Fascial and Membrane Technique

98 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.76 Treatment of the antebrachial fascia according to Ida Rolf. Treatment of the antebrachial fascia In order to achieve a truly three-dimensional according to Ida Rolf deep effect on the fascial network in the entire area of the forearm, it is helpful to enlist the aid of the Patient Lying supine, both legs flexed, arms rest- flexion and extension movements. While we main- ing next to the torso. tain an “anchor” point in the flexors and actively stretch the layers of the extensors, we ask the patient Therapist Standing at the level of the patient’s first to extend the hand flatly along the treatment upper arm. surface, then to stretch the fingers up toward the ceiling, and finally to allow the hand to follow the Contact With the fingertips of one hand below fingers in the stretch. In the countermovement, the medial epicondyle and surrounding the the palm returns first from the extension and then medial edge of the ulna. At the same time, with the the fingers follow. Then we ask the patient to slowly fingertips of the other hand alternating on the sur- make a fist and then open the fist again. rounding fascial layer of various extensors. The patient’s active movement allows us Action We surround the ulna from the medial access to very different areas of the fascial direction by reaching through the fascia of the network. In so doing, we take into account that forearm and the aponeurosis of the biceps brachii there are three fascial chambers in the forearm: into the flexor carpi ulnaris. Figuratively speak- one for the ventral muscle group of the ing, we anchor our fingertips deep in the tissue extensors, one for the dorsal group of the like a flexible hook. With our other hand, we also flexors, and finally one for the group that is use our fingertips to make contact with the layer displaced in the ventral direction and of fascia surrounding the level of the midsection of innervated by the radial nerve, and which has the brachioradialis. While we are then pushing the an intermediate position between the flexors tissue of the ulna, i.e. the flexors in the elbow joint, and extensors. Contact by the therapist with strongly in the cranial direction, we stretch the fas- both hands is strongly maintained on the cial layer of the extensors farther into extension. flexor side, while the therapist’s fingertips very While the contact in the region of the flexors slowly slide in the fascia of the extensors. remains the same, the strong contact in the region of the extensors ranges from the brachioradialis to the extensor carpi radialis longus and brevis.

FORM-ORIENTED TREATMENT TECHNIQUES 99 Annular ligament Figure 4.77 Interosseous membranes of of the radius the forearm, with the annular ligament in cross-section. Tendon of the Articular brachial circumference biceps muscle Oblique cord Interosseous of the membrane of elbow joint the foream Ulna Radius Treatment of the interosseous membrane direction of the interosseus membrane (using either of the forearm our fingertips or, in the case of strongly pronounced musculature, the second phalanges of the index and Patient Lying supine, legs flexed, arms resting middle fingers). It is essential to the efficacy of this next to the torso. technique that we pay precise attention to the direc- tion of the pressure we apply. The membrane has a Therapist Standing at the level of the patient’s hiatus in its upper portion for the radial tuberosity pectoral girdle. and the bicipital tendon that is attached there. Both bones of the forearm are stabilized against lateral Contact With the surface of the second phalanx displacement next to this hiatus by the strong fiber of the index and middle fingers of one hand, while tension of the oblique cord of the elbow joint. We the other hand supports the forearm from behind. must now ensure that the direction of the fibers is different in this oblique cord and the substantially Action Like the treatment technique described flatter main portion of the membrane (see Fig. 4.77). above, it is important here as well to surround the Only in the last fifth of the membrane, i.e. slightly forearm from below and press it against the upper above the wrist, is the orientation of the fibers once arm in order to ensure that the joint capsule relaxes again parallel to that of the oblique cord. during the application of pressure. With the other hand, we apply gradually increasing pressure in the

100 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.78 Treatment of the interosseous membrane of the forearm. Increased tension in the region of the oblique Contact With the flexed fingers of both hands on cord can be recognized by the fact that it is no the medial and lateral boundary of the palmar longer possible to compress elastically the ulna aponeurosis. and radius at this point. It is important to stabilize the tissue layers that are located directly distal to Action The patient positions the forearm verti- the elbow joint while we work our way layer by cally while the upper arm rests on the treatment layer through the extensors with the pressure of table in the shoulder region. The therapist now our fingers in the direction of the oblique cord so surrounds the layers distally from the flexor liga- that we can very slowly exert an impulse there ment slightly laterally and medially from the pal- between the two bones. The pressure should work mar aponeurosis, applies pressure to the tissue, diagonally between the ulna and radius, i.e. paral- and follows the effect of this pressure with “listen- lel to the fiber orientation of the cord. ing.” The patient’s hand initially remains flexed. The therapist now gradually begins to change the In the farther path of the forearm, we maintain position of the wrist in space and, while doing so, the diagonal pressure as if we were trying to rotate combines the subtly stretching of the fascia with the ulna toward the radius. With some practice, passive pronation and supination. Owing to the it is possible to apply “listening” to the membrane change in the tension conditions, “listening” now even during this extremely intense application provides information about the deep fascial cham- of pressure. Thus, we are able to connect our bers of the hand. It is important to give a sustained direct influence to the membrane’s self-regulating impulse only where the most distinct compression ability. of tissue is found. Treatment of the fasciae and the deep fascial Manual treatment of the hand requires precise, chambers on the flexor side of the hand detailed knowledge and a high degree of strength and sensitivity. The necessary strong Patient Supine, both legs flexed, arms next to the contact should not be alternated with stiff body, the hand to be treated is resting in the thera- pressure because the deep chambers of the pist’s hands. fascial system respond negatively to “pulling” attempts to stretch them. Therapist Sitting on the treatment table next to the patient.

FORM-ORIENTED TREATMENT TECHNIQUES 101 Figure 4.79 Treatment of the fasciae and deep fascial chambers of the hand. TREATMENT OF CARPAL TUNNEL the boundary surfaces. The nerve is able to correct SYNDROME the pressure conditions over the long term by forming additional fascicles and epineurial con- Conceptual background nective tissue. However, it is precisely this protec- tive process that can damage the nerve in the There are two fundamental preconditions for the passages where there is not enough room for con- undisturbed function of a nerve: the nerve requires nective tissue to absorb additional pressure. The a positive basic tension and a certain degree of carpal tunnel is one such passage. The carpal bones mobility relative to adjacent layers, known as and flexor retinaculum surrounding the tunnel boundary layers. Only then is it possible for the form a bottleneck in which even a small deposit of chemical life processes of the nerve to function opti- protective fascicles or Renaut’s bodies can over- mally. The basis of this process is primarily arterial load the nerve. Van den Berg (1999: 226) reports oxygen supply and, in addition, its supply of that the increase in volume by Renaut’s bodies can transmitters and enzymes.4 reach up to 30 percent of the volume of a nerve.11 To a large extent, the functionality of a nerve is However, the change to the connective tissue in dependent upon its oxygen supply. This supply and around the nerve is not the only source of the process in turn is dependent upon a particular changes in pressure conditions. As a rule, there is pressure gradient between arterial pressure and either already an edemic blockage due to inflam- the pressure acting on the nerve from the sur- mation or a cross-sectional increase in nearby rounding tissue. To a certain degree, the nerve is tendons over a long period in time before the capable of adjusting to conditions of unfavorable increased formation of connective tissue begins. pressure. It has a control organ, known as the nervi nervorum. The nervi nervorum are small Moreover, as we will see, there is an entire branches of the nerve that provide information to range of influencing factors that are not located the central nervous system about the interior con- directly at the carpal tunnel. dition of the nerve and the pressure conditions on Methodical considerations 4 A detailed discussion of this subject matter may be found in van den Berg (1999: 223–31). For decades, carpal tunnel syndrome has been dis- cussed in the orthopedic literature as the most

