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A Simple and Easy Hip Mobility Drill for Low Back Pain

Low back pain continues to be one of the most common health complaints that limit people, especially as we age.  Rehabilitation of low back pain has transition from simply focusing on reducing the local pain to emphasizing a biomechanical approach of how other areas of the body, such as the hips, impact low back pain.

Essentially we have done a great job moving away from simply treating the symptoms and working towards finding the movement impairment leading to the low back pain.  Sure, using something like a TENS device may have a role to neuromodulate pain, but it is now common knowledge that the improvements seen are transient at best and not addressing the real dysfunction.

One area that has received a lot of attention, and rightfully so, is looking at limitations in hip mobility as a cause of low back pain.  Much of the research to date has focused on looking at the loss of hip external rotation and internal rotation mobility.  In fact, I have an older article on the correlation between hip mobility and low back pain.

I can say that my own ability to help people with low back pain has greatly improved as I’ve learned to focus on hip mobility over the years.

 

hip extension mobility low back painHip Mobility and Low Back Pain

A new study was recently published in the International Journal of Sports Physical Therapy that adds to our understanding of the influence of hip mobility on low back pain.  In the current study, the authors evaluated hip external rotation, internal rotation, and extension mobility in two groups of individuals, those with and without nonspecific low back pain.

While using a Thomas test to assess hip extension, the authors found the follow:

  • Hip extension in those with low back pain = -4.16 degrees
  • Hip extension in those without low back pain = 6.78 degrees

That’s a total loss of 10 degrees of hip extension in those with low back pain.

 

A Loss of Hip Extension Correlates to Low Back Pain

So now in addition to rotational loss of hip rotational mobility, it has been shown that a loss of hip extension correlates to low back pain.  To me, this has always been something I have focused on and makes perfect sense, especially as we age.

The vast majority of our society sits for the majority of the day and becomes less and less active as they age.  Among many things, this results in tight hip flexors and an anterior pelvic tilt posture.

Putting recreational activities like sports and running aside, this anterior pelvic tilt posture with tight hip flexors causes a loss of hip extension mobility and the low back tends to take the load but hyperextending.  This happens while simply walking and in a standing posture.

Think about the results above, people with low back pain have negative hip extension, meaning they can’t even extend to neutral!

As we all know, the human body is amazing and will compensate.  Hips don’t extend?  No problem, we’ll extend our spine more.

So a pretty easy step to take to reduce back pain is to work on hip extension mobility.

One drill that almost everyone that trains at Champion PT and Performance gets is what I named the “True Hip Flexor Stretch.”  I’ve talked about it at length in past articles, but I am a believer that most of our hip flexor stretches commonly performed in the fitness world are disadvantageous and not actually stretching what we want to stretch.

The True Hip Flexor Stretch is a great place to start to work on hip extension mobility:

As you can see (and feel), this gets a great stretch on your hip flexors without causing any compensatory low back extension.  And by focusing on posterior pelvic tilt, we gear this towards those with a lot of anterior pelvic tilt.

 

I really believe that the “True Hip Flexor Stretch” is one of the most important stretches you should be performing.  [Click to Tweet]

 

Next, Focus on Reducing Anterior Pelvic Tilt in People with Low Back Pain

Updated Strategies on Anterior Pelvic TiltI’m not a big believer that static posture is the most important thing we should all be focusing on when outline our treatment and fitness programs, but it’s a start.  Someone in an anterior pelvic tilt static posture isn’t always evil, and can be the result of many things such as poor core control, poor mobility, and even excessive weight.  I tend to care more about how well people move.

But based on the current evidence, it’s a great place to start.

Once you’ve started to gain some hip mobility, there is a ton more work to do.  We also have to work on glute and core control, among other things.  If you’re interested in learning more, I have a hugely popular Inner Circle webinar on my treatment strategies for anterior pelvic tilt that goes into detail on what I recommend:

 

In summary, we now have a nice study that shows people with low back pain have 10 degrees less hip extension that those without.  This makes sense, and focusing on hip extension should be one of the key components of any low back pain program.

 

 

Training Rotational Power in Athletes

Training Rotational Power in AthletesSeveral weeks ago I was in San Francisco and stopped by TRX to see my friends Brian Bettendorf and Pete Holman.  We had a great time sharing thoughts and exercise techniques.

