doug keller - pelvic balance slides - part two

8/9/2019 Doug Keller - Pelvic Balance Slides - Part Two

1/41


2/41

Short Right Leg Syndrome

LR

Main Sources of Information concerning theShort Leg Syndrome: the chapter The Short

Right Leg Syndrome by Erik Dalton in his bookAdvanced Myoskeletal Techniques, second edition

2010,

and also his articles Treating Short Leg Syndromeand Leg Length Discrepancy (Parts 1 and 2)

published on his web site at

www.ErikDalton.com/media/published-articles.

2


3/41

Functional Leg Length Difference

There is not an actual difference in leg length

Instead one leg feels or acts as if it were shorter

3


4/41




The reasons for this are a combination of: Patterns of Rotation Compensatory Patterns of Rotation

possibly established by fetal positioning in the womb

4


5/41






Patterns of Side-Shifting of the Pelvis and weighting of thelegs

5


6/41






Patterns of Side-Shifting of the Pelvis and weighting of thelegs

Patterns of Side-Tilts and Rotations in the pelvis whichcause side-bends and rotations in the spine, ultimatelycontributing to a functional scoliosis

6


7/41


Compensations that the body makes to accommodate these patternscan lead to Decompensations or changes in and around the joints especially at key points in the spine with dysfunctions in

joints : damage to cartilage muscles : tensing of postural (tonic) muscles; and imbalances of

tension and weakness in larger movement (phasic) muscles nervous system : abnormal patterns of tension for holding

postural balance are written into the nervous system as normal.

7


8/41

Pelvic Rotations Contributing to a Functional Leg Length Difference:The primary cause in creating and perpetuating functional leg length differences is the rotationof the ilium on the sacrum often called iliosacral rotation or tilt.

Two Kinds of Rotation can take place in the pelvic girdle :

The hipbone rotates around the sacrum(Iliosacral tilt)

8


9/41


10/41

The Effect on the Musclesof Left Vestibular (Balance) Right Motor (Movement) Dominance

adductor

Iliopsoas:

psoas major

iliacus

TFL(tensor

fascia lata)

The bodys reaction to using the right leg for movement:

the bodys postural muscles on the right side , especially the hip exors and their synergistic stabilizers (adductors, TFL) react by tightening and shortening ,tilting the right hip bone forward .

10


11/41

adductor

Iliopsoas:

psoas major

iliacus

TFL(tensor

fascia lata)

this can exert a pull on the hamstring attachment (especially inforward bends)

weaken the piriformis (destabilizing the sacrum)

cause gluteus medius to be locked short , weakening its role asabductor/stabilizer for the hip, while inwardly rotating the thigh

gluteusmedius

piriformis

hamstringattachment


The bodys reaction to using the right leg for movement:

the bodys postural muscles on the right side , especially the hip exors and their synergistic stabilizers (adductors, TFL) react by tightening and shortening ,tilting the right hip bone forward .

11


12/41

The bodys reaction to using the left leg for balance: tightens the quadratus lumborum and iliocostalis on the left side tighten: which

rotates the left hip bone back and up (posterior/superior rotation) attens the lumbar curve on the left

quadratus lumborum iliocostalis


12


13/41

Summary on Functional Leg Length Difference:

Change the bodys habits from Shifting LeftUse weight-bearing one-legged balances to reduce our tendencies toward side-shifting

13


14/41

An indication that distortions in the pelvis come from our tendencies to side-shift:

Differences in the height orlevel of the hip points

disappear or shift signicantly when we check them while

reclining

If the imbalance remains the same, then the distortion is in the pelvis itself one of the causes of which may be a structural leg length difference

If the difference betweenhip points disappears, then the apparent leg length

difference is more likely tobe functional

14


15/4115


16/41

Hip Points In Tightening the Drawstring

The rst action takes place along lateral lines,and so it involves primarily the TransverseAbdominals at a level below the navel.