102 FASCIAL AND MEMBRANE TECHNIQUE widespread form of lesion of peripheral nerves. The wrist. On the radial side, the flexor retinaculum is anatomical units in and around the carpal tunnel connected to the tubercles of the scaphoid bone itself are at the center of the traditional orthopedic and trapezium bone and on the ulnar side to the viewpoint. Therefore, it is primarily the transverse tubercles of the pisiform bone and hamulus of the carpal ligament (also called the flexor retinaculum) hamate bone. Under normal conditions, the carpal and the sheaths of the tendons of the flexor muscu- tunnel guarantees that the sheath-covered tendons lature running through the carpal tunnel that have of eight flexor muscles and the median nerve can been described for almost a century as the pivotal pass through the narrow passage. Here, the flexor anatomical units for this problem. In orthopedic retinaculum functions as the “guiding band” for examination, the etiology is concentrated on the the tendons passing through the carpal tunnel local pressure and tension events in the carpal (Rauber and Kopsch 1987: 411). tunnel itself. Tension patterns located farther away from the wrist are therefore brought into considera- From the structure of the carpal tunnel, it can be tion only to the extent that they are necessary for seen that the nerve function of the median nerve differential diagnostic clarification. can be disturbed by spatial changes in the tunnel. Such a case occurs if constant pressure is exerted The treatment concept introduced here is based from outside on the narrow passage between the on the methodical assumption that disrupted ten- forearm and hand or if the tissue layers passing sion patterns in the connective tissue system origi- through the tunnel, i.e. the eight flexor tendons nate in an overarching context. In this sense, it makes with their surrounding sheaths, or the median sense to classify local tension and pressure events in nerve require more space than the diameter of the and around the carpal tunnel in the context of the tunnel. In such a situation with constantly increas- overarching pattern. This results in a technique that ing pressure in the carpal tunnel, the median does treat large-surface layers of connective tissue, nerve will be the victim of the stricture because the muscular fascia, septa, and interosseus mem- nerve tissue is less tolerant of pressure than the branes, but also details such as the sheath and divid- sheath layer of the tendons. ing layers of the affected nerve cords. It is significant for evaluating the pathology and Therefore, it is not only the tissues running also for treatment techniques that the median nerve through the tunnel that are at the center of the dis- is a “mixed” nerve, i.e. it contains motor, sensory, cussion, but also the tissue layers in the region of and vegetative fibers. The sensory fibers have the the shoulder, the upper arm, the forearm, and also largest portion in terms of space (Wilhelm 1987). the forehand on the other side of the tunnel. Correspondingly, the nerve that is decisive for the The nerve is composed of many fascicles in a pathology, the median nerve, is considered in its plexus-like connection. On the exterior, it is sur- entire path, from the cranial branch at the brachial rounded by a connective tissue epineurium that plexus into its very various paths after passing contains a considerable amount of fat. The fascicles through the tunnel. Accordingly, the practical treat- themselves are also surrounded by a thin perin- ment suggestions target not only the local events eurium, producing a septum-like division of the at the carpal tunnel itself, but also the larger “tissue fascicles. Within the fascicles, the individual nerve landscape” within which the unfavorable pressure fibers are embedded in an elastic, finely fibrous conditions of the carpal tunnel develop. endoneurium containing capillaries (Kleinau, unpublished: 17). Anatomical conditions In order to be able to understand the topic of the The carpal tunnel consists of a 2- to 3-cm long pas- carpal tunnel from a structural viewpoint, it is sage between the bones of the wrist and the flexor important to bear in mind that there are also ele- retinaculum. Viewed in cross-section, the bones of ments outside the tunnel that may be susceptible the wrist appear concavely arranged. The flexor to dysfunction on the nervous or muscular level: retinaculum consists of tough fibers that are con- the tendon of the long palmar muscle has particu- nected to the radial and ulnar eminences of the lar significance because it ends in the aponeurosis of the palm and thus comes into connection with the flexor retinaculum. The flexor carpi ulnaris

FORM-ORIENTED TREATMENT TECHNIQUES 103 within the tunnel; the structural basis may be found in the changes to the fascial and membrane layers that form the “tough spatial structure” of the tunnel itself. The connective tissue system is an endless system. The layers of individual types of tissue transition into one another. Therefore, purely local changes to tissue and fluid content or sliding ability of the shear lattice of collagen fibers are extraordinarily rare. Ulnar nerve Flexor Median nerve Examination retinaculum A simple test is helpful in evaluating the participa- Figure 4.80 Cross-section of the carpal tunnel. tion of the antebrachial fascia and interosseus membrane: we compress the forearm elastically muscle, a flexor that, with its tendon, runs outside and evaluate whether there are individual sections the carpal tunnel, as well as the ulnar nerve that where there is no elastic effect. runs in the immediate vicinity of this muscle are important for treatment techniques as well. We test the tunnel itself accordingly: is it possi- ble to move the bones to which the flexor retinacu- From the anatomical topography of the carpal lum is attached toward one another in such a way tunnel, we can gather that there are individual that the arch of the retinaculum becomes more structural elements that, through this narrowing concave? In order for this to occur, the scaphoid process, transfer increased pressure more or less bone must make a slight tilting movement relative directly onto the median nerve, and at a skeletal to the adjacent capitate bone. This simple test level these are primarily the hamate and capitate examines the “trampoline function” of the retinac- bones. However, any form of drastic restrictions of ulum. If no more elastic motion whatsoever movement of other bones of the wrist or signifi- results, this is a sign that the inner compression of cant subluxations can play a role as well. At a mus- the carpal tunnel is very advanced. cular level, it is primarily the tendon sheaths adjacent to the median nerve within the carpal The superficial fascia and the muscular fasciae tunnel that are most significant for the transmis- of the extremities must be differentiated sion of pressure, in particular the tendon that structurally from the deep membranes. The leads to the index finger, which usually runs treatment strategy should be selected directly below the median nerve. accordingly. Superficial and muscular fasciae may be successfully treated with strong contact. In the advanced stages of the syndrome, chief When it is necessary to intensify contact, the factors causing symptoms are the drastic adapta- weight of the therapist’s body should be used tions to tissues within the carpal tunnel, which is and the therapist should avoid any tension in his only a few centimeters long: or her own pectoral girdle. An elastic quality of the touch is important in order to permanently ● chronic fibrosis of the tendon sheaths of the observe how the adjacent fascial layers behave flexor musculature during treatment. Deep membranes respond very well to “indirect maneuvers,” i.e. the touch ● various forms of edematous blockage should follow the inner tensile forces of the ● demyelinization of the median nerve. membrane fibers up to a certain point before a correcting impulse is given. However, these changes are caused not only by physical forces and chemical metabolic processes

104 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.81 General treatment of the fascial network of Contact One palm supports the scapula to be the shoulder–arm connection. treated (here, the left scapula), the other hand sur- rounds the left shoulder joint in the region of the Treatment technique deltoid muscle. At the same time, using the ster- num, the therapist maintains contact with the point Step 1: Treatment of the fascial network of of the elbow of the patient’s raised upper arm. the shoulder–arm connection Action While the patient lies supine, the thera- This technique should precede an examination of pist uses the palm of the right hand to support the the sternoclavicular joints and the upper vertebral left scapula to be treated and anchors the fingertips joints of the ribs and, if necessary, a treatment of of the same hand like a “hook” in the connection any restrictions of movement that may be local- between the levator scapulae and the scapula. At ized there.5 the same time, the therapist’s left hand surrounds the shoulder joint to be treated from above so Patient Supine, both knees flexed, both arms ini- that the acromioclavicular articulation is elastically tially resting next to the torso. compressed in the direction of the fiber orientation of the coracoacromial ligament. At the same time, Therapist Standing at the level of the patient’s the therapist leans from the front—coming from fifth rib. above with the sternum slightly against the patient’s left elbow, which is pointing toward the 5 Tests for the examination of the sternoclavicular joint may ceiling, such that there is an elastic compression of be found in Barral et al. (1993: 69–75). Regarding the the humerus into the shoulder. In so doing, it is treatment techniques, see Chapter 4, Treatment of the fascia important that the hand surrounding the shoulder of the subclavius muscle. joint stabilize the scapula and clavicle against the head of the humerus sinking into the joint. While the parts of the joint located between both hands are kept under elastic pressure, an indirect correc- tion of relevant tissue structures is possible: the capsule is compressed, the therapist’s hands move the bony parts of the joint closer together and then, following the dominant direction of tension, releases the compressed parts of the joint at the moment when a tangible counterpressure builds up. A decelerated recoil effect then occurs in the ventral part of the joint. For fans of anatomical details, the recoil effect manifests in the following ligaments: ventrally on the coracoacromial, conoid, and trapezoid ligaments and on the superior trans- verse ligament of the scapula; dorsally on the acromioclavicular ligament and on the posterior portion of the conoid ligament and on the superior transverse ligament of the scapula. Step 2: Treatment of the tissue bed of the branch of the median nerve from the main nerve cord Patient Initial position as described in Step 1. Therapist Initial position as described in Step 1.

FORM-ORIENTED TREATMENT TECHNIQUES 105 Figure 4.82 Specific treatment of the tissue bed of the Step 3: Treatment of the transition between branch of the median nerve from the main nerve cord. the upper arm and forearm with simultaneous, specific effect on the radices of the median Contact With the palm of the right hand sup- nerve porting the scapula to be treated (here, the left scapula) from the posterior side, while the pisi- Patient Supine, both legs flexed, both arms rest- form bone of the left hand exerts pressure on the ing next to the torso. branch of the median nerve and the ulnar nerve of the brachial plexus from the anterior side. Therapist Standing to the side at the head. Action This time, the therapist uses his or her ster- Action The therapist’s right elbow is now num (and therefore the patient’s left elbow joint) to anchored directly at the level of the radices of the make a clockwise circular movement of 3 cm. median nerve and, at the same time, the therapist surrounds the elbow joint to be treated (here, the left Now, in order to be able to affect the median elbow joint) from behind. With the ring finger and nerve, the therapist’s left hand slides very slightly middle finger of the right hand, the therapist now downward in order to exert direct pressure from tries to produce as precise a contact as possible in the medial side of the humerus onto the branch the direction of the point at which the median nerve between the median nerve and the ulnar nerve on passes the elbow joint; this point is located precisely the brachial plexus. While the circular motion of between the aponeurosis of the biceps brachii and the elbow is continued (now carefully in the coun- the medial brachial intermuscular septum. terclockwise direction as well), a passive mobiliza- tion of the tough tissue layers around the nerve With the left hand, the therapist now produces occurs. a strong contact in the direction of the interosseus membrane. The pressure should be exerted diago- nally between the ulna and radius and be trans- mitted with slow gliding centimeter by centimeter in the direction of the lower head of the radius. Step 4: Specific effect on the passage of the median nerve in the elbow joint with simultaneous stretching effect in the carpal tunnel Patient Supine, both legs flexed, arms resting next to the torso. Therapist Standing to the side at the level of the abdomen. Contact With the index and middle finger of one hand at the place at which the median nerve passes the elbow joint to be treated (here, the left elbow joint), with the palm of the other hand on the tip of the elbow, while the patient’s upper arm is flexed. Action The therapist uses the index and middle fingers to reach around the aponeurosis of the biceps while guiding the joint over the patient’s head from extension into flexion in order to access the nerve as precisely as possible. The patient places the hand on the treatment table cranially of

