Archive for the ‘manual therapy’ category

The Scalenes, the Dynamic Duo +1

July 2, 2012

The Scalenes are an important neck muscle comprised of three parts, the anterior, the middle, and the posterior. The anterior and the middle will be the subject of this post because the posterior is mostly involved as a synergist for the upper trapezius. The brachial plexus passes through an opening between the anterior and middle scalenes, making it subject to dysfunction if the scalenes are hypertonic. The scalenes are also accessory muscles of respiration and can cause breathing imbalances if one is a chest breather. The scalenes are also involved in the kinetic chain of the arm as well as the front line and lateral line. We will examine all of these relationships to reveal just how dynamic these muscles truly are.

In cervical dysfunction the scalenes can be either facilitated or inhibited. If the sternocleidomastoid muscle is inhibited, the scalenes may compensate to stabilize neck flexion. In the case of whiplash, the scalenes may become inhibited by facilitated neck extensors. I find it very important to release the scalenes indirectly by stabilizing the first and second ribs while performing a myofascial stretch. I have found that working directly on the scalenes can cause them to rebound and tighten up even further. To strengthen the scalenes, resist at the forehead while nodding towards the ipsilateral shoulder. The scalenes also ipsilaterally flex the neck, and therefore can become inhibited by either the ipsilateral or contralateral upper trapezius. The scalenes produce ipsilateral rotation of the cervical spine, and can become facilitated by an inhibited contralateral sternocleidomastoid or an ipsilateral longus colli.

Because the brachial plexus passes through an opening between the anterior and middle scalenes, hypertonicity, whether caused by facilitation or inhibition, must be addressed. The extra pressure on the brachial plexus caused by hypertonic scalenes can result in Thoracic Outlet Syndrome. Symptoms include numbness and tingling in the arms and hands, as well as loss of strength in both the arms and hands. I have found the scalenes to be compensating for 13 different functions in the arm line with someone who had TOS. Reestablishing the proper relationship between the scalenes and these 13 different functions was crucial in the resolution of the TOS.

The scalenes are an important part of the front line kinetic chain. It is not unusual for the scalenes to be facilitated for an inhibited ipsilateral psoas and adductors. They may also be facilitated for an inhibited contralateral TFL and adductors. Even dysfunction of the extensor hallucis longus can be compensated for by the ipsilateral scalenes. In the lateral line, the scalenes oftentimes become facilitated in combination with the peroneals in cases of over pronation or ankle sprains. The most likely inhibited muscle in this scenario is the TFL. The scalenes can also be dynamically involved with the obliques and the quadratus lumborum.

The scalenes are also accessory muscles of respiration. They elevate the first and second ribs, and in chest breathers, they can become,along with the pectoralis minor, dominant muscles of respiration. In this situation they can become facilitated for inhibition of the muscles that depress the rib cage, such as the quadratus lumborum and the obliques. Resolution of these dynamic muscular relationships along with restoration of proper breathing patterns can go a long way to resolving this issue.

The scalenes are important to consider in cervical dysfunction, Thoracic Outlet Syndrome, problems with the arms and hands, dysfunction of the muscles of the front line, dysfunction of the muscles of the lateral line, and improper breathing patterns. Remember to treat these muscles with respect and they will reward you with outstanding therapeutic outcomes.

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The Pectoralis Minor, King of Compensation

May 26, 2012

The pectoralis minor is a muscle that becomes easily shortened and tight due to many factors, including rounded shoulder posture, glenohumeral joint dysfunction,breathing dysfunction, and a variety of compensation patterns. It sits on top of the brachial plexus, and can therefore contribute to Thoracic Outlet Syndrome. The pectoralis minor is located in an area of the shoulder with many other muscles, including the pectoralis major, biceps, deltoids, coracobrachialis, subscapularis, serratus anterior, and the latissimus dorsi. I find that clusters of muscles like this often can become dysfunctional due to poor biomechanics. This can lead to adhesions, facilitation/inhibition, and synergistic dominance. The pectoralis minor is often the overactive muscle in these compensation patterns.