Zipping Up

The second action of toning and lift at the pitof the abdomen involves the combinedactions of Rectus Abdominis and the Internal

and External Obliques, while keeping thespine stable (particularly at T12, whilestabilizing the tilt of the pelvis).

The work of Rectus Abdominis prevents theobliques from tilting the chest and pelvis andimpinging on the spine.

16


17/41

A rst practice for learning to zip up from bottom to top is to practice the Cat Tilt, rounding thespine up vertebra by vertebra.

Initiate from the tailbone, but let the movement

come from the lower belly.It is helpful to practice with a par tner, to see if anysegments of the spine are stuck.

Release the stuck areas by engaging theabdominals in that specic area to release andround the spine.

Press the hands into the earth to help you engage the abdominal muscles.

Focus not just on the exion or forward bending of the spine, but on thefeeling of wrapping around through the abdominals along the latitudes of thespine to lift up toward the spine.

Zipping Up

17


18/41

The multidi, which originate at the transverse processes of the vertebraeand insert below that at the spinousprocesses, are involved in rotation of the

spine but because they run vertically to the vertebrae, they do not directlycause rotation of the vertebrae, butrather stabilize by resisting rotation . Theyare similarly involved in side-bending .

The multidi, because they are at the back of the spine, have a bowstring effect in thelumbar, supporting the lumbar curve . Without

them, when the obliques cause the torso to

twist, they would also cause the torso to bendforward. The multidi keep the spine uprightduring twisting .

18


19/41

The Core = Transverse Abdominals + Multidi Working TogetherThey co-contract : when the transverse abdominals activate to stabilize the trunk

particularly in the area below the navel the lumbar multidus muscles activate as well.

Their combined action helps the vertebrae facets stack rmly against each other, so that the individual spinal segments can work together as one strong cohesive unit.

If the transverse works unevenly , or if there is a failure in one or two segments of the multidus , the vertebrae at that segment are vulnerable to having the disc slide which is one of the most common dysfunctions in low back pain.

In particular at L5, the multidus must produce enough tension to ensure that L5 does not slide forward on thesacral plateau (spondylolisthesis), which can happenespecially because this surface naturally, and sometimessignicantly, slopes downward. To counter this, themultidus is thicker especially at this segment of thespine. Unfortunately, it often suffers from disuse, atrophy,and is often inltrated with fat.

And beyond the matter of the discs sliding, research has shown (Carolyn Richardson andothers) that failure of a particular segment of the multidus is the most commondenominator in cases of chronic back pain in precisely the location where the failuretakes place .

19


20/41

As stabilizers, the transverse abdominals and multidus work together best within the neutral zone or in the range of a relatively neutral spine

The Multidus: The multidus muscles work to support the inward curve of the lumbar spine . They continue this

work as you go into a forward bend , stabilizing the spine.

Their work is made harder when the spine compresses or overly rounds in a forward bend from theaction of the abdominals pulling the rib cage downward . Hence a forward bend begins with a neutral spine and the lifting action of the bandhas maintaining the connection with

the abdominals and can round progressively. As the forward bend goes further toward the end range of motion , its up to the ligaments of the spine to protect it.

The Transverse Abdominals: The transverse abdominals likewise are less and less effective as a stabilizer as you go beyond the

neutral zone of muscular stabilization and deeper into a backbend; it is up to the ligaments to protect

the spine in deep backbending, as the core becomes less and less effective.

The Ligaments: By the same token, if the stabilizer muscles take too long to re while in the neutral zone , then the

ligaments are at risk for injury since they are not sufciently taut to protect themselves or the joint .

20


21/41

How Do You Get Them To Work Together?These are not movement muscles: their job is to stabilize. And so the exercises for

these muscles should challenge them to stabilize the trunk, without putting more loadupon them than they can bear.

In other words, for these muscles, you dont need to go outside of the neutral zone (i.e. toward theouter reaches of a stretch or action no extreme yoga poses necessary)

And if you overload the body , you will simply recruit other movement muscles rather than thestabilizers to do the action and fail to work effectively with the stabilizers.