 

TRX Rip Trainer

Pete Holman is the Director of Rip Training at TRX and original creator of the Rip Trainer.   Many are familiar with the TRX Suspension System but TRX also has the newer Rip Trainer device that I have been using a ton.  I’ve shown some exercises that I have incorporated into my programs using the TRX Rip Trainer during presentations, but Pete really takes it to the next level.  His enthusiasm is contagious and his ability to educate is fantastic.  I asked Pete if we could “bottle” some of his thoughts to include as webinars over at RehabWebinars.com.

Pete came through in a big way and sent me three fantastic webinars that were posted over at RehabWebinars.com last week:

  • Training Rotational Power in Athletes
  • The Pitchfork Exercise for the Posterior Chain
  • Shoulder Prehab Exercises for Athletes

The webinars came out so great that I couldn’t resist sharing one of them here with my readers.  Below is Pete’s webinar on Training Rotational Power in Athletes.  Pete discusses the biomechanics and anatomical considerations of transverse plane training, demonstrating several techniques using the TRX Rip Trainer.

I love using the Rip Trainer because it really helps incorporate multiple planes of motion into our exercise techniques.  This 3D muscle training is something I have been preaching in my Inner Circle webinars lately.  As basic as a device this seems, you absolutely need to use it to see the many benefits.  I know just from hanging out with Pete for a day, I have learned many new uses and will continue to learn more.  There are a ton of rehab, fitness, and performance uses.

 

Training Rotation Power in Athletes

These are just a small handful of exercises you can use the TRX Rip Trainer for when designing rotational power programs.  I’ll try to keep trying to share what exercises I come up with, but I want to hear what you think.  Have you used the TRX Rip Trainer and if so what do you like to perform with the device?  If you haven’t checked them out yet, pick up a TRX Rip Trainer.

TRX Rip Trainer

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The Influence of Pelvic Position on Lower Extremity Stretching

Inner Circle Premium Content

The latest webinar recording for Inner Circle members is now available below.

 

The Influence of Pelvic Position of Lower Extremity Stretching

The below webinar will help you understand:

  • Why lower extremity stretching is essentially flawed
  • Why we aren’t always in neutral position or symmetrical
  • The influence of pelvic tilt on pelvic position
  • Simple assessments to see if you are “neutral”
  • How to adjust stretches to assure proper form and alignment
  • How to individualize lower extremity stretching based on pelvic alignment
  • What to avoid while stretching to maximize movement quality

 

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

 

Assessing the Sacroiliac Joint: The Best Tests for SI Joint Pain

SI JointThe sacroilliac joint, or SI joint, is one of those challenging areas of the body that we all have to deal with from time to time.  When I learned how to assess the SI joint, I know that I felt like I didn’t have a firm grasp on the best way to test for SI joint pain.  Many of the commonly performed assessments for SI joint pain seemed to not be very reliable and sometimes not even valid.

So treatment almost sometimes became taking a shot in the dark as I never truely felt confident in my exam findings.  This led me to perform treatments and progressions of patients based on trial and error rather than because of exam findings.  (Photo from Wikipedia)

Assessing the Sacroiliac Joint

Treating this way, to me, is a huge pet peeve, so I started to research the area to gain more comfort in my SI joint examination.  I found some interesting research regarding palpation, SI joint motion, and provocative testing.  Here are some of the things that I found along that way that really helped me get better at diagnosing SI joint pain, hope it helps you too.

Palpating the SI Joint

One of the simplest methods of assess the SI joint is palpation.  However, the reliability and validity of palpating the SI joint has come into question in recent years.  Several studies have been published showing poor inter-tester reliability for static SI joint palpation, including a nice study from Holgren and Waling.

McGrath has published an interesting article, entitled “Palpation of the sacroiliac joint: an anatomical and sensory challenge” in which the concept of SI joint palpation is scrutinized.  It is an interesting paper, that certainly makes you think.  In the paper, the author describes the several layers of tissue that sit between the skin and the posterior SI joint, which is 5-7cm deep to the skin, and the inherent challenge of both reliability and validity of palpating something so deep.

Assessing SI Joint Motion and Symmetry

Assessing the amount of SI joint motion and the symmetry of the SI joint itself is a very commonly performed technique during SI joint examination.  This method of examining the SI joint is popular and accepted, despite the lack of research supporting the technique.