Rounded shoulder posture and forward head posture will cause the pectoralis minor to shorten. This action is called protraction and is opposed by the muscles of retraction.  These include the middle trapezius and the rhomboids. Commonly the pectoralis minor becomes facilitated and the middle trapezius becomes inhibited. Release of the pectoralis minor followed by strengthening of the middle trapezius can be very effective in these cases. Because the pectoralis minor rounds the shoulder, it is opposed by the latissimus dorsi which moves the shoulder back and down. Again, release of the  pectoralis minor followed by strengthening of the latissimus dorsi can be very effective.


    The pectoralis minor is a downward rotator of the scapula and oftentimes involved in glenohumeral dysfunction.  If it is facilitated, it can inhibit the serratus anterior, which contributes to upward rotation of the scapula. This can lead to impingement syndrome and sometimes winging of the scapula. The resultant scapular instability greatly contributes to shoulder joint dysfunction.

 

The pectoralis minor is also an internal rotator of the humerus. When facilitated it can inhibit the external rotators of the humerus, including the long head of the biceps, the posterior deltoid, and the infraspinatus. A common  shoulder injury that occurs from this is that the long head of the biceps comes out of its groove and moves medially towards the short head of the biceps. Release of the pectoralis minor followed by relocation of the long head of the biceps tendon is very effective in these cases. http://youtu.be/vDUI4IR8OzY

The pectoralis minor also contributes to kinetic chain dysfunctions. For example, in the front line, the pectoralis minor often inhibits the psoas. In the diagonal line, it can inhibit the contralateral psoas. This is a factor in gait dysfunction. Also in gait it can inhibit the backward swing motion of the contralateral arm and the backward swing of the ipsilateral leg. Right thoracic rotation can be inhibited by the right pectoralis minor because of its contribution to internal rotation.

Lastly, the pectoralis minor can contribute to breathing pattern dysfunctions. People who are “chest breathers”, commonly have facilitated pectoralis minors and scalenes, which elevate the rib cage. These are opposed by the quadratus lumborum, which   depress the rib cage. If the QLs become inhibited, the possibility of lower back pain greatly increases. Release of the pectoralis minor followed by strengthening of the QL not only can relieve lower back pain, but also can help to repattern faulty     respiratory mechanics.

The pectoralis minor is a short and powerful muscle that can frequently become facilitated and contributed to a host of compensation patterns. Don’t forget this muscle when treating neck pain, shoulder pain, arm and hand pain, hip and leg pain, and breathing pattern dysfunctions.

The Popliteus, the Tiny Muscle of Knee Pain

April 22, 2012

ANATOMY

The popliteus tendon originates on the lateral surface of the lateral femoral condyle (in front of and below the lateral collateral ligament origin) and also from the fibular head. It also has an origin stemming from the posterior horn of the lateral meniscus. The tendon then courses under the lateral collateral ligament, descends into the ‘popliteal hiatus’, and becomes extra-articular (outside the knee joint) before joining its muscle belly. It inserts into the tibia above the popliteal line. It is therefore a relatively horizontal muscle lying deep in the back part of the knee.

FUNCTIONS

The popliteus is believed to have a number of functions, made possible by its unique ability to reverse its origin and insertion, depending on whether the femur or the tibia is fixed.

1.Internal rotation of the tibia in an already extended knee. Due to the contour of the femoral condyles, this internal rotation of the tibia ‘unlocks’ an extended knee. In essence it initiates knee flexion.
2.External rotation of the femur on a tibia that is fixed, as in the stance phase of gait. It is an important controller of knee rotation during the stance phase of locomotion.
3.Helps to bring the knee out of a position of full extension.
4.Helps the PCL (posterior cruciate ligament) maintain stability by preventing excessive posterior translation of the tibia.
5.Helps to withdraw the lateral meniscus during knee flexion.
6.Provides some rotary stability of the femur on the tibia.
7.Prevents excessive external rotation and varus rotation of the tibia during knee flexion.