106 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.83 Treatment of the transition between the upper arm and forearm with simultaneous, specific effect on the radices of the median nerve. Figure 4.84 Specific effect on the passage of the median nerve in the elbow joint with simultaneous stretching effect in the carpal tunnel. the shoulder. The patient’s thumb is abducted, the therapist reaches somewhat higher, the ulnar nerve contact between the hand and the treatment table will be found in the direction of the triceps slightly is initially slightly elastic, the wrist should not be above the medial brachial intermuscular septum; guided too far into hyperextension, especially not the ulnar nerve may be treated in an analogous if there is restricted movement at a carpal bone. manner. Treatment of the ulnar nerve is particularly The therapist’s left hand exerts a shear-like pres- advisable if, in addition to the carpal tunnel, a sure against the elbow joint. At the same time, the compression of the ulnar nerve has also occurred therapist’s other hand reaches into the interior of in Guyon’s canal, i.e. outside of the carpal tunnel. the elbow joint passage in order to reach the medial nerve precisely next to the path of the blood ves- In both cases, in the treatment of the median sels, i.e. next to the aponeurosis of the biceps. If the nerve and of the ulnar nerve, it is essential to access the corresponding nerve as precisely as

FORM-ORIENTED TREATMENT TECHNIQUES 107 Figure 4.85 Treatment of the flexor retinaculum (from the dorsal direction). Figure 4.86 Treatment of the flexor retinaculum (from the palmar direction). possible. The effect on the nerve’s sheath can be Contact Both hands surround the carpals to be increased by pressure against the elbow joint and treated. by changing the angle at which the patient’s fore- arm is flexed. In this manner, we achieve a direct Action The therapist’s thumb presses against the stretching of the fascia of the pronator quadratus. head of the ulna and the end of the radius as if to slide both longitudinal bones away from the Step 5: Treatment of the flexor retinaculum carpals. At the same time, both of the therapist’s index and middle fingers strongly compress the Patient Supine, both legs extended. patient’s carpal tunnel and exercise a drastic stretching force on the layers of the palm. In this Therapist Standing to the side at the level of the manner, we have the opportunity to affect different patient’s hips.

108 FASCIAL AND MEMBRANE TECHNIQUE Action It is recommended that the median nerve be treated directly at the point at which it passes the tunnel. It is best if we place the patient’s elbow with the medial and lateral epicondyles vertically on our fingertips. With our right hand, we search for the point at which the median nerve leaves the carpal tunnel, produce as direct as possible a con- tact with the “nerve line,” and modify the contact in the transverse and longitudinal direction. While modifying the quality of the touch on the median nerve, we allow gravity to lower the patient’s fore- arm onto our supporting fingers as if we were try- ing to reduce the distance of the nerve line between the carpal tunnel and the elbow joint. The contact on the elbow then acts like a mini-trampo- line in the interior of the joint, while an alternating tensional force is exerted on the nerve on the other side of the carpal tunnel. With some skill we will thus be able to guide the nerve into a subtle sliding motion within its fascial environment. Figure 4.87 Direct influence on the median nerve within In order to have reliable results from such the carpal tunnel. treatments, it is helpful to become acquainted with the anatomical variations of the median layers of tissue at the same time. Precisely stated, nerve (e.g. Lanz 1987). we are treating the interior of the carpal tunnel in an indirect manner in that we are moving the origin Additional remarks and insertion of the flexor retinaculum together while we subject the exterior tension layers that run The goal of a manual treatment of carpal tunnel over the joint and end in the palm of the hand to a syndrome is to achieve a positive change in the pres- direct treatment. sure gradient between the nerve and its adjacent boundary layers. This treatment is directed exclu- Step 6: Direct influence on the median nerve sively at a pattern of symptoms that arises from below the carpal tunnel overloading. The treatment steps described concen- trate on the fascial tissue bed of the median nerve as Patient Supine, both legs extended. it runs between the shoulder region and the hand. The prognosis for a successful treatment is good as Therapist Standing to the side at the level of the long as the compression in the tunnel primarily patient’s pectoral girdle. affects the sensory fibers, i.e. the fibers that spatially constitute the largest portion of the median nerve. Contact With the fingertips of one hand on the As soon as motor functions are affected, the danger medial and lateral condyles of the elbow joint, of lasting damage is present. with the ring finger of the other hand at the point at which the median nerve leaves the carpal tun- Carpal tunnel syndrome caused by a mechanical- nel distally. traumatic effect should be referred to a surgeon immediately. This is particularly true in cases in which damage to the ulnar nerve in Guyon’s canal is present as well.

FORM-ORIENTED TREATMENT TECHNIQUES 109 In any event, neurological examination to can affect the pelvis and thus involve the back as accompany treatment is advisable in order to guar- well. However, this process can occur in reverse as antee objective information regarding progress of well: a structural weakness in the back forces one treatment. leg or both legs into a compensatory movement pattern and thus causes a long-term change to the 4.5 LOWER EXTREMITY: THIGH, fascial network. LOWER LEG, AND FOOT Thus, there is an interdependency between the Aspects of form local hypotonic or hypertonic tension patterns of a problem zone and a larger context of form. For the Upon closer observation of the fascial and mem- lower extremity, this context is primarily relevant brane system, chronic structural problems of an in standing and walking. organism should not only be classified as local restrictions of movement and changes to tissue; From an anatomical perspective, the close con- rather, they should also be classified into the nection between the myofascial complex of the overarching structural patterns of muscular coor- upper leg and pelvis is responsible for this fact. dination and comprehensive tone patterns of the On the posterior side of the thigh, there is a direct connective tissue. For this reason, in the case of connection between the fascia of the leg and the lig- chronic problems, it is not sufficient to treat the aments of the pelvis: at the ramus of the ischium, the local complex of symptoms. For some acute prob- fasciae of the biceps femoris muscle and the adduc- lems, the precise treatment of a few individual ele- tors unite with the strong cords of the sacrotuberous ments is sometimes sufficient. However, in the ligament. The layers coming from the distal side act case of chronic problems that have existed over a on the lower edge of the pelvis with a massive lon- period of time, the circumstances are different. gitudinal pull. In this manner, the tension pattern of However once the compensations for local dys- the posterior side of the thigh becomes the deter- functions have exceeded a critical threshold, they mining factor in the tilting of the pelvis around the develop their own problem dynamic, which con- hip axis. tinues to exist even if the original problem has been successfully treated. We try to be as precise as Once additional increased tension initiates from possible with detailed corrections within the prob- the adductor group, the ischial bones are no longer lem zone but combine this with a global correction able to move apart from one another during sit- of the cohesive form of the body’s structure. ting, and the pelvis retains a posterior tilt during the most various sequences of movement. The This cohesion may be studied by way of exam- “posterior tilt” becomes the determining posture ple on the lower extremity with pelvic and back pattern.6 structures. An onset of arthrosis in the hip joint will influence the movement pattern in the lower As a result, the curvature of the lumbar spine is leg and, over the long term, change the fascial, reduced. Seen from the side, a flat back results membrane and band structures of the ankle joint. while, on the level of the vertebral bodies, a direct Damage to the knee joint will not only impact the curve occurs between the last lumbar vertebra and joint’s function, but will cause a change in coordi- the upper edge of the sacrum instead of the curva- nation over entire sections of the body. If they exist ture. As soon as a lasting structural image of the long enough, changes of this type will produce structure of the body has resulted from this, the new tone patterns of the musculature and finally organ column of the pelvic and abdominal cavities influence the fasciae as well. will respond as well: One characteristic of the connective tissue sys- ● In men, the posterior tilt of the pelvis and the tem is that, as a three-dimensional network, it reduction of the distance between the ischial allows for compensatory changes in all spatial rami increases the pressure on the prostate directions. So, the altered tone pattern of one leg because more of the weight of the 6 See the detailed description in Flury and Harder (1988).