Based on the above information regarding palpating the SI joint, one would question the ability to palpate AND now accurately assess motion in addition.  If palpation has poor reliability, this automatically makes assessing motion difficult.

Freburger and Riddle performed a literature review looking at our ability to perform SI joint motion testing.  They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed tests.  This is a particularly interesting article to read if you have interest in this area.

Another study from Robinson et al had similar conclusions, stating that SI joint motion palpation tests have poor inter-tester reliability.

Riddle and Freburger in another study noted that the ability to detect positional faults of the SI joint also has poor reliability.

Thus it appears that the reliability and validity of assessing SI joint symmetry and motion may be too poor to be used clinically.  The amount of motion of the SI joint motion is extremely small, perhaps less than 2mm and 2 degrees of translation and rotation.  This makes detecting patholgoical movement extremely challenging.

However, I still think symmetry and motion assessment may be a valuable component of the SI joint examination in the case of significant malalignment and pathology, and still should be assessed.  Just realize that you are looking to “rule in” more significant pathology.  I would not “rule out” SI joint dysfunction based solely on symmetry and motion assessment.

Location of SI Joint Symptoms

Van der Wurf et al (2006) published an interesting study looking at the location of symptoms reported in patients with SI joint pain and dysfunction.  In the study, the authors performed local SI joint injections to block the patients’ pain.  The authors found that:

  • All subjects that responded to the SI joint block had symptoms located at the Fortin area (3cm horizontally by 10 cm vertically inferior to the PSIS)
  • All subjects that did NOT respond to the SI joint block had symptoms at the Tuber area (just inferolateral to the ischial tuberosity)

Again, I wouldn’t rule in or rule out SI joint dysfunction based on this alone, but it appears that if you DO have pain at the Fortin area AND do NOT have pain at the Tuber Area, you may be experiencing SI joint pain.

SI Joint Provocative Tests

Two recent studies by Laslett et al and Van der Wurff et al have demonstrated that there probably isn’t one perfect SI joint provocative test that we can perform to definitively diagnose SI joint pain or dysfunction.  Basically, there is no “gold standard” such as using the Lachman test for ACL tears in the knee.

However, by performing several tests together, you can increase your sensitivity and specificity of detecting SI joint dysfunction.

Combining the two studies, there are 5 provocative tests to perform when attempting to diagnose SI joint pain:

  1. Gaenslen
  2. FABER / Patrick’s test
  3. Thigh thrust / femoral shear test
  4. ASIS distraction (supine)
  5. Sacral compression (sidelying)

Laslett et al report that the accuracy of detecting SI joint dysfunction is increased with at least 3 of the 5 tests are positive.  Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint.  Van der Wurff et al report that if at least 3/5 of these tests were positive, there was 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain.  Interestingly, another study by Kokmeyer et al agreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire serious performed together.

It seems like performing a series of provactive SI joint tests is better than one true test in isolation, though I would specifically emphasize the thigh thrust test.  In my experience, you have to use a decent amount of force during the thigh thrust technique to avoid missing a positive provactive sign.

In an attempt to find good demonstration videos on youtube of these techniques, I came across Harrison Vaughn’s excellent videos (I mentioned Harrison in the past and recommend you also check out his website).  Great job and thanks for sharing Harrison!  These are the tests recommended by the above authors to use together:

Gaenslen Test

FABER / Patrick Test

Thigh Thrust / Femoral Shear Test

ASIS Distraction

Sacral Compression

 

The Best Tests for SI Joint Pain

I will admit that I am not a SI joint expert, so I am interested in hearing the opinion of my readers that deal with a lot of SI joint dysfunction.  It appears that palpation, symmetry, and motion testing of the SI joint may have concerns in regard to reliability and validity.

Some things to keep in mind when assess the sacroiliac joint:

  • It is difficult to palpate the deep SI joint, making reliability and validity challenging
  • The reliability of assessing symmetry, SI joint motion, and SI joint position also has poor reliability
  • Pain along the Fortin Area without pain in the Tuber Area may indicate SI joint pain
  • A series of provocative SI joint tests yields better results that performing tests in isolation, with at least 3/5 positive tests demonstrating the highest accuracy of detecting SI joint dysfunction

Based on some of the research above, we should all consider the location of symptoms and a series of provocative testing when attempting assessing the sacroilliac joint and diagnosis SI joint pain and dysfunction.