I have heard it said that the popliteus can contract to up to 300% after knee surgeries such as meniscal repair, and ACL and PCL reconstruction. Inability to fully extend the knee after such surgeries may be a result of a hypertonic popliteus. Let’s now look at some of the  functions to see where and why an overactive popliteus can become such a problem.

It’s ability to initiate knee flexion makes it an antagonist for the quadriceps and a synergist for the hamstrings and gastrocnemius. Inhibition of the quadriceps, either of all four or one in particular, may cause facilitation of the popliteus. Inhibition of the vastus medialis is very common. Inhibition of the hamstring group, especially the biceps femoris, may also cause facilitation of the popliteus.

The hamstrings group is the main torque producer for knee flexion. It helps control tibial rotation during the stance phase of gait. The lateral hamstrings (biceps femoris) actively externally rotate the tibia on the femur but also control internal rotation of the tibia on the femur in stance phase of gait. The medial hamstrings (semitendinosus and semimembranosus) control external rotation of the tibia on the femur in stance phase of gait.A poorly functioning hamstring due to weakness or pathology may result in a compensatory overuse of the popliteus to control tibial rotation in stance phase.

KINETIC CHAIN ANALYSIS

In the superficial back line, there is a chain from the bottom of the foot, through the calf muscles, to the popliteus, to the hamstrings, and the gluteus maximus. In the extension phase of gait, these muscles work together. Inhibition of one or more of these muscles may cause another muscle in this chain to become facilitated. The popliteus may become facilitated due to inhibition of the gluteus maximus. The popliteus can also become facilitated due to inhibition in the superficial front line. Inhibition of the extensor hallucis longus, rectus femoris, and psoas commonly cause facilitation of the popliteus. In internal rotation of the tibia, inhibition of the medial head of the gastrocnemius may cause facilitation of the popliteus. In external rotation of the femur, inhibition of the biceps femoris may cause facilitation of the popliteus. I have also seen compensation patterns involving the popliteus due to inhibition of the neck extensors, flexors, and rotators.

It is very important to consider the popliteus not only when dealing with knee pain, but also when dealing with complex kinetic chain compensations. Never underestimate this tiny but critical muscle.

Thanks to Chris Mallac for his excellent article. http://www.sportsinjurybulletin.com/archive/popliteus.html

The Often Overlooked Tensor Fascia Lata

March 15, 2012

The Tensor Fascia Lata (TFL) is a muscle with many different functions. It is an abductor, and internal rotator of the hip, and a hip flexor. Having so many functions, the TFL can be involved in many dysfunctional movement patterns throughout the body. We will explore its role in each of the aforementioned functions, assessing the resultant dysfunctions based on whether it is facilitated or inhibited. The TFL is most commonly associated with the IlioTibial Band, which unfortunately has led to its being treated as one unit. The usual treatment for this unit is myofascial release or foam rolling without assessing whether or not it is facilitated or inhibited. This can lead to further biomechanical complications and unnecessary pain and discomfort.

As an abductor, the TFL works in conjunction with the gluteus medius and the gluteus minimus. If one or two of these become inhibited, the other may become facilitated and overburdened. Often times inhibition of the gluteus medius is associated with a valgus knee and foot pronation. I find more often, using the manual muscle testing techniques from NeuroKinetic Therapy, that the TFL is inhibited in this situation. This can lead to ACL tears and other knee problems. http://ow.ly/9FUT2 . Here is an excerpt from an excellent article that references this very topic, “The more accurate description of the anatomy of the glutei and the new biomechanical theory that has been presented describe the abductor mechanism as a system in which the tensor fasciae latae has the primary function of balancing the weight of the body and the non-weight-bearing leg during walking. Gluteus medius with its three parts and phasic functions is responsible for the stabilisation of the hip joint in the initial phase of the gait cycle. It is important also in initiating the major gait determinant of pelvic rotation.Gluteus minimus functions as a primary hip stabiliser during the mid- and late phase of the gait cycle. This proves the importance of the TFL and the resultant dysfunctions when it is inhibited.” http://ow.ly/9FUwH . Inhibition of the TFL can also cause IT band syndrome, where the ITB is compensating for the TFL. In this scenario, rolling out the ITB without strengthening the TFL first, will prove fruitless.

