We all know pain is a liar. It may hurt in one place while originating somewhere far from the pain site. In past articles, I’ve discussed the importance of properly assessing two common clinical conditions:
Descending Syndromes—cervicocranial disorders affecting pelvic alignment—and Ascending Syndromes—lower extremity imbalances manifesting as head and neck pain (Fig. 1). Regrettably, it’s not always easy locating the “key” lesion perpetrating the imbalance. When in doubt, try performing two simple tests: the Bruger and Derifield.
Bruger Test: Brace the client’s forehead with your left hand while your right fingers and thumb gently palpate the suboccipitals…standing and sitting. If tension/tightness eases when the client sits, then the client’s neck or head pain may be coming from lower quadrant imbalances (ascending syndrome).
Derifield Maneuver: With client prone (feet off table), place each thumb under the medial malleoli and ask the client to slowly begin rotating the head side-to-side. If leg length changes when the head turns right, one should suspect cervical spine dysfunction (usually on the right side). If turning left alters leg length, examine and correct head and neck imbalances…and recheck.
Common Compensatory Pattern
Figure 2 illustrates a common postural imbalance pattern seen daily in our practices. Although this lower quadrant disorder can manifest from ascending or descending origins, it usually indicates a breakdown in one or more of the body’s four major spring systems (Box 1). (Visit erikdalton.com/article_DontGetMarried.htm for a detailed explanation of spring system functioning.)
Most therapists viewing Figure 2 conclude the dysfunction arises from a hyperpronated foot … an ascending syndrome. However, this ‘tricky’ strain pattern often originates from the top down. For example, a tight right iliopsoas (possibly from right motor dominance), can reciprocally weaken its antagonist gluteus maximus. Tone in G-max is essential for smooth coordination with the contralateral latissimus dorsi to help counter-rotate the torso and pelvis (cross-patterned gait). A neurologically weakened G-max disrupts synchronization with the lats causing Posterior Spring System (PSS) breakdown.
Notice how the short iliacus anteriorly/inferiorly rotates the right innominate forcing the pelvic bowl and lower limb to left rotate. As the psoas pulls the lumbar vertebrae into left rotation and sidebending (non-neutral mechanics), deep core structures such as spinal ligaments, facets, discs and joint capsules are squashed on one side and overstretched on the other. In an effort to maintain a smooth cross-patterned gait, the brain is forced to over-recruit the adductors and contralateral external obliques to aid the weakened PSS in pelvic/torso counter-rotation.
Lateral Spring System
In Box 1, the ad-ductors are stabilizing the stance leg so the ipsilateral ab-ductors can right sidebend the pelvis allowing the left leg to step over a fence or climb a hill. However, tight/short adductors sometimes overpower the abductors impairing the Lateral Spring System’s firing order. To make matters worse, prolonged ipsilateral pull on the pubic symphysis (working in conjunction with the tight iliacus) creates pube dysfunction and destabilizes the other two pelvic joints (Figure 2). Shortened adductors tug on the pubic symphysis at one end, and cram the femur and tibia together at the other. The combination of femoral internal rotation and adduction causes the valgus knee to hyperextend. With each step, the medial meniscus cartilage grinds away on the uneven tibial plateau.
Stirrup Spring System
During the normal walking cycle, the tibia must slightly internally rotate as the medial arch pronates and springs back up. But in the Figure 2 leg, the tibia is ‘stuck’ in internal rotation which allows excessive weight to travel down through the medial arch creating subtalar eversion, hyperpronation and chaos in the muscles of the Stirrup Spring System.
As weakened and overstretched tibialis anterior and peroneus longus muscles fail to support and spring the medial arch, antigravity pumping action is lost. With no mechanism available for delivering ground reaction forces back up through lateral leg through the biceps femoris and external hip rotators, the other spring systems must take up the slack. Bottom line: Any ‘kink’ along the kinetic chain can cause spring system failure. These people walk with a labored gait and will suffer recurring back, hip and leg pain unless their myoskeletal imbalance patterns are systematically addressed.
Possible Pain Patterns
At this point, the client may report:
- Low back, sacroiliac or sciatic pain from inflamed facets, discs and ligaments;
- Trochanteric bursitis or piriformis syndrome due to weak abductors and overstretched gluteus medius;
- Groin pain: femoral nerve entrapment or osteitis pubis (inflammation of the pubic symphysis);
- Adductor tendinopathy at the attachment on the superior pubic ramus;
- Medial knee pain from cartilage degradation or medial collateral ligament strain; and
- Foot and ankle pain from plantar fasciitis, stress fractures, etc.
Muscle imbalances are thought to be caused by abnormal afferent stimuli due to tension, trauma, poor posture, joint blockage, painful or noxious stimuli, excessive physical demands and habitual movement patterns. Of course, neurologic and genetic factors also play a major role. Some conditions are serious and others are not. Regardless, any dysfunction that interferes with the client’s quality of life must be thoroughly evaluated. Manual therapy in its various forms is still the treatment of choice for correcting many of these strain/pain patterns.
Erik Dalton, Ph.D., has devoted 29 years to the study of massage, Rolfing® and osteopathy while maintaining a full-time practice. Developer of the Myoskeletal Alignment Techniques® and founder of the Freedom From Pain Institute®, Dalton shares a passion for teaching, research and treatment of chronic pain conditions. Visit www.ErikDalton.com to read additional MASSAGE Magazine articles.