 

Breathing and Low Back Pain: Is There a Correlation?

Breathing and Low Back PainAs our knowledge of the core and proper lumbopelvic stabilization continues to improve, our understanding of  the diaphragm’s function as a postural muscle continues to improve as well.  We know that as the diaphragm contracts during inspiration, intra-abdominal pressure increases, and lumbar spine stiffness is increased.  During activities the diaphragm acts in coordination with the abdominal muscles, spinal muscles, and pelvic floor to create lumbar stability in all directions.  This is what Stuart McGill refers to as “360 degree stiffness.”

Individuals with Low Back Pain Breathe Differently While Lifting

A recent study publish in JOSPT sought to assess if people with back pain breathe differently when trying to lift an object.  The examiners looked at 32 subjects with chronic, nonspecific low back pain for at least 1 year and compared their breathing performance to a group of 30 healthy controls.

Results of the study revealed that individuals with low back pain lifted objects with 7.2% more air in their lungs than healthy individuals.

Several studies have shown that increases in inspired lung volume correlate to increases in intra-abdominal pressure and subsequent increase in lumbar spine stability.  The results of this study are interesting.  My first thought was that the study was going to show the exact opposite – that individuals with low back pain would have LESS air in their lungs, thus making the diaphragm less effective at stabilizing the lumbar spine.

This could be a protective mechanism in the subjects with low back pain.  They could be breathing this way as a compensatory mechanism to assist the other core musculature that may be performing poorly.  We are unable to know exactly why this difference exists and wether or not it is causative or compensatory.

However, if we dig a little deeper into the results of the study, another interesting finding emerges.  Not only do individuals with low back pain have a different amount of inspired air in their lungs, they also breathe differently during the task.

Individuals with low back pain took a deeper breathe at the start of the lift then rapidly exhaled, while the healthy subjects began with less inspired air but inhaled slightly during the lift.  This perhaps may have a bigger impact on low back pain.  Nevertheless, interesting results that may indicate that educating people how to breathe during lifting tasks is an important part of postural and ergonomic education.

Breathing and Low Back Pain

There are obvious implications for the strength and fitness group, but often overlooked in the rehabilitation community.  Perhaps we need to be educating proper breathing during our exercises and functional movements more during the rehabilitation process as well?  This is something that Eric Cressey and I discuss in our Functional Stability Training of the Core program.  One potential way to incorporate this concept is to use breathing rather than seconds when we perform timed exercises.  What do you think?  How does this study change the way you think about breathing and low back pain?

Functional Assessment and Exercises to Enhance Hip Flexion

Last week, Chris Johnson wrote a nice guest post on the importance of hip flexion strength.  I received a lot of questions about what to do next, how to strengthen, and how to assess functionally.  I wanted to add to the discussion a little bit and talk about more than just the assessment of static hip flexion strength.  As Chris points out, we still may be missing the boat on assessing hip flexion strength.  The research certainly supports it.  Many of us tend to focus on Janda’s lower cross syndrome and assume that the hip flexor group is chronically shortened and needs to be inhibited, while we focus on the abs and glutes for motor control.

 

Hip Flexor Muscles

In my experience, a tight or shortened muscle group does not always have to mean that the muscle group is strong and does not need strengthening.  But by all means, if you are going to focus on hip flexion strengthening, you have to also assure that mobility is optimal.

I also think that another important concept to consider is that sometimes a lack of hip flexion strength can be due to poor movement patterns and compensation.  There are many muscles that help flex the hip to some extent (sartorius, TFL, rectus femoris, pectineus, adductor longus, adductor brevis, gracilis, and even the back extensors are agonists with the hip flexors).  Sometimes our postural habits, such as seen with the lower body cross syndrome, can alter our normal muscle firing.  In this example, the psoas is at a disadvantage in the shortened position with an anterior pelvic tilt.  This ultimately results in the body using secondary hip flexors to achieve the hip flexion motion, either due to alignment issues or inhibition.