The TFL is also involved in internal rotation of the hip along with the gluteus medius and minimus, adductors, and iliacus. If the TFL becomes inhibited, a greater burden is placed upon these other muscles. I often find facilitation of the adductor magnus and iliacus, which can lead to groin pain. Because internal rotation is opposed by external rotation, inhibition of the TFL can cause facilitation of the external rotators of the hip, especially the piriformis and the obturators. Facilitation of these can lead to an impingement of the hip joint.

The TFL is also a hip flexor working in conjunction with the psoas, iliacus, rectus femoris, adductors, and sartorius.  Inhibition of the TFL may result in a facilitation of any of these muscles. Not uncommonly, the psoas is inhibited and the TFL becomes facilitated. Facilitation of the TFL can result in inhibition of the opposing muscles such as the gluteus maximus, lumbar erectors, and hamstrings.

Trendelenburg’s sign is found in people with weak or paralyzed abductor muscles of the hip, namely gluteus mediusminimus, and TFL. The Trendelenburg sign is said to be positive if, when standing on one leg, the pelvis drops on the side opposite to the stance leg. The weakness is present on the side of the stance leg. The body is not able to maintain the center of gravity on the side of the stance leg. Normally, the body shifts the weight to the stance leg, allowing the shift of the center of gravity and consequently stabilizing or balancing the body. However, in this scenario, when the patient/person lifts the opposing leg, the shift is not created and the patient/person cannot maintain balance leading to instability. This can cause a shift in the trunk leading to a variety of compensations with the obliques, QLs, and head position.

Inhibition or facilitation of the TFL can cause numerous compensation and dysfunctional movement patterns to occur throughout the body. Please don’t ignore this very important structure!

The Piriformis is a Real Pain in the Ass

February 19, 2012

The piriformis muscle is the most superior of the deep external rotators of the hip. The sciatic nerve passes underneath it and sometimes through it. Hypertonicity of the piriformis can contribute to many kinds of Low Back Pain, also known as Piriformis Syndrome. We will examine the factors that make for a hypertonic piriformis muscle so that we can have an effective treatment strategy. The most common imbalance associated with this condition is a facilitated piriformis inhibiting the ipsilateral hip internal rotators. These muscles, such as the gluteus medius, gluteus minimus, and the tensor fascia lata are prone to inhibition. This balance can easily be ascertained through the manual muscle testing protocol employed by NeuroKinetic Therapy. Release of the piriformis muscle is immediately followed by activation of the internal rotators to reprogram the dysfunctional movement pattern that has been stored in the motor control center. This change is first stored in short-term memory, so it becomes imperative for the client to perform their homework twice a day in order to convert this new functional movement pattern into long-term memory.

The piriformis is also a synergist for the gluteus maximus in extension of the hip. Problems occur when the gluteus maximus becomes inhibited, which is very common. The piriformis was not designed to carry the load of the gluteus maximus, much like a local to global muscle relationship. Furthermore, when hip flexors, such as the psoas become inhibited, the piriformis can become facilitated in this agonist/antagonist relationship. Often times the piriformis will be assisted by the quadratus  lumborum ipsilaterally to compensate for an inhibited psoas. This will create a significant case of lower back pain.