110 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.88 Median section of the pelvis. Iliac muscle Sacral bone Greater psoas Piriform muscle muscle Ischiococcygeal Superior ramus muscle of the pubis Sacrotuberal Obturator ligament fascia Ischical Pubic tuberosity symphysis Ramus of the Internal obturator ischium muscle Greater Semimembranous Long head of the Inferior ramus of adductor muscle muscle biceps muscle the pubis of the thigh Adductor Semitendinous muscle muscle Gracilis muscle (a) (b) (c) Rectum Uterus Bladder Vagina Figure 4.89 Competition for space between the uterus, rectum, and bladder: (a) with an empty bladder and empty rectum; (b) with a full bladder and empty rectum; and (c) with a full bladder and full rectum. intraperitoneal organs is placed on it and the Douglas space, develops and a pressure effect pubic bone pushes the bladder somewhat shows up on the sections of the large intestine farther backwards over the prostate. located behind the uterus. ● In women, the uterus tends toward a posterior tilt while a part of the small intestine appears We have already been able to see that the tension to push upward over the pubic bone and the relationships at the lower edge of the pelvis are intraperitoneal space expands backwards onto responsible for tilting around the hip axis (see sec- the retroperitoneal end section of the bowel. It tion 4.1) and that the posterior tilt is associated with is possible that altered tensile forces of the a reduction in lumbar lordosis (see section 4.6). As a uterovaginal septum acting on the cervix are rule, this reduction is not without consequences for responsible for the tendency toward posterior the sections of the back and spine located above it. displacement of the uterus. It is possible that a Changes to one curved section of the spine bring reduction of the retrouterine area, the so-called changes to all of the other sections as well. By the sinking of the lower pelvic organs, a tensile effect

FORM-ORIENTED TREATMENT TECHNIQUES 111 on the front of the spine occurs that must be caught the tibia and influences knee joint function there by the autonomic musculature with increased tone. because individual fibers are connected to the This causes forced tensions and compressions in the capsule. intervertebral region to occur simultaneously. As has been mentioned above, the fascia lata Because of these circumstances and interdepen- has a considerable tissue density in its lateral por- dencies, it can be seen that, for example, the roots tion, known as the iliotibial tract, and thus has the of an acute, recurring ischialgia may well be found appearance of a flat aponeurosis. To a certain in the tension patterns of the lower extremities. For degree we find this tissue density in the dorsal this reason, the treatment techniques described in region as well, although without the aponeurotic this chapter are not only extremity techniques, but structure. In contrast, in the ventral and medial belong to the armory of pelvic and back tech- region of the upper leg, the fascia lata is very thin. niques as well. On the medial side, it manifests as part of the fas- cial covering of the adductor group. It is therefore Anatomy of the fascia of the thigh part of a fascial group that acts as a displacement layer during muscular activity. In anatomical literature, reference is repeatedly made to the fact that only a portion of the mobility Although the fibers of the fascia lata have a that is typical for the upper extremity is available ring-shaped orientation, they cover only part of to the lower extremity. Compared with the dynamic the thigh. Predominately, they connect to the arm, which is dominated by the grasping function, intermuscular septa and are thus anchored in the the leg has a clearly pronounced static component. deep layers of the leg. However, there is also a This fact is revealed in the determining fascia of smaller portion of the fibers with a low level of the thigh, the fascia lata. In some sections, it shows tensile strength that encircles the entire thigh. a mesh-like density of tissue that is not found in These fibers are located directly below the subcu- the region of the upper extremity even in the pres- taneous layer. ence of the greatest pressure. The greatest density of the intersecting fibers of the fascia lata is found in The core layer of the fascia lata is so tough that the lateral section of the upper leg. This is because it can inhibit the mobility of the muscle fibers. The the fascia has a unique function to perform here: its change in the muscles’ shape in flexion and exten- increased basic tension catches the immense pres- sion is only possible because another loose sliding sure acting on the thigh during standing and walk- layer is located between the actual fascial layer ing. By its existence, the fascia lata prevents the and the musculature. We find a comparable slid- femur from flexing outward. Functionally, it works ing layer in the front and rear region of the thigh like an interosseus membrane that has been dis- between the subcutis and the fascia. In this man- placed toward the outside. The density of collagen ner, the solid, difficult-to-stretch elements of the fibers in the fascia lata is so strongly pronounced fascia lata are embedded on the surface and in the on the side of the leg that, at first glance, one tends deep layers of the thigh in sliding layers with a to doubt the efficacy of manually influencing such greater elasticity. I think that this results in a kind tough layers. However, upon closer examination, of “combinational elasticity” for these fascial lay- we recognize that the deep layer of the fascia lata ers, which at first glance appear to be impossible has a high degree of elasticity and movability that to stretch. allows manual influence to appear quite plausible. It is important for treatment techniques that we The fascia lata surrounds the entire thigh. In its keep in mind that the fascia lata does not function upper part, where it is connected to the inguinal only as a superficial layer. In the deep layers, it is ligament and iliac crest, it is a component of the linked to the intermuscular septa of the thigh. gluteal fascia and thus part of the connective tis- sue bridge between the lower extremity and the Moreover, there are a few other peculiarities in pelvis. With its distal branches, it connects to the the region of the fascia lata that are worthy of atten- superficial fascia of the knee and the periosteum of tion for treatment practice: the muscles embedded in the fascia lata have their own directional fascial sheaths, inside of which the muscles can slide some- what with the aid of an epimysium. In isolated

112 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.90 Treatment of the fascia lata (lateral layer). cases, this epimysium is a cylindrical fascial tube, Action With an elastically closed fist, we gently such as in the case of the sartorius muscle. This is a push through the skin and fatty layers just under special form that is typical of diagonal muscle the gluteal fold in order to produce a flat hand con- paths. Also, the fascia of the sternocleidomastoid tact on the seat halter of the fascia lata. We main- muscle has a similar position in the region of the tain a flat contact at this point without sliding. The fasciae of the neck. We find a comparable invagina- holding surface that results is significant because tion in the case of the gracilis muscle. Finally, there the seat halter has a unique, three-dimensional is one other peculiarity of the fasciae of the lower branching, specifically outward in the direction of extremity that has significance for the circulatory the skin, laterally toward the iliotibial tract, and system. Von Lanz and Wachsmuth (1972: 48) have medially until the tuberosity of the ischium. Thus, shown that the large vascular routes of the leg are it connects the subcutaneous layer, the aponeuro- located not inside the musculature, but rather sis, and the periosteum. With the palm of the other between the “stiff-walled fascial tubes.” hand, we press on the posterior edge of the longi- tudinal path of the iliotibial tract, first anteriorly in The musculature requires the resistance of the a diagonal direction. The pressure that we exert stiff fascial tubes in order to produce their charac- goes barely past the outer edge of the femur. We teristic effect as muscular pumps on the accompa- follow the tract along its entire length with strong nying veins of the arteries. contact up to the layer of the head of the fibula. It is important to adapt the contact to the density of Treatment techniques the fibers and the sliding layer located below them in order to prevent a squeezing effect on the bones. Treatment of the fascia lata (lateral layer) Treatment of the fascia lata (posterior layer) Patient Lying on one side with knees flexed, and the fasciae of the biceps femoris, small pillow between the knees. semimembranosus, and semitendinosus muscles Therapist Standing next to the patient’s hips. Patient Supine, one leg flexed, one knee pulled up and held with both hands. Contact With a slightly closed fist at the medial end of the subgluteal, horizontal part of the fascia Therapist Standing at the level of the diaphragm, lata (see Figure 4.94), with the other hand right on facing distally. the posterior edge of the longitudinal path of the iliotibial tract.

FORM-ORIENTED TREATMENT TECHNIQUES 113 Figure 4.91 Treatment of the fascia lata (posterior layer) and the fasciae of the biceps femoris, semimembranosus, and semitendinosus muscles, first treatment step. Contact Using the shoulder to provide counter- This technique can be applied analogously to pressure on the patient’s pulled-up knee, strong, the semitendinosus and semimembranosus, while sliding contact in the posterior layers of the fascia. we work between the semimembranosus and adductor magnus muscles. Action We ask the patient to hold the knee with both hands so that the thigh rotates minimally The efficacy of this technique depends on the inward. It is important for the other leg to maintain careful graduation of the very strong pressure a good functional contact with the treatment table as well as the coordination of this pressure with so that the orientation of the hip axis remains hori- the pull that the patient is exerting on the upper zontal, even if massive pressure is exerted on the leg. The pull should be just strong enough that posterior side of the thigh. The therapist’s shoulder the ischial bones expand somewhat, but the hip now leans against the patient’s pulled-up knee so joint should not be compressed too strongly. as to apply some of the therapist’s weight against this knee. At the same time, the majority of the Treatment of the deep layer of the iliotibial weight of the therapist’s upper body is transferred tract in connection with the subgluteal, into the palms, and the therapist exerts a slow horizontal part of the fascia lata stretching force on the posterior layer of the fascia lata. This stretching motion extends over the entire Patient Supine, one leg pulled up with both hands. posterior side of the thigh, beginning just below the hollow of the knee and ending at the point where Therapist Standing distally of the hip axis, fac- the gluteal fascia overlaps the biceps femoris. ing in the cranial direction. In a second treatment step, we produce contact Contact One palm on the upper third of the ilio- specifically between the posterior boundary of the tibial tract with the second phalanx of the index iliotibial tract and the biceps femoris by reaching and middle fingers of the other hand on the with our second hand between the biceps femoris medial portion of the subgluteal, horizontal part and semitendinosus muscles. We exert strong, of the fascia lata. slowly gliding pressure, which this time acts deeply into the grooves between the muscles. This Action The therapist’s hands move in opposite contact is less two-dimensional than in the first directions. In order to protect the therapist’s own step. In the case of a high degree of muscle tone, it neck, it is essential to keep the shoulders loose and is advisable to use the edge of the hand.

