Ok Here it is Finally.... a variety of issues kept me off the computer last week but here is the article promised.
Let’s talk about the lumbo-pelvic-femoral system.
Pelvic alignment is the keystone to correct alignment of the rest of the frame. Without pelvic alignment and even more important, stability, you simply cannot correct either up or down the chain. I have seen this demonstrated over and over in the clinic with patients having complaints as wide ranging as neck pain to plantar fasciitis. Patients will do ok with traditional therapy techniques but often times come back or never fully get back to 100% until we start looking at the pelvis and alignment/stability thereof.
There are three key anatomical structures that we must look at when determining pelvic alignment and stability: the inominants or iliac bones and their influence on the SI Joint, the AF Joint (Acetabular-Femoral), and the lower lumbar spine itself. There are a variety of common complaints associated with these structures that are directly related to misalignment. To name a few: SI joint Dysfunction with associated back pain, Sciatica, some forms of Spinal Stenosis, Degenerative Disk disease, degenerative joint disease, Snapping hip syndrome, piriformis syndrome, Patella/femoral syndrome... the list goes on. According to Ron Hruska of the Postural restoration institute, the most common misalignment problem encountered in the clinic stems from a functional patterned instability of what we call The Left AIC (the Left Anterior Interior Chain). The Anterior-interior chain consists of: Two tracts of Muscles, one on the left side of the interior thoraco-abdominal-pelvic cavity and one on the right, muscular structures include: the Diaphragm, psoas, iliacus, tensor fascia latae, biceps femoris and vastus lateralis. This group of muscles provide support and anchor for abdominal counterforce, trunk rotation and flexion1 This patterned misalignment results in the following anatomical misalignments: anterior tilted pelvis in either the hemi pelvis or bilaterally, a varying degree of habitual pelvic rotation, usually to the right (clockwise), excessive right AF joint internal rotation and left AF joint external rotation, rotation of the lower lumbar spine often in the opposing direction. This pattern is considered multidirectional do to its sagital and oblique influences. This pattern results in habitual compensatory movement strategies. These compensatory movement strategies may manifest in the following joint movement deficits: excessive lumbar lordosis locking the facet joints and limiting rotational movement of the lumbar spine and placing excess stress on the lumbar disks,
decreased right hip extension, poor adduction of both hips with the left hip being worse than the right, sacral torsion with associated Sacroiliac joint dysfunction, mal-alignment of the iliac bones resulting in an apparent ( false )leg length difference.
There are a number of variations of this pattern that people can present with in the clinical setting, quite often I meet people who have let their pain go on for too long and have developed compensatory movement strategies that leave them bilaterally symptomatic. With this in mind, we often have to try and put the fire out, so to speak,
Before we can do any real investigating into what the underlying problem is. Usually however, a weakness in one or more of the following areas is associated with most patients’ lumbo-sacral-femoral pain: glutes, both maximus and medius, hamstrings, abdominals and IC (Iscio-Condylar) adductors. Let’s talk about each of these areas in order to better understand their job duties and purpose.
GLUTES-
Gluteus Maximus is primarily known as a hip extender and external rotator. The attachment points or insertion/origin of the glute-max is from, the lateral border of the sacrum, the lateral face of the PSIS (posterior superior iliac spine) and the femur directly below the anatomical neck of the femur as well as fibers running to the Illio-tibial band. It has the following duties: creates extension of the femur within the Acetabulum. It also “compresses the femur into the acetabulum” creating AF joint stability. It also approximates the Sacrum to the innominant i.e. iliac bone. It’s purposeful chain of cause and effect goes like this: Sacrum to innominant-sacrum to femur- femur to acetabulum.
Gluteus Medius- Primarily known as a hip abductor and lateral pelvic stabilizer. The attachment points for it are at the lateral upper third of the iliac bone and the later surface of the Greater Trochanter. It performs the following duties: In open chain- abduction of the femur on the acetabulum. In closed chain- approximates or pulls the acetabulum onto the femur again stabilizing the AF joint and providing joint stability. It is also responsible for elevation of the opposing pelvic crest during gait. The anterior fibers of the glute-medius also internally rotate the femur on the acetabulum.
