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Inside-Out Paradigm

By Dale G. Alexander, LMT, MA, PhD

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The Strain of Compression

In order to enhance the distribution of strain through the kinetic chain between the foot, ankle, leg, knee, thigh, hip joint and pelvis, imagine the lower extremities as circles and columns that are designed to load share the compression of standing and movements of all kinds. These are concepts that have aided my efforts to assist clients desiring to prevent hip, knee, and shoulder replacements or to improve the quality of their rehabilitation after surgery.

Jon Zahourek, the developer of the Maniken System of Anatomy in Clay, was my inspiration for the circles notion when Lansing Barrett Gresham and I attended a rive-day workshop with him in 1990. During that week, we used clay to form every muscle in the human body and then placed them on a 3 1/2 foot skeleton. It was an amazing experience. However, one might also visualize the lower extremities as composed of articulated column segments. Thousands of clients have been my hands-on teachers guiding me to the experience of how these concepts successfully work to enhance their lives.1,2

What are the proposed circles and columns that may more evenly distribute compression in the lower extremities? Visualize, if you will, the longitudinal and transverse arches of the foot. The space between and including the tibia and fibula. The angular shape of the femur bordered laterally by the iliotibial band and medially by the muscular band of the gracilis and encased in all the soft tissues of the thigh. The ovoid shape of the pelvis itself with the pubic symphysis and the two sacroiliac joints. And, even the circular shape of the acetabula.

compression - Copyright – Stock Photo / Register Mark Consider directing your hands-on efforts toward creating a more balanced suspension into the center of each circle or column, thus enhancing the load sharing capacity of the lower extremity upward through the kinetic chain from the feet to the pelvis. In my previous articles, I have described the more superior anatomical and physiological elements that may predispose a posterior slide in the femoral head. Of course, these inferior circular and columnar relationships may also influence hip joint deterioration, especially if trauma to any of these lower extremity joints and soft tissues has occurred.

Who among us hasn't sprained an ankle, twisted a knee, or landed rather unceremoniously on our duff, aka, ischial tuberosity, sacrum, or tail bone. And, if one has had a fracture of any of the bones that intersect with these joints, then the resulting compensations may still be skewing the load sharing. Creating expanded, more normalized, more integrated space is our intent to enhancing the function of this system of interrelated circles and columns:

  • Space within the foot.
  • Space within the tarsal tunnel.
  • Space between the tibia and fibula.
  • Space surrounding the femur.
  • Space within the pelvic floor and pelvic bowl.
  • Space relating to and within the acetabula.

The simple concept to highlight in your awareness is that such trauma injuries (as well as injuries due to repetitive misuse, etc.) may alter the symmetry and structural integrity of these circles and columns and lessen their ability to distribute strain and contribute to the tendency for the femoral head to slip posterior.

Our job is as bodyworkers and massage therapists is to restore the soft tissue balance and suspension of these geometric spatial relationships as best we can. This new perceptual orientation will enhance your ability to mobilize the joints within the feet, ankles, knees, thighs, hips and pelvis.

To aide you in your quest, the golden key is to recognize that by directing your efforts toward mobilizing each of these joints toward their normal range of motion, is the fastest and usually least painful avenue to restore the balance of each circle and column. And, as you facilitate these changes for your clients, visualizing and working from the inside-out is the more natural and effective approach.

To say this another way, realize that soft tissues serve the joints. It is nature's hierarchy. Much of any excessive tension around and between the joints is created because the joint surfaces become stuck in mid-range, prevented from completing their full range of motion and thus are structurally mis-aligned in their proper tracking relationships.3 Restoring appropriate tracking within these joints along with utilizing our additional skill sets for enhancing soft tissue suspension together is a more comprehensive approach for us to aspire toward.

Below, I describe some of the more crucial osseous and soft tissue relationships which are instrumental to the distribution of strain within these circles and columns. Many others are also important; yet, if you master these, your competence to assist your clients will leap forward, as will your income. Increasing your anatomical and physiological knowledge and the depth and breadth of your hands-on skill sets is your best marketing tool. What generates new clients faster than anything else is your clients speaking your name associated with a proclamation that they are feeling and functioning better after working with you!

In the feet, the navicular and cuboid bones counter-rotate in order to unlock the arches during the heel strike and foot flat phases of the walking cycle, thus allowing the foot to adapt to the irregular surfaces of the earth as was necessary before we began to wear shoes. Then they re-rotate to provide a rigid lever during push-off.3,4 Since the line of joints from the navicular to the cuboid is where the longitudinal and transverse arches intersect, this is a key concept to understanding foot function. Often, one or both bones will become stuck in the mid-range of their rotational motion.