114 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.92 Treatment of the fascia lata (posterior layer) and the fasciae of the biceps femoris, semimembranosus, and semitendinosus muscles, second treatment step. Figure 4.93 Treatment of the deep layer of the iliotibial tract in connection with the subgluteal, horizontal part of the fascia lata for the movement impulse to originate from the respond to the shifting pull and pressure forces elbows. The palm on the tract slides freely, with the and readjust itself in its fascial bed. pressure moving first through the tough superfi- cial fascial layers into the sliding intermediate Treatment of the fascia lata (medial layer) and layer, and then acting almost parallel to the exterior the investing fascia of the adductors of the femur. In no way should we attempt to pull on the exterior layers. The contact by both pha- Patient Lying on one side, the lower leg almost langes on the subgluteal, horizontal part of the fas- extended, the upper leg to be treated slightly flexed. cia lata wanders slowly. It works in slow motion, as if we were constantly waiting for the bone to Therapist Standing behind the patient at the level of the thigh.

FORM-ORIENTED TREATMENT TECHNIQUES 115 Thoracolumbar gliding manner in the cranial direction as if we were fascia trying to separate their fascial sheaths from one another. The efficacy of this technique can be Middle gluteal increased if we ask the patient to accompany our muscle manipulation by bending the hips, i.e. pulling the knee up slightly parallel to the treatment table and Iliotibial tract extending it again somewhat, specifically just after we have produced an strong contact between the Greater adductor Subgluteal part fasciae of the adductor muscle and semitendinosus muscle of fascia lata muscle. It is possible to treat the fascial boundaries between the adductor magnus and the gracilis mus- Gracilis Biceps muscle cle in a corresponding manner. muscle of the thigh Because the fascia lata is usually only very Semi- Semi- thinly pronounced on the inside of the leg, we membranous muscle tendinous muscle should ensure that the stretching effect reaches through the superficial layer into the deep Figure 4.94 Fiber orientation of the subgluteal, horizontal layer without overstretching the superficial part of the fascia lata. layer. Over the gracilis muscle and adductor magnus, the group fascia of the adductors Contact With one hand on the medial side of the functions simultaneously as a superficial knee at the level of the insertion of the sartorius, fascia. For this reason, it is helpful to use the gracilis, and the tendon of the semitendinosus; weight of the leg to be treated for the purpose with the other hand between the fascial layers of of accessing deeper layers. In the manner, we the adductor magnus and the semimembranosus are able to protect the nerves running parallel muscles. to the sartorius muscle in spite of the strong contact. Action The patient’s ankle is allowed to rest on the therapist’s flexed thigh while the therapist Treatment of the anterior layer of the fascia surrounds the patient’s knee on the medial side with lata in combination with the posterior layer one hand. With the fingertips of the other hand, the therapist now absorbs the weight of the thigh and Patient Supine, one leg flexed, the other leg carefully reaches through the fascia lata, which is extended. very thin here, in order to arrive behind the sartorius muscle at the boundary of the fascial sheath of the Therapist Sitting at the level of the patient’s adductor magnus and the semimembranosus mus- hips, facing distally. cles. No contact is established here with the blood vessels or the saphenous nerve at the level of the Contact With one palm on the front of the thigh intermuscular septum. The therapist first waits for and with the fingertips of the other hand lateral of the tissue response and then, using the weight of the the group fascia of the adductors. thigh, gradually reaches between the fascial tubes. At this point we maintain contact and now we mod- Action First, we produce a flat contact with the ify it with our other hand by slight abduction and fascia on the front of the leg, which is relatively adduction of the angle of our contact. Subsequently, thin there. As the same time, our fingertips reach we follow the course of the muscles in a slowly into the tissue behind the leg, lateral to the adduc- tor fascia and toward the femur. While we now cross the fascial fibers with flat contact in the distal direction on the front of the leg, the far more

116 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.95 Fascial tubes of the thigh from the medial direction Iliopsoas (according to Benninghoff). muscle Internal obturator muscle Fascial sheath of the sartorius muscle Fascial sheath of the long adductor muscle Fascial sheath of the short adductor muscle Fascial sheath of the rectus femoris muscle Fascial sheath of the greater adductor muscle Medial vastus muscle Fascial sheath of the semimenbranous muscle Fascial sheath of the semitendinosus muscle specific contact on the rear side wanders in the lata by way of the intermuscular septa before cranial direction as if we were trying to produce a we intensify the contact. By doing so, we are groove between the adductors and the semitendi- respecting a fundamental rule of fascial and nosus muscle. As we do so, we ask the patient to membrane techniques, which states that we alternately flex and extend the knee slightly. On should give an impulse into the superficial the front, the contact remains gently sliding, while layers only strongly enough that the deeper we use the weight of the leg on the rear side, layers can follow the response of the superficial which has more strongly pronounced fasciae, to layers. slide more strongly and very slowly. Although we are working on the front and rear Anatomy of the fasciae of the lower leg of the leg with different qualities of touch, we and foot have a common technical strategy. In both regions, we are “waiting” for the response of Analogously to the upper extremity, we find a the tissue and the bone connected to the fascia superficial fascia that is connected to the deep lay- ers in the calf as well. There is a direct connection

FORM-ORIENTED TREATMENT TECHNIQUES 117 Figure 4.96 Treatment of the fascia lata (medial layer) and the investing fascia of the adductors. Figure 4.97 Treatment of the anterior layer of the fascia lata in combination with the posterior layer. between the superficial and deep crural fascia in the triceps surae of the calf is also formed by the that one anterior and one posterior intermuscular deep lamina of the crural fascia, forming an addi- septum runs inward from the superficial layer. tional chamber between the superficial and deep Similarly to the forearm, longitudinal displace- plantar flexors. ment of the bones is prevented in the lower leg by a strong interosseus membrane. Along with the A few peculiarities of the crural fascia are of tibia and fibula, this membrane separates the importance for the techniques described below. extensor musculature located in the front section of From a purely mechanical viewpoint, its superfi- the lower leg from the flexor musculature located cial layer is closely connected to the periosteum of in the rear section of the lower leg. In addition to the tibia. A connection to the fibula by way of the this osteofibrous separation, a fibrous chamber for front intermuscular septum is present as well. From a neurological viewpoint, since Staubesand’s

118 FASCIAL AND MEMBRANE TECHNIQUE Superficial crural fascia Extensor compartment Figure 4.98 Fascial and muscular canals Tibia of the lower leg in cross-section at the Anterior intermuscular level of the lower third. septum Superficial crural Peroneal compartment fascia Fibula Posterior intermuscular septum Superficial flexor compartment Deep flexor compartment Deep lamina of the crural fascia research, the fascia has prompted far-reaching con- This dissimilarity in the morphology of the fas- sideration (Staubesand and Li 1996; Schleip 2003): cia requires an extremely precise differentiation in Staubesand found contractile fibers in the crural the quality of touch when treating the lower leg. fascia. Using altered tensile stress, the fascia could therefore modify the tough spatial delimiters in the There is one other characteristic of the crural lower leg down into the interconnection of mem- fascia that requires a particular treatment tech- branes and periostea. nique. At its lower end, where it comprises only a relatively thin layer, it transitions seamlessly into This sort of modification would have a substan- the retinacula; it forms regular guiding canals into tial influence on the muscle tone because the fascia which the tendon sheaths are embedded, in the serves as the origin of the muscle in the proximal front it forms them for the extensor tendons along direction. with two retinacula and in the rear it forms them for the flexor tendons. For treatment techniques, it is helpful to pay attention to the different formations of the fascia. Each of the retinacula continues on the rear of Depending on the level of load, the fascia on the the foot and the sole of the foot into the fascial lay- superficial and deep levels will develop in a more ers of the foot. Thus, the retinacula provide a con- or less fibrous fashion. It can sometimes be so stiff nection to the plantar aponeurosis in the distal that it can hardly be distinguished from the adja- direction and to the crural fascia in the proximal cent musculature. In individual deep sections, it direction. For the treatment of these structures, can also function as a simple displacement layer. it is important to bear in mind that the retinacula Von Lanz and Wachsmuth (1972: 303) have do not represent a separate band structure; referred to the fact that the deep crural fascia dou- rather, they are a functionally determined local bles over the tuberosity of calcaneus while farther thickening of fascia. Correspondingly, any effect in the cranial direction it becomes quite delicate on their tough fibrous structure is always also an and, in the proximal direction, it frequently effect of the overall fascial complex of the leg and becomes a simple “displacement device.” foot.