Because the piriformis is an external rotator of the hip, it works with the opposite internal rotators of the hip to create ipsilateral lumbar rotation. Therefore inhibition of the contralateral internal rotators of the hip or contralateral external rotators of the hip will create facilitation of the piriformis. Pictures of these tests are in my book, “NeuroKinetic Therapy”. The piriformis also externally rotates the sacrum and can be a major contributor to sacroiliac joint dysfunction. This is often seen in a dysfunctional gait pattern where loading on the forward moving leg is compromised. The sacrum normally externally rotates during this action. Examination of the muscles that contribute to this action, including those that create lateral flexion of the spine, is crucial in unraveling this pattern. For example, the right piriformis could be inhibiting the left quadratus lumborum, left lumbar erectors, left psoas, etc.

A properly functioning piriformis muscle is crucial in maintaining a healthy low back and sacroiliac. Understanding how to assess and treat a hypertonic piriformis is crucial in resolving dysfunctional movement patterns associated with Low Back Pain and Sacroiliac Dysfunction.

Temporomandibular Joint Dysfunction

January 21, 2012

Temporomandibular Joint Dysfunction or TMJD is a common malady affecting millions throughout the world. According to statistics most sufferers are women. I believe the reason for this is, that in many cultures women are not allowed to express their anger, and as a consequence, it somatizes in the jaw. We do know that suppressed anger and stress contribute greatly to TMJD. Most jaw clenching occurs at night but can also happen on an unconscious level throughout the day. In my experience, treatments like EMDR, are very effective for the psychological aspects of  TMJD. The physical causes include malocclusion, improper orthodontia, cranial trauma at birth, whiplash, and of course any blows to the jaw. Standard treatments include night guards, oral appliances, adjusting tooth height, orthodontia, cranial osteopathy, physical therapy, and chiropractic. It is my contention and experience that these treatments would be more effective if they included a method to make  the jaw muscles less facilitated/reactive to other muscles and functions throughout the body.

Symptoms of  TMJD include jaw pain, headaches (especially around the eyes), neck pain, and tinnitus (ringing in the ears). Tinnitus often is caused by a hyperactive lateral pterygoid muscle which has fibers that connect to the inner ear. But to treat the jaw as if it existed without any connection to the rest of the body is to do it a great injustice. Let’s explore some of the basic and more complex relationships. Mastication is a very complex movement. It involves movement superiorly, inferiorly, anteriorly, posteriorly, medially and laterally. All of these planes of motion affect other muscles throughout the body creating similar planes of motion. Jaw opening creates superior, inferior, anterior, and posterior movement. Chewing adds the medial and lateral components. I will first address the four major muscles of mastication: the temporalis, the masseters, the medial pterygoid, and the lateral pterygoid.

NeuroKinetic Therapy views the jaw muscles as a default mechanism for overcompensation. In other words, the jaw muscles can become facilitated for other inhibited muscles throughout the body. The temporalis muscle can compensate for muscles along the Front Line, including the neck flexors, pectorals, abdominals, hip flexors, and dorsiflexors. Due to its interesting configuration, the temporalis muscle can also compensate for muscles along the Back Line. These include the spinal muscles, the gluteals, the hamstrings, and the plantarflexors. The masseters, the strongest muscle in the body for its size, affects the Front Line and Back Line in a similar fashion. This muscle is capable of medial and lateral translation of the jaw, creating ipsilateral lateral movement. Thus it can affect muscles that side bend the neck, side bend the torso, hip abductors, and the peroneals. Both the medial and lateral pterygoids create contralateral lateral movement of the jaw. Therefore they can affect the same muscles as the masseters, only on the opposite side.

Some good examples of these relationships are as follows. The temporalis often compensates for inhibited neck flexors and gluteals. The masseters often inhibit those same muscles and the hip flexors. The pterygoids often inhibit the scalenes, the latissimus dorsi, the obliques, the quadratus lumborum, and the hip abductors. If these relationships are left unattended the tension in the jaw muscles increases tremendously resulting in the aforementioned symptoms. Remember that the tension in these muscles is a result of a faulty relationship with other muscles/functions. To simply release these muscles without first figuring out what they are compensating for, could result in destabilizing functional integrity. Treat the cause not the symptoms.

