, while ignoring the real cause - a potential alteration of visceral position and function.

Exploring Perfect Posture

To fully understand why aberrant postural patterns create chronic head, neck, back and hip pain, perfect posture must be clearly defined. Simply put, perfect posture is a condition in which body mass is evenly distributed. Muscles are not actively working toward appeasement of pain. Ligamentous tension must be perfectly balanced against compressive and tensegrity forces, so the typical activities of standing and walking require minimal energy expenditure. Because locomotion requires the controlled loss and regaining of balance, movement of any body part with respect to the rest of the body shifts its centerline of gravity, causing an inevitable change in overall balance.

Wasting Precious Energy

Ideally, during standing, postural muscles should be in a state of normal tonus and not actively contracting. However, as the body is subjected to micro or macrotraumas during the normal routines of life, postural balance becomes less than perfect. When this happens, active muscle contraction is required to redistribute body mass and effectively hold it in place. At this point, the muscles are working against gravity requiring them to perform the ligament's job of stabilizing the joints.

Muscle contraction requires energy; therefore, postural imbalances result in an enormous energy drain, proportional to the magnitude of the postural imbalance. Of course, this becomes lost energy unavailable for its original purposes. Energy drains have a dramatic effect on the limbic system - the highest cortical level controlling muscle tone. As whole-body tension builds, clients begin to report strange symptoms resembling fibromyalgia, chronic fatigue syndrome and digestive or hormonal disorders.

Faulty posture becomes magnified in clients who participate in athletic competitions. For example, short leg syndromes from a tilted pelvis can create a dramatic loss in time, strength, coordination and endurance in both amateur and professional athletes. In addition to energy loss, the body's joints are often subjected to abnormal mechanical stresses. When the spinal musculature is involved in lateral curvatures due to compensations from a tilted or side-shifted pelvis, shortening of the ligaments and muscles on one side and lengthening on the other occurs. Alterations in joint function, caused by capsular restriction or loss of joint play, inhibit or facilitate the muscles that cross the misaligned joint.

If proprioceptive impulses from sensory receptors located in joint capsules, ligaments, tendons, muscles, fascia and intervertebral discs become agitated from pelvic misalignment, compensations resound up and down the spine. Even the slightest alteration in the normal balance of the various spinal segments leads to some degree of soft tissue change. Nature inherently attempts to automatically restore equilibrium, by contracting and shortening certain muscles and inhibiting and weakening others.

When a joint's axis of rotation changes, one side of the joint capsule and its supporting muscles and ligaments become overstretched and weak. Meanwhile, sensitive mechanoreceptors imbedded in the articular cartilages and discs on the compressed side send a barrage of mechanical distress signals to the spinal cord.

Facet joints are possibly the most innervated structures in the spine. Their cartilages despise prolonged compression and soon become swollen, inflamed, and eventually degraded. As chemical inflammatory agents accumulate, chemoreceptors are stimulated and join the mechanoreceptors in flooding the neuronal pool with warning bells of possible tissue damage. This stimulates the pain-producing nociceptors that cause the brain to tighten and shorten specific muscles to avoid further pain - the embodiment of our" crooked" clients in acute pain. The brain twists and torques the body in an attempt to alleviate the pain. Regrettably, the cerebellum has the ability to memorize these aberrant patterns and re-learn them as normal. This condition, when the deformed posture long outlasts the painful stimuli, is called neuroplasticity, reflex entrainment or spinal learning.

Feet-Shufflers

In the presence of joint blockage caused by capsular tightness and compression, normal articular reflexes may become so disrupted that when the tightened area of the joint capsule is overstretched, reflex inhibition of the overstretched muscle prevents further capsular elongation.

"Feet-shufflers," occasionally seen in malls and supermarkets, represent the perfect exaggerated embodiment of how a dysfunctional hip capsule can disrupt the firing order of muscles that cross a joint. During the walking cycle, the feet-shuffler's push-off leg can't extend backward, due to adhesions in the anterior part of the hip capsule. Therefore, he or she uses the hip flexors to throw the feet forward to walk. Therapists usually attribute this condition to tight hip flexors that won't allow the back leg to follow through in extension. However, during therapy treatment, attempts to increase hip extension by actively or passively stretching the hip flexors can cause an immediate firing of the joint and ligament mechanoreceptors creating a sort of stretch reflex. The adhesive capsule fools the joint receptors into believing the hip has already reached its end range of motion. A condition called arthrogenic muscular weakness inhibits the hip's prime mover, the gluteus maximus, and facilitates the already tight/short iliopsoas. This appears to be a local genetic protective device to prevent excessive hip extension and further jamming of the joints' compressed cartilage.

Regrettably, anterior hip capsule adhesions are a widespread and overlooked source of flexion addiction in our society. Some may conclude that this insidious hip condition is the reason for so many hip replacements being performed in this country each year. Athletes who complain of loss of speed in their competitive trials may also suffer from a lack of full hip extension in one or both hips. Hip flexor work alone just won't solve the problem. One helpful routine is to first dig-out, plunger and stretch the adhesive hip capsule, then tonify the weak gluteus maximus with fast-paced, spindle-stimulating maneuvers. To finalize this procedure, use techniques ranging from assisted stretching, myofascial release, trigger point therapy or muscle energy to lengthen the tight iliopsoas.

Conclusion

The mysterious yet potentially stressful force of gravity affects each of us here on planet Earth. Our body's somatic system is intrinsically involved in its reaction to a shift in the center of gravity. Muscle and ligamentous tension is maintained by negative feedback from sensory receptors located in joint capsules and intervertebral discs. When the normal function of any part of the somatic system becomes overstressed, the vicious cycle of pain and dysfunction begins. Our job as bodyworkers is to maintain normal mobility of all components of the somatic system, to help minimize gravitational strain and any consequences from postural imbalance.

Emerging from an industrial society to one rich in technology, we now live in a world in which our external environment greatly impacts the healthful functioning of our bodies. As therapists working with a flexion-addicted population, we must garner a greater understanding and respect for the goal of perfect posture and its relationship to chronic pain, so we can teach our clients how to lead healthier, happier and more productive lives. May we all be graceful dancers, stretching artlessly to the sky.