In the ankle, the talus bone has no muscular attachments, so it is often vulnerable to displacement. Mobilizing it positionally in relationship to the mortice structure of the malleoli of the tibia and fibula is another important skill to develop. The talus bone frames much of the tarsal tunnel, the opening through which blood, nerve and lymph supply flow in and out of the foot. Mobilizing its position toward a more balanced perch above the calcaneus bone positively affects both proprioceptive stability and neurovascular supply.

Moving upward to the leg and knee, remember two important goals: mobilizing the proximal head of the fibula then diving into and opening the interosseous membrane between the tibia and fibula is the quick path to re-balancing the column of the leg.

Learning to guide the tibial plateau through a figure eight range of motion is an approach that often allows the femoral condyles to naturally reset in relationship to the concave surfaces of the tibial plateau. This change toward greater joint mobility can be a miracle to a client with a chronic knee misalignment. Similar to the foot bones, the knee must twist to open and then flex forward, initiating the walking cycle. Then it needs to twist back to its original position for there to be stability and power during the extension/push off phase of walking.3,4 Again, the femoral condyles in relationship to the tibial plateau often become stuck in the middle of their reciprocal counter-rotations.3

Within the thigh, developing an awareness of the lateral and medial intermuscular septa radiating and spiraling outward from the femur is a core anatomical understanding to creating space within this cylinder/circle. Make it a priority to learn to mobilize the range of motion within the hip joints. Visualize the femoral head moving within the acetabulum. Direct your efforts to increase the roll and spin of the femoral head within the socket itself.

In the pelvis, learning to mobilize the pubic symphysis and the sacroiliac joints are exceptionally useful skills along with learning how to release the attachments of the adductors whose fascia blends with that of the pelvic floor muscles. Finally, to complete this holistic view of the body, we come to the relationship between these circles and columns of the lower extremities and the shoulder girdle, which is so often functionally vulnerable to the distortions in this kinetic chain of support.

Allow me to begin with Dr. Richard MacDonald's articulation from osteopathic theory that there exists a contiguous fascial line from the latissimus attachment to the humeral bone through the fascia associated with the sacroiliac joints, then following the lateral hamstrings and peroneal muscle group downward all the way to the lateral ankle/foot. His stated inference was that distortions could begin from above, and refer downward or from below, and refer upward.5

One of Ida Rolf's most enduring quotes guides our understanding of this dynamic relationship, if the body is not supported from below then it will endeavor to hang from above.6 I believe that the physiological mechanism(s) related to the meaning and understanding of this assertion are principally mediated by the large body reflexes and the flexor/extensor reflex systems, as well as the effects of fascial suspension, vertebral segmental motion, and many other additional variables.

My theory is that the constant activation of these reflexes will invariably distort the smooth range of motion of the shoulder joints adding to the progression of arthritic changes and the deposition of calcium salts. Most clients coming to me considering shoulder joint replacements have complex histories all involving some degree of trauma which most likely initially activated these reflex systems.

As loss of support from below progresses over time, these reflexes begin to insidiously lock the scapulae against the rib cage, often creating some degree of frozen shoulder; while in others, the arms are unconsciously pulled medially against the side of the chest. Both of these actions will add external compression against the expansion of the thorax as a whole, thus also increasing resistance to heart and lung expansion. Then inevitably, the entire general physiology becomes strained without adequate supplies of nutrients, oxygen, and hormones that fresh blood delivers. The elegance of the human design is really all that connected and more.

Please do consider Jon Zahourek's notion of multiple circles and Glenn Gaffney's concept of multi-articulated columns as paradigms for how we may imagine creating a more balanced distribution of strain and load bearing along the kinetic chain of the lower extremities into the pelvis.

Please do consider that mobilizing opposing joints surfaces picks the protective lock of soft tissue spasms. And, yes, many will need a lot of "coaxing to more fully release." Many physiological therapeutic principles and techniques will be needed: fascial spreading and unzippering, muscle energy technique, trigger point therapy, reciprocal inhibition, cross fiber friction, indirect techniques such as strain-counterstrain or its English cousin orthobionomy, and many many others.

References:

  1. Anatomy in Clay Learning System, Loveland, CO. Zahourek Systems Inc.
  2. Glenn Gaffney, B.S., L.M.T., KMI Structural Integrator, St. Augustine, Fl.
  3. Muscle Energy Technique Tutorials with Dr. Richard MacDonald D.O. and assisting at his courses, Upledger Institute,1986 -89.
  4. Physical Examination of the Spine and Extremities, Stanley Hoppenfeld, MD, phases in the walking cycle, Appleton-Century-Crofts, 1976.
  5. Dr. Richard MacDonald D.O., Functional Anatomy Courses, Upledger Institute, 1988-90.
  6. Rolfing: The Integration of Human Structures, Ida P. Rolf, PhD., Santa Monica, CA: Dennis-Brown; 1977.
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