The multidus muscles are worked best by small extension movements of the spine(small versions of back bending / slight extension of the spine that does not overly kink

the spine at any par ticular point). When you challenge the body to maintain its balance par ticularly in hands-and-knees versions the body is forced to recruit the transverse abdominals to stabilize

the trunk while the spine is being extended.

21


22/41

Structural Leg Length Difference often manifestsas the Short Right Leg Syndrome , and usually involves thefollowing:

LR

R L

low right femoral head lumbar convexity to the short leg side (side

bent to the left and rotated to the right) pelvic rotation

There can be variations in the bodysresponse to a structurally shorter leg

22


23/41

Defying Expectations

The Leaning Tower of Pisa principle : would lead you toexpect that when the right leg is short, the weight wouldlean or shift toward the short right side, putting moreweight on the short leg .

23


24/41

Defying Expectations

The Leaning Tower of Pisa principle : would lead you toexpect that when the right leg is short, the weight wouldlean or shift toward the short right side, putting moreweight on the short leg .

24


25/41

Those with short right legs who bear more weight to the short right side usuallyreport greater SI joint pain in the right hip and low back .

tests usually reveal that the right sacral base is rotated forward (deep), the ilium is rotated forward and stuck (xated), and the iliolumbar and sacroiliac ligaments are tender .

Along with these shifts and side-bends, there can be

variations in which leg is more weight-bearing

25


26/41

Those who side-shift over the left leg (often because of motordominance) usually experience greater left-sided SI joint pain .

Usually the left ilium is posteriorly rotated and stuck . symptoms get worse during prolonged walking or running , as

overstretched abductors rub against the greater trochanter in theleft hip , creating bursitis gluteus medias tendinosis and piriformis syndrome.

Along with these shifts and side-bends, there can be

variations in which leg is more weight-bearing

L

R

Superior

Posterior

26


27/41

Patterns Of The Hips Showing Up In The Feet

Usually when one hip point is lower (from forward tilt of thepelvic bone), there is a corresponding drop in the arch of thefoot (pronation) , along with an internal rotation of the thigh at the knee and lack of tone in the quadricep.

When the opposite hip point is higher (from posterior tilt of the pelvic bone), the foot usually supinates , bringing theweight to the outer heel . The thigh is often externallyrotated , with greater tone in the quadricep.

The effect of these tendencies on the hips will depend upon the degree of shift of the hips, both forward-backward andside-side

27


28/41

Awareness of Weight-Bearing Patterns in the Feet

28


29/41

Medial column hypermobility The medial column the inner edge of the foot has too much motion

when the muscles from the base of the big toe fail to take their share of theweight, allowing the arch of the foot to collapse.

A Tight Calf Muscle

Symptoms of Flat Feet:

extra pressure is placed on the tendon of tibialis posterior,overstretching the tibial nerve

compression forces on the outside of the ankle joint, which canwear out the outside of the ankle joint leading to ankle arthritis.

Overload on the base of the 2nd toe, because the base of the big toe does not take its share of the weight, can lead to overload the2nd toe, leading to metatarsalalgia or even stress fractures in the2nd metatarsal.

Overstretching of tibial nerve

CompressionForces on theOuter Ankle

Stress on the Second

Toe

CHARACTERISTICS OF A FLAT FOOT

29


30/41

CHARACTERISTICS OF A HIGH ARCHMedial Column StiffnessA high arch foot is known in medical terms as a subtle cavus foot. People

with high arch feet tend to be very stiff through the midfoot, with very littlemovement through the main midfoot joints (ex. the talo-navicular joint). Theheel tends to be pointed inward in what is known as a varus position.

Symptoms of High Arches:

The excess loading on the base of the big toe can predispose people to develop sesamoiditis and sesamoid fractures.

Stress on the outer ankle can lead to tendinitis in the peroneals. Compression is greater on the inner ankle, which can lead to ankle

arthritis from damage to the inner (medial) aspect of the ankle joint.