The muscles of the floor of the mouth can also compensate globally, but I find them most involved in bracing with the diaphragm and the pelvic floor muscles, similar to the Valsalva maneuver. This kind of “bearing down” is a very common compensation pattern often involved with emotional issues. When treating the muscles of the floor of the mouth, it is important to consider the diaphragm and pelvic floor muscles. Clenching, breath holding, and anal tightening are common reactions to stressful situations which can result in developing dysfunctional movement patterns. These can often be the missing pieces to solving long-standing puzzles.

Successful treatment of  TMJD  must include a consideration of the global relationships between the jaw muscles and the rest of the body.

Hip Joint Jam

December 22, 2011

Hip joint impingement or Femoroacetabular impingement is a common malady affecting millions of people. If left untreated, this condition will result in osteoarthritis, hip replacement, severe groin and buttock pain, and limited and painful range of motion. FAI can result from playing sports or sitting too much. A student of mine brought his client to me who was suffering for years from severe buttock pain. She had had several MRIs as the doctors suspected she had sciatica resulting from some impingement in her lower lumbar spine. The MRIs were of course negative. She also received anti-inflammatory injections in her lumbar spine which did nothing. After getting her history I put her through some range of motion testing which included her hip joint. I found her hip joint to be very jammed. After balancing the muscles around her hip joint, I applied light traction to her leg, and voila, there was an audible pop, and while weeping, she reported that her pain was completely gone.

Let’s go over the important muscular components of FAI. First and foremost are the obturator internus and externus. These two muscles suspend the femur in the hip joint. If they become too tight the femur jams into the acetabulum. The question then becomes why are they tight? A very common compensation pattern that I see is the obturator muscles inhibiting the gluteus maximus. This is something that happens from sitting too much. The obturator muscles can also inhibit the psoas. Again, this is due to sitting and sometimes athletics. The obturator muscles, just like the rotator cuff muscles, are not meant to do motions that require load bearing. So when there is a dysfunctional movement pattern, and they are required to compensate, naturally they tighten up. The result of all of this is a painful hip joint. I know about this from personal experience. From doing a lot of mountain biking, my hip joint became increasingly painful, to the point where when I sat with the soles of my feet together, my one knee was much higher than the other. I tried stretching my  adductors to no avail. Finally I learned about the obturator muscles, and was able to resolve my problem.

I use the standard range of motion tests to determine if FAI exists. I have the client perform internal and external rotation of the hip via the foot, knee to chest, cross one leg over the other, put the soles of the feet together, and do a circular range of motion. Often times many of these are restricted, and depending on the severity, sometimes only one is restricted. After balancing the obturators, the next thing I check is strength in the rectus femoris. With FAI, this is often inhibited. This muscle is also inhibited after hip joint replacement, and it’s facilitation is crucial in postsurgical recovery. What I find commonly facilitated is the iliacus. Naturally, the adductors can be facilitated and inhibit the rectus femoris. Dysfunction of the hip joint commonly can lead to lower back pain via antagonistic relationships, neck pain due to kinetic chain compensation, and knee pain also due to kinetic chain compensation. Only after all of these relationships have been resolved, will I gently traction the leg to facilitate a release of the hip joint.

Of course, if there has been too much degeneration in the joint, I will recommend a hip replacement. Optimally, if there hasn’t been too much damage, a hip resurfacing procedure can be done. Let’s remember that hip joint replacement is amongst the most successful of surgeries. I have seen people’s lives changed dramatically from such a procedure. Remember to be a pragmatist not a fanatic. Conservative management of FAI is very successful if you understand its components and how to resolve the specific dysfunctional movement patterns.