 

Functional Assessment of Hip Flexion

So to piggy back on Chris’s excellent article and recommendation to test hip flexion strength, I would add that we also test functional movement patterns into hip flexion.  The hurdle step of the FMS would do this well, and compensatory patterns seen may indicate deficiencies with hip flexion.  The hurdle step takes a good look at the hip flexion movement pattern, but since it doesn’t require the person to maximally flex their hip, it isn’t always specific to the psoas.  Using Chris’s demonstration of a hip flexion strength assessment in the seated position is a good adjunct test to perform, as the psoas is needed to flex the hip past 90 degrees in the seated position.

FMS Hurdle Step

 

Michael Boyle also often mentions a quick assessment that he does that tests the ability to hold your leg in hip flexion.  In this assessment, you passively raise the hip into flexion and then let go, trying to keep the hip flexed.  It’s harder than it looks for some people, especially those with inhibited psoas function.  Here are a couple of a quick video clips of two different demonstrations of the technique (sorry, filmed an impromptu clip of this at the home office, where the magic happens…).  In the first example, notice the difference in height of the leg on the left and right:

Did you notice that the right leg flexes much more than the left?  This is actually a demonstration of a compensation pattern.  Notice on the right that he lets his pelvis tilt posteriorly and his lumbar spine flex, which looks like a false amount of hip flexion mobility.  On the left, he is cued to not allow lumber motion and his true mobility is revealed.

In the second clip, I’m a good example because I have some deficits.  I consider no drop to be perfect, a mild drop but still able to keep the knee above 90 degrees to be a mild deficit (like me in the video), and the leg dropping to 90 degrees or below to be a problem.  As with any test involving hip flexion, again, be careful not to posteriorly tilt the pelvis and flex the spine.

Exercises to Enhance Hip Flexion

I don’t think it is rocket science to show many of the common hip flexion strengthening exercises, though I would add that the most important aspects of the exercise needs to be lumbopelvic control and flexion past 90 degrees.  We need to train hip flexion without compensatory patterns at the spine and contralateral pelvis.

That being said, there are a few drills that I have used over the years that I think tend to help.  The first is a simple resistance band drill that involves laying on your back with a resistance band around your ankles.  This is a popular drill with many of the strength coaches that I have worked with but also works well for the rehab patient.  I know Michael Boyle talks about this in his sports hernia talks.

In this drill, it is easy to just focus on contralateral leg extension, but that isn’t the real goal of the drill.  The main goal is to drive into hip flexion and maintain.  I like this drill because it works on hip flexion drive as well as disassociating the two hips.  This exercise can be progressed and there are several similar drills in other positions, but I like to start supine as it helps keep the spine stabilized.  Like anything else, an abdominal brace with neutral spine is a must.

Another technique I like to work towards is incorporating hip flexion drive into other exercises.  Here is an example of incorporating hip flexion drive into a walking lunge.

Why do I like this type of exercise?  The lunge (especially when using ipsilateral weights like I do in the video) incorporates glute and quadratus activity into a quad exercise.  As these muscles contract to switch the leg into mid stance and stabilize the spine, adding a hip flexion drive again works on disassociating the two sides of the pelvis.

Again, this isn’t rocket science, especially to the strength community, but some rehab specialists don’t always have this train of thought.  So don’t forget to assess functional hip flexion ability and to incorporate some of these hip flexion exercises into your programs.

The Importance of Hip Flexion Strength

Today’s post is a guest article written by Chris Johnson on the the importance of hip flexion strength when dealing with lower extremity pathology.

 

The Importance of Seated Hip Flexion Strength

Just over eight years ago, I accepted my first job as a physical therapist at the Nicholas Institute of Sports Medicine and Athletic Trauma (NISMAT) of Lenox Hill Hospital. This experience afforded me the opportunity to train under the late Dr. James A Nicholas, one of the “Founding Fathers” of sports medicine, and the winner of the 2004 President’s Cup award from the Sports Section of the American Physical Therapy Association (APTA). One of the greatest lessons I learned from Dr. Nicholas pertained to “linkage” and the importance of assessing seated hip flexion strength in patients presenting with lower extremity pathology, especially patellofemoral pain syndrome (PFPS).