The foot is more susceptible to ankle sprains fractures on the outside of the little toe

pain directly under the big toe (sesamoiditis)

With a genuinely high arch, the innerheel remains grounded, though theAchilles Tendon may still show somebowing.

Compensation for a fallen arch simplyrolls the weight to the outer edge of

the foot; the inner heel is notgrounded.

30


31/41

The Paradox Of The Shorter Leg Syndrome When the right leg is shorter the body tries to accommodate, and often shifts thepatterns in the feet.

The following patterns are fairly predictable:

On the Long (Left) Leg: The body tries to make the leg shorter by pronating or attening the foot.

The leftward shift of the hips tends to bring the weight toward the outerheel, while the foot attens at the same time, trying to shorten the leg. Thiscan lead to exhaustion in the foot.

The knee tends to ex on the long leg. circumduction of the long leg the leg swings around to the front while

walking

On the Short (Right) Leg:

The body tries to make the leg longer by supinating the foot knee hyperextension on the short side, rotating the knee inward and putting

strain on the inside of the knee as the foot attempts to supinate, it turns the shin outward, while the thigh boneis rotating inward; this can cause tibial torsion at the knee

R L

Foot Supinates tomake the short leg

longer

Foot Pronates tomake the long leg

shorter

Arch support for the shorter leg is not always effective because of the twisting actions of pronation and supination

taking place in the feet especially in response to the hips!31


32/41

SCOLIOSIS

LR

32


33/41

LR

33


34/41

Shortening ofQuadratus Lumborumon the Long Leg Side

Shortening of:

ScalenesLevator Scapulae

SternocleidomastoidUpper Trapezius

on the Short Leg SideLR

Recognizable patterns during walking: shoulder tilting to one side unequal arm swing pelvic tilt foot supinated on the short side and pronated on the long side ankle plantarexed on the short side (toe pointed, or walking on toes) and/or knee exed on the long side

34


35/41

What to Address: Shifts and Tilts First

LR

35


36/41

some suggestions concerning lateral poses

36


37/41

Too much emphasis is put on supine (reclining) leg length assessment:

Commonly, one leg will appear shorter when checking the medialmalleoli (inner ankle) when, in fact, the leg lengths are actually equal or

just the opposite of how they appear when standing .

For example, in the presence of a true (structural) short right leg, the

right hip point will be dropped while standing; however, when lyingdown (supine, removed from vertical compression from gravity) theleft leg may test shorter than the right.

One of the most common reasons for this is the length/strengthimbalance in deep intrinsic postural muscles such as the quadratuslumborum. When it is shor t and tight on one side, the QL can pull

the left hip upward when there is no weight on the leg, making theleft leg shorter than the right.

37


38/41

In prone leg length assessments, when lying facedown, both

hip points are pinned to the oor, preventing ilial rotation

38


39/41

The head should be in a neutral position.

Place your thumbs on the medial malleoli, and slightly point the toes whileslowly bending the knees to 90, looking for any changes in heel height.

Three possible things may happen:

1. The short leg stays short : the leg that appeared shor t in the

beginning, if it is anatomically short, will not change in length as youbend the knee to 90.

39


40/41

2. The short leg gets shorter : muscular tightness in the sacroiliac andlumbar region can shorten the leg in appearance as the knee isexed. Use techniques for derotating the pelvis to correct sacroiliac

and lumbar spine asymmetry.

Adjustment for Anterior Tilt (rightside), using the gluteal. Combinewith quadriceps stretching on theright side.

40


41/41

3. The short leg gets longer - as the long leg gets shorter : a posteriorly rotated and stuck Ilium (usually the left one) shortens the (left) leg (making the left leg the initially shor ter leg).

When this is combined with an adhesive right anterior hip capsule, the pull of the quadriceps(rectus femoris) shortens the right leg, causing the left leg to appear as long as or longer than theright a seeming cross-over effect in which the legs switch length.

Light or passive Anjaneyasana for the right hip capsule; hip adjustment for posteriorly rotated leftilium.

doug keller - pelvic balance slides - part two

Documents