FORM-ORIENTED TREATMENT TECHNIQUES 119 In contrast to the retinacula, the fascia on the Transverse axis rear of the foot is thin and easily displaceable. This of the hip joint layer should be included in treatment only in the case of an extremely high arch of the foot and, even Shaft axis in these cases, treatment should occur on the adja- of the femur cent retinacula to the greatest extent possible so as to protect the tendon sheaths located farther in the Baseline of the knee distal direction on the back of the foot. Caution is Exterior angle of the advised on the sole of the foot as well for the plan- knee, 174° tar fascia, which usually has a strong structure. Only in the case of extremely high arches of the foot should we attempt to have a massive effect on the plantar fascia. Because the foot has lost its grasping function over the course of human devel- opment and muscles have been converted into lig- aments, its form and structure are determined substantially more by bands than by fasciae. Treatment techniques for the axes of hinge Transverse axis of joints at the level of the ankle, knee, and the upper ankle hip joints Figure 4.99 Hinge joint axes of the ankle, knee, and hip joints. The following techniques can be traced back to Ida Rolf. These techniques have proven themselves pri- continues to hold the joint within the hinge axis in marily in the treatment of decreased flexion or a very decisive manner. This causes an activation extension function in joints of the lower extremity. I of muscle fibers that are usually involved in move- have achieved the best results in treatment after sur- ment only to a limited extent as well as an orienta- gical interventions and after immobilization (splint tion of the fasciae and membranes that also or cast). In my opinion, the efficacy of these tech- corresponds to the hinge joint axis. niques is due to the successful combination of a direct effect on the connective tissue and precisely Treatment of the ankle and knee joint using coordinated active movement on the part of the the hinge joint axis technique in three steps patient. These methods are based on the notion that, in the vicinity of a joint, we will only ever be able to First step reach some of the tissue layers using direct contact. Patient Supine, one leg flexed, one leg extended Another part of those layers can be accessed only in in such a way that the heel extends over the edge an indirect manner using active movement by the of the treatment table. patient. Therapist Sitting at the foot, facing in the cranial These techniques can be varied in a variety of direction. ways. However, they always follow a clear treat- ment strategy: the therapist’s hands create several Contact With the surface of the distal phalanges fixed points, or more accurately fixed surfaces of of both hands at the point at which the inferior the deep fascia, and exercise pressure in such a extensor retinaculum intersects with the tendon way that the joint positions itself as normally as sheaths, while both thumbs support the arch of the possible. In other words, the therapist holds the foot just in front of the heel. joint in the normal hinge axis position to the great- est extent possible. Then the therapist asks the Action The therapist uses the distal phalanges to patient to slowly perform flexion and extension reach in a two-dimensional manner toward the movements of the affected joint while the therapist

120 FASCIAL AND MEMBRANE TECHNIQUE inferior extensor retinacula of the lower legs and, at then the toes. During this entire sequence of move- the same time, supports both longitudinal arches ments, the therapist maintains strong contact with from below with the thumbs. The therapist asks the the retinacula and fixes the hinge joint axis. While patient to adduct first the toes and then the foot. the patient repeats the sequence of movements sev- Subsequently, first the foot should be stretched and eral times, the therapist stretches the fibers. Figure 4.100 Load on the knee joint with a normal hinge axis and an altered hinge axis. Normal legs Genu varum Genu valgum (bow-legged) (knock-knee) Figure 4.101 Treatment of the ankle and knee joint using the hinge joint axis technique, first treatment step.

FORM-ORIENTED TREATMENT TECHNIQUES 121 Second step to push against the therapist’s thoracic cavity. The In a continuing treatment step, the therapist uses therapist asks the patient to move the knee the ulna, just below the elbow joint, to contact the approximately 5 cm toward the ceiling and, at the medial side of the retinaculum, while strongly same time, moves the patient’s foot upward using surrounding the lateral side of the ankle. At the the sternum so that a correct hinge joint move- same time, the therapist’s sternum supports the ment occurs at the same time in the ankle, knee, foot as if the sole of the patient’s foot were trying and hip joints. The therapist remains in extremely energetic contact so that the hinge joint axis Superficial crural fascia remains precisely in the same position as soon as the patient raises and then lowers the knee. Superior More simply, the therapist exerts pressure inward retinaculum extensor using the ulna and the hand, compressing the joint while maintaining the hinge joint axis while Inferior the patient provides a correcting impulse with retinaculum extensor the movement described above. Depending on the extent of the deviation from the hinge joint, this sequence of movements may have to be repeated up to five times. The efficacy of this method can be increased by asking the patient to perform the movement only in a minimal fashion and finally, following an idea by Moshe Feldenkrais, advising the patient to only imagine performing the movement. Figure 4.102 Fiber orientation of the retinacula at the Third step transition between the lower leg and foot. Patient Same position as above. Therapist Standing, one knee flexed on the treat- ment table. Figure 4.103 Treatment of the ankle and knee joint using the hinge joint axis technique, second treatment step.

122 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.104 Treatment of the ankle and knee joint using the hinge joint axis technique, third treatment step. Contact With the therapist’s knee at the sole of The efficacy of the hinge joint technique the patient’s foot, with the second phalanges of the depends on the precision of the guided index and middle fingers of both hands below the movements. It is important to position the leg as hinge joint of the knee. if standing with the heel on the floor so that the three hinge planes at the ankle, knee, and hip Action While the therapist’s knee is pressed run parallel to one another. This is only possible against the sole of the patient’s foot, the second to a certain extent in the case of pronounced phalanges of the index and middle fingers of both knock-knee or bow legs. In cases of drastic hands are used to contact below the client’s knee, deviation from the hinge joint, we leave the leg specifically medially at the level of the patellar in its deviation and ask the patient to perform tendon and laterally on the level of the cranial por- the movement for only a few millimeters. tion of the tibialis anterior. On the medial side, the fascial fibers are diagonally oriented between the The three treatment steps described above can front edge of the tibia and the interior of the knee; be varied by selecting the lateral and medial con- on the lateral side, they are oriented almost verti- tact points above one hinge joint and below the cally to the head of the fibula. The therapist ini- next highest hinge joint. tially maintains the contact while the patient raises the knee against the therapist’s pressure. The con- Treatment of the superficial layer of the tact on the sole of the foot is maintained so that a crural fascia guidance of the joint occurs in a hinging motion. While the patient repeats this sequence of move- Patient Lying supine, one leg flexed. ments several times, the therapist begins slowly to intersect the fascial fibers below the knee at both Therapist Sitting at the foot. contact points: horizontally on the lateral side and in a crescent-shaped line against the diagonal path Contact The therapist’s shoulder supports the sole of the fascia on the medial side (see Figure 4.104). of the foot. With one hand, the therapist slightly Even during this strong contact with the fascia, the guidance of the hinge joints at the ankle and knee must be maintained.

FORM-ORIENTED TREATMENT TECHNIQUES 123 Figure 4.105 Treatment of the ankle and knee joint using the hinge joint axis technique (variations). lifts the lower leg by grasping the crural fascia in on the medial side of the tibia instead of on the the distal direction from the medial portion of the head of the fibula and to follow the leg farther into gastrocnemius muscle and the fingertips (medial the genu varum. side) and the thumb (lateral side) of the other hand surround the head of the fibula. In both cases, genu valgum and genu varum, the indirect guidance into joint fixation should be com- Action The foot of the patient’s slightly raised bined with the direct impulse applied to the fascia. leg is in contact with the therapist’s shoulder. The The effect presumably arises because we are simul- therapist surrounds the head of the fibula while taneously exerting influence on the ligaments near using the other hand to produce a flat contact on the joint and the insertion of the crural fascia in the the rear side of the lower leg. The therapist uses proximal position of the tibia and fibula. the shoulder contact to move the patient’s ankle passively while using the contact with both hands Treatment of the interosseous membrane to move the knee and hip joints in the movement of the lower leg direction of the hinge joint axis. While doing so, the therapist follows the deviations from the hinge Patient Supine, both legs extended. joint axis passively, with “listening” and without reducing contact with the fascia. Therapist Sitting at the feet. In the case of genu valgum, the leg will move Contact Initially, with two fingertips of one hand farther into the knock-knee configuration. The from behind on the farthest distal point of the lat- therapist follows the movement until it has almost eral malleolus, with the fingertips of the other come to a stop and, at this moment, applies a hand also from behind, slightly above the distal sustained impulse into the fascial tissue and/or fifth of the tibia. the connecting ligaments at the head of the fibula in order to then follow the leg in its countermovement. Action The therapist’s fingertips gently push the lateral malleolus from the distal and posterior In the case of genu varum, the leg usually moves directions precisely parallel to the fiber orientation somewhat more strongly into the bow-legged of the anterior tibiofibular ligament so that the lat- shape. In this case, it is better to maintain contact eral malleolus slightly approaches the lower

124 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.106 Treatment of the superficial layer of the crural fascia. Anterior ligament Figure 4.107 Interosseus membrane of the of the head of lower leg from the anterior direction. the fibula Tibial tuberosity Head of the fibula Crural interosseous Anterior membrane tibiofibular ligament Medial Lateral malleolus malleolus