In 1976, Dr. Nicholas and colleagues published an article in The American Journal of Sports Medicine entitled, “A study of thigh muscle weakness in different pathological states of the lower extremity.” This study documented that subjects with patellofemoral problems exhibited significant hip flexor weakness on the involved side when compared to a group of controls. Furthermore, Dr. Nicholas and his co-authors concluded that the hip flexor resistance test affords a quick and accurate way of detecting unilateral weakness of the trunk, thigh flexors, and quadriceps group making it a valuable clinical assessment tool.

More recently (2006), Tim Tyler and colleagues did a study investigating the role of hip muscle function in the treatment of PFPS. This study corroborated Dr. Nicholas’s original findings and demonstrated the importance of addressing hip flexor strength in the context of PFPS. The authors proposed that improving hip flexor strength helps to establish a stable pelvis during gait thus preventing it from going into excessive anterior tilt, which would result in excessive femoral internal rotation. The iliopsoas is also a secondary femoral external rotator and strengthening this muscle helps to align the trochlear groove and patella. It should also be mentioned that this study documented the importance of establishing adequate flexibility of the hip flexors and iliotibial band (ITB), which would induce posterior pelvic tilt and relative femoral external rotation. One of the major takeaways from this article is that in addition to resolving any hip flexor tightness, it is also important to ensure adequate strength of this muscle group.

 

Assessing Hip Flexion Strength

While clinicians and fitness professionals routinely assess for and correct hip flexor tightness, it has been my experience that screening for hip flexor weakness in a seated position is not routinely performed. Considering the research, medical and allied health professionals should include this as part of their screening or examination process, especially in the context of lower extremity pathology such as PFPS. To perform this test, the patient should be seated at the edge of a table or plinth with their back straight and legs dangling over the edge of the table while holding on to the front of the table. The patient is then instructed to flex one hip by bringing the knee up towards the chest and to hold it in place while the examiner pushes down on the thigh with the palm of his or her hand. Comparison is then made to the contralateral side. It is the author’s opinions that break testing is the best approach to strength test the hip flexors given the limited range available in a seated position. Standard manual muscle testing grades can be applied or clinicians can use a handheld dynamometer/manual muscle tester to establish a more specific strength index.

When assessing seated hip flexion strength, there are several key to ensure the test is properly performed. First off, patients should have 120 degrees of clean hip flexion so that they can get the involved extremity in to the proper test position without any compensatory motion. Secondly, patients should hold on the front of the plinth to prevent leaning back, which is a common substitution or trick movement when testing hip flexor strength. This will allow the examiner to isolate the hip flexor muscle group as well, thereby ensuring accurate results. Lastly, pay close attention to the low back during testing as patients presenting with hip flexor weakness often fall into excessive anterior pelvic tilt secondary to poor spinal stability, which can result in shearing of the lumbar segments. This may also indicate the need to incorporate spinal stabilization exercises in to the overall treatment program.  Here is a quick video demonstration:

 

Next time you find yourself evaluating or treating a patient suffering from a lower extremity injury, make sure to test their seated hip flexion strength, especially in the context of PFPS.  And remember that it is not only important for the hip flexors to be extensible but also for them to be STRONG, and without assign hip flexion strength you’ll never know!

 

References:

  1. Nicholas JA, Strizak AM, Veras G. A study of thigh muscle weakness in different pathological states of the lower extremity. Am J Sports Med. 1976 Nov-Dec:4: 241-8.
  2. Tyler TF, Nicholas SJ, Mullaney MJ, McHugh MP. The role of hip muscle function in the treatment of patellofemoral pain syndrome. Am J Sports Med. 2006 Apr; 34(4): 630-6.

 

About the Author

Chris Johnson, MPT, MCMT, ITCA is a physical therapist and competititive triathlete.  He has a private physical therapy practice in Manhattan.  Youcan learn more from Chris at his website ChrisJohnsonPT.com and Twitter.

Chris has a great website that has a lot of information, especially in regard to running and triathlons.  Thanks for such a great article on the importance of hip flexion strength!

 

 

 

Thoracolumbar Fascia – An Area Rich with Activity

Today’s guest post is about the thoracolumbar fascia from Patrick Ward.  I have been reading Patrick’s website for a while now and have always been impressed his content, but he also has the ability to write and communicate in a fashion that fosters thought and learning.  I have been talking with him for months about sending me a guest post, so I am happy to finally have one, thanks Patrick!