Gluteus Minimus- An internal rotator of the femur on the acetabulum. Attachment of the glute-minimus is from the anterior third of the lateral and middle third of the innominant bone to the anterior Greater Trochanter of the femur
ABDOMINALS-
An extremely important and complex area, the abdominals perform a variety of functions. I am going to restrain myself from attempting to list the numerous functional duties at this time for fear that I would forget something important. Instead we are going to focus on the duties of the abdominals relevant to pelvic stability. The abdominal complex is made up of fibers running both sagitally (forward and back), frontally (side to side) and obliquely. These fibers are known as: abdominus rectus, external and internal obliques and transverse abdominus. Collectively they provide stability to the trunk as well as stability to the lumbar spine and lower ribs creating counter force and opposition to the diaphragm. They also assist with support to the internal organs through maintaining intra-abdominal pressure assisting with peristalsis and elimination of waste. They also provide support for the anterior pelvic rim and maintenance of neutral pelvic rotation in the sagital plane. How many times have we all seen someone with a distended abdomen due to stretched out abdominals also demonstrating excessive lumbar curvature and complaining of back pain? I have read studies in the past that have concluded that most patients seen in the therapy clinic with a diagnosis of “low back pain” DO NOT NECESSARILY HAVE A WEAK BACK! Their pain can instead be related to a dysfunctional transverse abdominus which no longer contracts to provide compression of the abdominal contents and stability to the lumbar spine but instead it functions only in an eccentric manner providing a rigid but distended wall which utilizes surface tension in the expanded and rigid muscle fibers to assist with lifting pushing and pulling activities. The next time you attempt to lift a heavy object or push or pull a similarly heavy object pay attention to how you breathe. Do you inhale sharply and then hold your breath in an attempt to “brace yourself” for the task? Or do you “exhale with exertion” utilizing a much safer and preferred abdominal contraction to engage all the core muscles for support.
HAMSTRINGS-
The hamstrings consist of the: Biceps Femoris, semitendinosis and semimembrinosus. The hamstrings are known primarily as flexors of the knee they also act as extensors of the hip in closed chain and stabilizers of the knee for gait activities. They can also play a role in external and internal rotation of the femur depending on position. It is in the closed chain (feet planted on a surface) that they also become stabilizers as well as primary posterior rotators of the pelvis. With a large portion of low back pain complaints demonstrating excessive lumbar lordotic curvature and accompanying anterior pelvic tilt of either one or both of the iliac bones, positional strengthening of the hamstrings becomes a primary focus in achieving a neutrally rotated pelvis with respect to it’s sagital alignment. Isometric contractions of the hamstrings in the 90/90 position re used to positionaly strengthen the hammy’s for pelvic stability.
ADDUCTORS-
For our purposes here we are only concerned with that portion of the adductors, Adductor Magnus in particular, that we will refer to as the IC adductor the IC adductor is that portion of the Adductor Magnus that runs from the medial portion of the Ischial Tuberosity and run to the medial condyle at the adductor tubercle. This portion of the Adductor Magnus is part of what is sometimes known as the “hamstring portion of the Adductor Magnus2. This portion of the adductor is primarily an internal rotator. An important part of the“pelvic repositioning” protocol is utilization of what is known as Left AFIR (Acetabular-Femoral Internal Rotation) positioning. It is the last key in re-establishing normal closed chain functional movement in the pelvic-femoral part of the lumbo-pelvic-femoral complex. Why is this important!? The million dollar question! Because Left AFIR is NECESSARY FOR NORMAL WALKING MECHNICS! And far too many of us (meaning all of humanity) spend way too much time bearing the majority of our weight on our right leg leading to an excessively tight left AF joint capsule and a stretched and unstable Right AF Joint Capsule. Think about this… How many Times a day do you stand on your Right leg and Reach into the fridge with your right hand or open your car door or your office door or the door to your home with your weight on your right leg and reaching with your right hand. How often do you stand around chatting with friends or co-workers with 70-80% of your weight shifted over your right side and your belly button over your right pinky toe? Or how about this watch other people without letting them realize you are paying attention to their movements see how often you catch them standing for lengths of time with their weight shifted almost exclusively to one side or the other (usually the right side). You may be in for a shock once you start keeping track of all the single leg standing you are doing in a day. Now keep in mind that shifting our weight back an forth from one side to the other is Not a pathological pattern and in fact is something I try to promote in the clinic, it is the habitual and excessive single leg standing that becomes a pattern early in life and results in adaptive shortening of the posterior joint capsule of the Left AF joint (usually) and the adaptive lengthening of the Right AF joint posterior capsule over time that lead to compensatory movement patterns. This in concert with adaptive shortening of the Hip Flexors including the Psoas, Iliacus and rectus Femoris as well as tensor fascia latae result in the pelvic misalignment patterns which can become pathological postural dysfunctions
If you have made it this far I would like to thank you for bearing with me and hopefully what I have put down here gives you some insight into how the glutes, hamstrings and adductors as well as the abdominal muscles influence Pelvis alignment as well as stability. I have not included any exercise information or pictures at this Time as I need to get permission from the Postural Restoration Institute to share some of their color images from the Pelvic repositioning protocol. The Black and white images I have at my disposal in an instructional manual do not scan well and would be virtually unusable as jpegs. In the meantime I will do my best to answer any questions regarding general pelvic stability issues. I unfortunately must avoid answering anything that might be misinterpreted as diagnosing a specific problem or as delivering a treatment as it could be considered practicing without a license depending on the state you are asking from
I will post specific exercise images when they become available to me. Thanks everyone
Blackwolf_101
Aka
Rich Artichoker