FORM-ORIENTED TREATMENT TECHNIQUES 125 Figure 4.108 Treatment of the interosseous membrane of the lower leg. medial end of the tibia and the band running align them relative to one another in their between them relaxes somewhat. During this, the muscular and fascial beds. This technique can fingers of the therapist’s second hand surround be applied accordingly on the upper end of the the inner edge of the tibia from behind and guide lower leg; here, we must bear in mind the the entire bone gently toward the contact point almost horizontal orientation of the fibers of the of the other hand. While this causes the tibia to be anterior ligament of the head of the fibula and very slightly displaced in the distal direction, the should therefore guide the head of the fibula fibula will go into either rotation or a longitudinal almost parallel to the hinge joint of the tibia shift depending on the dominant fiber tension of while supporting the tibia from behind. the interosseus membrane. The therapist follows this movement, which occurs spatially in several Critical readers may doubt that this technique steps, while the quality of contact achieves in the even affects the interosseous membrane. It is cer- patient as deep as possible a relaxation and reduc- tainly correct to assume that the effect is transmit- tion in tone of the exterior muscle layers. The ther- ted to the deep crural fascia, which is more elastic, apist accepts the weight of the lower leg more and to its insertion in the distal portion of the bones of more and, while doing so, performs the “listen- the lower leg, and to the corresponding muscular ing” described above until the movement comes insertions. The following technique attempts to to a stop. take this possible connection into account. This technique can be varied by using mobility Treatment of the deep crural fascia in the tests to find the point with the strongest overarching fascial context restriction between the two bones of the lower leg. We frequently find this point in the region Patient Supine, both legs extended. of an old fracture. In practice, it is important to ensure that the contact points that we select Therapist Sitting at the feet. with both hands are diagonal to one another so that both of our hands can follow the dominant Contact With the side of the flexed index finger direction of pull and, in so doing, be able to facing the thumb on the rear of the lower leg near the talus and slightly below the gastrocnemius muscle.

126 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.109 Treatment of the deep crural fascia. Action Both of the therapist’s hands are placed on force and break off the process. However, if we can the treatment table with the outer edge and the fin- feel a difference, we first follow the more elastic side gers are slightly flexed. The hand applied below in as far as we can and wait for the reverse impulse to the region of the talus is somewhat flatter under the exert a subtle shear pulse on the side that was origi- patient’s lower leg than the second hand so that the nally more strongly “blocked” until the lateral and patient’s knee is slightly raised. The therapist now medial edges of the knee offer the same amount of gradually modifies the quality of the touch—it resistance. This is the moment of equilibrium in becomes gradually more elastic until the tone of the which we remove our touch. superficial muscles relaxes more and more and a contact is produced with the deep crural fascia. At TREATMENT OF THE HIP JOINT IN THE this moment, the therapist applies a slight impulse CASE OF ONSET OF ARTHROSIS upward, in the direction of the ceiling, as if to gently reach upward with the fingertips through the deep In recent years, considerable advances have been crural fascia. In so doing, the therapist follows any made in the implantation of artificial hip joints. tensile forces that may occur that guide both hands The implants themselves as well as the surgical together or apart while remaining constantly in procedures have improved substantially so that strong yet elastic contact. It is as if the therapist were today a positive long-term prognosis can be given touching a stretched trampoline from below, tracing in most cases. the tension patterns that manifest there, and noting the tensional forces working on this trampoline in The manual techniques described below are order to set them against one another and gradually directed at two goals: neutralize them. Successful neutralization can be recognized by the patient’s lower leg finally resting ● On the one hand, the attempt should be made on the therapist’s fingertips in a completely motion- to optimize the transmission of pressure forces less fashion. At this moment, it is worthwhile to gen- onto the hip joint, to facilitate a better tly push both contact points in the cranial direction distribution of joint fluid and thus slow the until the resistance of the knee joint is felt. If the course of progressive changes to cartilage. In resistance has the same quality in the medial and lat- the most favorable case, it should be possible eral directions, it is advisable to remove the shear to postpone the time at which an implant is required.

FORM-ORIENTED TREATMENT TECHNIQUES 127 ● On the other hand, the treatment of the way that tendencies toward “normal” pressure involved connective tissue structures should and tension conditions are already manifest in the achieve a type of rehabilitation before the myofascial units that intersect the joint capsule or surgical intervention. have their course in its vicinity before the implan- tation of the artificial hip joint. In order to achieve In the course of progressive arthrosis of the hip an effective treatment result, it is necessary to joint, considerable compensatory changes occur combine globally applied techniques that act on not only in the pelvic region, but also in the distal the fascial complex above and below the joint cap- direction from the hip joint, primarily in the sule with techniques that influence structures ankles. In the superior direction from the hip joint, inside the capsule. primarily in the region of the pectoral girdle, com- pensatory changes to muscle tone and fascial ten- Anatomy of the fasciae and membranes in sion may be frequently observed as well. In my the region of the hip joint practice, I have observed again and again that manual treatment as preparation for an implant, Because the hip joint is located directly at the tran- i.e. rehabilitation before the surgical intervention, sition between the lower extremity and the interior is more important than postoperative care. This of the pelvis, very different myofascial units of the may be due to the fact that compensatory changes body components mentioned above—pelvis, legs, already emerge in the myofascial system at the feet—can have an influence on the function of this beginning of arthrosis. These compensations man- joint. The joint must be able to withstand compres- ifest themselves progressively in the muscular sional forces originating from the torso as well as units of the pelvis, primarily in the rotators, which strong tensional forces from the lower extremity. connect the sacrum to the femur on the greater trochanter. After a longer period of time, these In the superficial layer, we encounter the ante- changes not only act on the musculature, but also rior portion of the fascia lata. It is significant as the extend to the fibers of the ligaments: overarching layer for the hip joint because it is connected to the iliac crest, inguinal ligament, ● the sacrotuberous ligament pubic bone, and ischial bone and continues in the ● the sacrospinous ligament distal direction to the superficial fascia of the knee ● the obturator membrane. (Lanz and Wachsmut 1972: 100). If these changes are not treated before the surgi- In addition, the fascial sheath layers of the adduc- cal intervention, the implant will be included in tor group, which are referred to in their distal region the compensatory tension pattern that corre- as the pectineal fascia, are significant as the middle sponds to the inflamed joint that was restricted in layer. I would speculate that these fascial sheath lay- its movement. In the case of a strongly pro- ers, along with the predominant tone pattern of nounced compensation pattern, the ability of the their associated musculature, play a role in the distal organism to adapt is overextended. In this case, portion of the hip joint. It is possible that the tensile we are confronted by a situation in which, in spite forces that act on the medial and distal portion of the of a “new,” functional hip, the dysfunction of the joint are responsible for the narrowing of the seam surrounding tissue continues to hinder coordi- of the joint that is visible in radiographic images. It is nated overall function. possible that tensile forces acting in the posterior direction, i.e. the entire myofascial complex of the It is not simple to differentiate to what extent rotators, play a role. In the case of these layers that the changes mentioned above actually correspond run posteriorly between the sacrum and the great to a compensatory pattern and to what extent they trochanter, individual muscles have a particularly already had an effect before the onset of the arthro- important role because they are able to intensify the sis, perhaps as a mechanical component of changes compressive forces within the joint. All muscles that to cartilage. This differentiation, however, does rotate the leg outward and that run parallel to strong not play any role in our practical treatment strat- ligaments should be emphasized. For example, the egy. In any event, we must treat the hip in such a

128 FASCIAL AND MEMBRANE TECHNIQUE superior gemellus muscle, which runs from the capsule, there is a cushion of connective tissue and spine of the ischium to the trochanteric fossa, should fat as well as the ligament of the head of the femur. be mentioned because its fibers have an orientation The mobility and cushioning function of these ele- that runs parallel to that of the sacrospinous liga- ments play a considerable role in intracapsular ment, which has a high tensile strength. The three- distribution of fluid. dimensional, not just two-dimensional, impact on the hip joint becomes clear when we observe that Treatment techniques the fibers of the obturator internus muscle have an orientation parallel to that of the sacrospinous liga- Treatment of the myofascial tension patterns ment. The obturator internus has a strongly pro- that transmit onto the ischial ramus nounced fascial sheath and, in its tendinous portion, is connected to the tendons of the superior and infe- Patient Supine, one knee flexed. rior gemelli muscles where they insert into the trochanteric fossa. Therapist Sitting next to the treatment table at the level of the patient’s knee. In this myofascial context, the iliopsoas fascia also plays an important role. Along with the perios- Contact With the flat underside of the fingertips teum of the iliac fossa, it forms an osteofibrous tube of one hand between the origin of the adductor that offers space for the iliac muscle. Von Lanz and magnus and semitendinosus muscle as near as Wachsmut (1972: 98) have pointed out that the possible to the ischial tuberosity; at the same time, posterior side of this tube has grown into the cap- the other hand supports the entire thigh from the sule of the hip joint. posterior direction. Moreover, the interrelation of connective tissue Action The supporting hand raises the thigh elements of the pelvic cavity with the iliopsoas slightly so that a passive flexion of the hip and knee fascia is significant as well: the path of the renal joint occurs. At the same time, the fingertips of the fascia is in the direct vicinity of the psoas muscle. other hand gradually move between the adductor Its posterior layer is connected to the psoas fascia magnus and semitendinosus toward the ischial and the medial crus of the diaphragm (Breul 2002). tuberosity. The passive movement of the thigh causes the contact to wander gradually inward and, For the diagnostic evaluation of the hip joint, it is once it arrives under the subgluteal, horizontal part important to bear in mind that disease processes can spread by way of the renal fascia from the perirenal Iliac bone Connective tissue space in the inferior direction by way of the lacuna cushion in the of muscles to the lesser trochanter. In the latter case, Iliofemoral pain occurs in the region of the hip joint, the cause of ligament acetabular fossa which can be found in the perirenal space. Ligament Finally, it should also be mentioned that the of the head chamber of the pelvic and abdominal cavities of the femur located above the hip joint transmits pressure in the direction of the hip joint. We can only specu- Transverse late as to the extent to which this transmission of acetabular ligament pressure has unfavorable effects on the hip joint due to restrictions in organ movement. In practice, Figure 4.110 Frontal section of the right hip joint. techniques that take into account the peritoneal space and the retroperitoneal concentration of con- nective tissue of the organs have proven useful. In addition to the numerous layers that inter- sect with the hip joint outside of its capsule, the interior of the joint capsule has significance for the treatment concept described above as well. Between the head of the femur and the hip joint