Thoracolumbar fascia: An area rich with activity 

The thoracolumbar fascia can be thought of as a transitional area between the lower extremity and the upper extremity where forces are transferred in athletic and sporting movement.  For this reason, the thoracolumbar fascia plays an integral role in the movement system of the body as it connects many joint systems – hips, pelvis, lumbar spine, and thoracic spine.   Also, considering that the latissimus dorsi has attachments onto the thoracolumbar fascia and inserts onto the lesser tubercle of the humerus, the glenohumeral joint can also be thought of as ‘connected’ with the thoracolumbar fascia.  Additionally, the cervical fascia and the thoracolumbar fascia are continuous, so this fascial structures effect can be seen into the cervical and potentially even the cranial regions.

For this reason, the thoracolumbar fascia can be an important area for treatment both in instances of injury/pathology or when developing a recovery/regeneration treatment protocol for certain athletes.

 

Three layers of Thoracolumbar Fascia

Thoracolumbar FasciaThe thoracolumbar fascia can be thought of as having three layers which help to separate the muscles in this region into compartments:

  • Anterior layer – Attaching to the anterior aspect of the lumbar transverse processes and the anterior surface of the quadratus lumborum.
  • Middle layer – Attaching to the medial tip of the transverse processes and giving rise to the transverse abdominus
  • Posterior layer – Covering all of the muscles from the lumbosacral region through the thoracic region as far up as the splenii attachments.  Additionally, this posterior layer attaches to both the erector spinae and gluteus maximus aponeurosis.  It is in this posterior layer that the gluteus maximus and contralateral latissimus dorsi attach with each other and coordinate together to allow for pendulum like movements between the upper and lower extremity that make walking and running possible.

 

Together, the muscles that connect into the three layers of the thoracolumbar fascia help to provide both a stabilizing and biomechanical role for the body.  Additionally, the vast amount of mechanoreceptors in this region hint to the importance of the thoracolumbar fascia’s sensory role, making it a potentially rich target for hands on therapy.

Photo from Wikipedia

 

A Stabilizing Role 

The transverse abdominus, internal oblique, and quadratus lumborum all invest themselves into portions of the thoracolumbar fascia.  According to Neumann (2010), the transverse abdominus provides anticipatory/feed-forward stabilization of the lumbo-pelvic region via a tensioning of the thoracolumbar fascia and an increase in intrabdominal pressure.  The connection that the thoracolumbar fascia has with the posterior ligaments of the lumbar spine allows it to assist in supporting the vertebral column when it is flexed by developing fascial tension that helps control the abdominal wall (Gracovetsky, 1981) and it may also provide some sensory function to the body aid in both postural and protective reflex activity (Yahia, et al., 1992).

The biomechanical role of the thoracolumbar fascia is generally understood by individuals in the strength and conditioning and rehabilitation professions.  Exercise programs or “core training” programs are typically designed to elicit some sort of stabilization activity to the muscles in this region.  However, insight into the myofibroblasts and mechanoreceptors of the thoracolumbar fascia may require us to look a bit deeper if we wish to make larger changes to the function of the human body.

 

Myofibroblasts

Myofibroblasts are cells that have a sort of dual function, being part fibroblast and part smooth muscle.  It is because of these smooth muscle properties that the myofibroblasts can contract on their own – like other smooth muscles cells – placing them under the control of the autonomic nervous system and allowing the autonomic nervous system to potentially regulate fascial pre-tension independently of muscular tone.  Thus, the fascial system is an adapting organ which almost has a “life of its own.” 

Schleip and colleagues (2006) showed that the lumbar fascia, via its myofibroblasts, has the ability to contract in situations of either chronic tissue contractures, such as tissue remodeling, or during more smooth muscle-like contractions, which may help to influence low-back stability.  Furthermore, Yahia et al. (1993) showed that the thoracolumbar fascia had the ability to spontaneously contract when the tissue was stretched and held at a constant length repeatedly, causing the fascia to slowly begin to increase resistance.  This information could be potentially beneficial in understanding pathologies where increased myofascial stiffness is present.  However, influencing the system to make a change in this stiffness is a more difficult question.

 

Does it Come Back to Breathing?

Given the smooth muscle properties and the control that the autonomic nervous system may have over the fascial network, perhaps a potential window into effectively dealing with increased myofascial tone can circle around to breathing.

Respiratory function is on aspect of the autonomic nervous system that we actually have direct control over.  We can change our breathing and help to elicit a parasympathetic response to allow for greater relaxation and potentially less overall tissue tone/tension, hopefully leading to more of a comfortable state of being a decreased threat perception.  Additionally, the role of the diaphragm in stabilizing the lumbar region cannot be overlooked and the fact that it shares a fascial connection with the quadratus lumborum (as well as the psoas major) and the transverse abdominus fibers invest themselves into part of the diaphragm means that the diaphragm is in a potentially prime position to have an influence over the thoracolumbar fascia, since both of these muscles invest into layers of that fascial structure.

 

Manual Therapy of the Thoracolumbar Fascia

The thoracolumbar fascia is richly innervated with mechanoreceptors providing it with a strong sensory role and making it a target for manual therapy.

There are many ways to address the body with manual/touch therapy.  The idea of treating “fascia” has been a hot topic as of late and oftentimes therapists are doing similar things however explaining them in different ways, leading to large semantics debates.  With regard to treating fascia I believe that it is important to not leave out the nervous system, as the goal of any manual hands on treatment is to somehow effect the brain to create an environment that is ripe for healing – one which decreases overall threat perception, decreases fear avoidance, and opens a window for the individual to perform some sort of non-painful movement that increases confidence, and create relaxation (again, helping to achieve a parasympathetic response).

Several types of receptors have been found in connective tissue (not just the thoracolumbar fascia) such as pacini and paciniform corpuscles, ruffini organs, interstitial receptors, and golgi receptors.  Different receptors are responsive to different sorts of techniques and forms of therapy.  For example, pacini receptors are responsive to pressure changes and vibrations, while ruffini receptors are responsive to sustained pressure and tangential forces such as a lateral stretch.

 

Practical Applications

The thoracolumbar fascia plays an important role in human movement as it not only serves as an attachment site for numerous muscles in the lumbar, thoracic, and sacral regions, but also is an important area of transition between the upper and lower extremities where forces are transferred to allow for coordinated function.

Understanding the implications that the thoracolumbar fascia has over the body will help therapists to develop both exercise programs and manual therapy/hands on treatment programs for either rehabilitation or recovery (to help increase relaxation in this area between competitions and prevent overuse or excessive strain which is common in sport).

The smooth muscle properties of the thoracolumbar fascia (and all fascia of the body) indicate a potential role of the autonomic nervous system in regulating fascial tone.  For this reason, understanding the individual athlete and levels of stress as well as their individual stress resistance can be helpful in managing overall fascial tension.  The pH of the body plays an important role in fascial tension, as greater levels of alkalinity create vasoconstriction and increased muscle tone.  The pH of the body can be influenced by increased levels of threat and changes in breathing, which cause alterations in expired CO2.  Thus, breathing, relaxation, and/or meditation, may be potential ways in which the fascial system can be influenced in a training or therapy session.  Managing stress using a variety of recovery modalities in between competitions can be help to keep athletes healthy and performing well.

Finally, the high number of mechanoreceptors found in the thoracolumbar fascia (and in all fascia) indicate that the fascial system provides an important sensory role for the body.  Various manual/hands on therapies can be utilized to influence the sensory system (and the brain) to help decrease tone/tension, improve proprioception and awareness to the area being treated, decrease threat perception, increase relaxation, and provide a window into the parasympathetic nervous system which can potentially create an optimal environment for healing.

Taking all of this into consideration, when assessing an athlete it is important to look at the entire body and keep in mind that the thoracolumbar fascia shares a connection with many structures and its influence can be seen as far up as the cervical region and into the extremities.  With that in mind the thoracolumbar fascia may be a potential area for therapy when attempting to influence other parts of the body.

 

About the Author

Patrick WardPatrick Ward, MS, CSCS, LMT is a certified strength and conditioning specialist and licensed massage therapist.  He owns Optimum Sports Performance (www.optimumsportsperformance.com), a sports conditioning and soft tissue therapy company which provides training, treatment, and consulting to professional, amateur, and high school athletes.  He writes excellent articles on his website OptimumSportsPerformance.com.

 

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