FORM-ORIENTED TREATMENT TECHNIQUES 129 of the fascia lata, it should work determinedly and Treatment of the myofascial complex of the unyieldingly in the deep layer. As soon as the con- rotator group tact arrives in the deep layer between the two mus- cles, we can increase the efficacy by using our Patient Supine, one leg flexed. supporting hand to guide the entire leg passively in slight inward and outward rotations. In so doing, it Therapist Sitting next to the treatment table at the is important for our contact to be applied parallel to level of the patient’s knee. the muscle fibers and transverse to the primary direction of the fascial fibers. Contact With the fingertips through the exterior gluteal muscles in the direction of the rotator Figure 4.111 Treatment of the myofascial tension patterns that transmit onto the ischial ramus. Figure 4.112 Hand position for the treatment of the right hip.

130 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.113 Treatment of the myofascial complex of the rotator group. Figure 4.114 Hand position for the treatment of the right hip. group, while the other hand maintains contact the foot in a flat manner, the patient’s attention is with the sole of the foot. directed toward the tactile perception of the “artificial ground” formed by our hand (this des- Action The therapist uses the patient’s weight ignation was originated by Moshe Feldenkrais, initially to reach through the superficial gluteal although he used a wood board held in both of the musculature. The contact of the therapist’s fingers therapist’s hands to produce the artificial floor). is placed precisely between the obturator internus The patient is now asked to exert slight pressure and the piriformis. The pressure is thus transmit- with the soles of the feet; the therapist’s hand pro- ted approximately to the layers of the gemellus vides counterpressure so the patient’s knee is raised superior. While the other hand supports the sole of somewhat. During this process, the therapist

FORM-ORIENTED TREATMENT TECHNIQUES 131 Iliofemoral Acetabulum Ligament of the Obturator ligament head of the femur membrane Orbicular zone Ischiofemoral Pubofemoral Ischiofemoral Pubofemoral ligament ligament ligament ligament Figure 4.115 Reinforcing ligaments of the joint capsule of Figure 4.116 Right hip joint after the opening of the joint the hip. capsule. follows the contact on the level of the gemellus Treatment of the connective tissue cushion in superior in “listening,” so that the entire leg the acetabular fossa and the ligament of the rotates minimally, either outward or inward. This head of the femur movement is followed until it stops, then the ther- apist attempts to slightly reinforce the counter- Patient Supine, both legs extended. movement that occurs. At the same time, the contact with the fascia of the superior gemellus Therapist Sitting at the foot of the treatment table. muscle is intensified as if the therapist’s fingertips were trying to reach through the patient’s pelvis in Contact The sole of the patient’s foot presses gen- the direction of the ceiling. tly against the therapist’s sternum, the weight of the leg is resting on both of the therapist’s hands; The technique described above requires the the therapist is using one palm to support the thigh independent use of both of the therapist’s hands, from the posterior direction and the other hand to and attention to the contact of the sole of the foot support the lower leg from the posterior direction. from the patient. If there is sufficient coordination between the therapist and the Action While the therapist’s sternum gently patient, it is possible for us to produce an indirect touches the sole of the foot, the therapist supports connection to the ligaments that surround the the lower leg and thigh from the posterior direction hip joint from the outside. In order to do so, it is and follows rotations that occur between the two important that we actually follow the rotation of sections of the legs, which may take on a slight the leg within only the most minimal spatial knock-kneed or bow-legged shape. It is important changes without inducing too much muscle to follow the dominant pattern and, at the same activity. In the most favorable case, this allows us time, maintain contact with the sole of the foot. As to achieve a three-dimensional division of the soon as the dominant pattern is manifest, the thera- reinforcing ligaments of the joint capsule. pist gently pushes along the central line of the leg toward the hip joint. This push should be per- formed at the same time with the sternum against the sole of the foot and the supporting hands on the thigh and lower leg. At the moment at which the

132 FASCIAL AND MEMBRANE TECHNIQUE Figure 4.117 Treatment of the connective tissue cushion in the acetabular fossa and the ligament of the head of the femur. resistance in the hip joint becomes obvious, the such a subtle effect that it reaches the interior therapist guides the entire leg slightly in the medial of the joint capsule. Any rough, mechanical direction, i.e. in the direction of the connective tis- traction on the leg must be avoided because it sue cushion in the acetabular fossa and ligament of would only lead to the movement of exterior the head of the femur. The therapist thus presses the layers and usually does not address the fovea of the head of the femur against the connec- interior movement pattern in the capsule. If tive tissue cushion and against the ligament on the the technique described above is successful, medial portion of the acetabulum. As soon as the the patient has a sensation as though the entire therapist detects a counterforce, the therapist fol- leg were wandering out of the hip in the distal lows the tiny wave of pressure that manifests in the direction and becoming longer. entire leg and thus allows a tiny expansion of the joint space and thus a redistribution of joint fluid. Supplementary treatment techniques This technique may be summarized in a simpli- The techniques described in the chapter on the fied fashion as follows: the therapist guides the lower extremity for the treatment of the fascia of head of the femur in small steps farther into the the lower leg (treatment of the superficial layer of joint socket until a slight counterpressure is felt. the crural fascia and treatment of the deep crural The therapist intensifies this counterpressure fascia) and of the band structures in the region of gradually with the feeling of the fingertips so that the ankle (treatment of the ankle) are suitable to the head of the femur figuratively wanders out of supplement the treatment techniques described the joint socket. Even though this is a minimal here. If restrictions in the movement of the pelvic spatial change, its effect is lasting in terms of the organs can be felt on the side of the affected joint, distribution of joint fluid. treatment with the techniques described in detail by Jean-Pierre Barral and Paul Mercier is advisable This is an effect of the connective tissue and (Barral and Mercier 2002). ligament structure in the interior of the joint capsule. Because the goal of this treatment is a The organs of the urogenital tract are particu- better distribution of joint fluid, it is essential larly significant in this context, particularly the that the shear force exerted by the therapist has kidneys and bladder.

FORM-ORIENTED TREATMENT TECHNIQUES 133 There is also one other starting point for treat- its boundary surfaces. In the region of the hip ment that deals with the nerves bordering the hip joint, the technique mentioned above can be region. Barral and Croibier have developed tech- applied to the femoral and obturator nerves. niques for the treatment of the peripheral nerves that go beyond the original visceral concept. These A very efficient technique for the treatment of techniques appear to act directly on the connective the obturator membrane may be found in Prat tissue sheath layers of the nerves and therefore (1993: 7–33). influence the forces acting between the nerve and

135 Chapter 5 Special joint techniques CHAPTER CONTENTS 5.1 VERTEBRAL JOINTS 5.1 Vertebral joints 135 Before treatment of vertebral and costal joints, the 5.2 Treatment of intervertebral disk restriction of motion of the joint is first examined protrusions 146 in the context of the small muscular and ligamen- 5.3 The sacrococcygeal joint 153 tous units near the joint. Then we look for a possi- The significance of the coccyx as the stabilizing ble connection between the restriction of movement element of the lower pelvic cavity 153 and larger tissue layers or structures. In the case of Anatomy of the coccyx and adjacent the spine, we are concerned with the curvatures structures 154 of the individual sections of the spine along with Examination 155 all of the structures in the region of the cervical, Treatment techniques 160 thoracic, and lumbar spine. 5.4 Joints of the foot 162 When performing this treatment in practice, the therapist must be able to use both hands and the individual fingers independently of one another so as to produce five or more contact points to the side of the spine with one hand. This plurality of contact points is necessary because only in this manner can we achieve an effect on tissue layers near the joint while keeping a large portion of the back in a position that facilitates treatment. Treatment of motion restrictions of vertebral joints in the thoracic spine Patient Supine, both legs extended. Therapist Sitting at the head. Contact The back of the patient’s head rests on both of the therapist’s forearms; the fingertips of both of the therapist’s hands are touching the tis- sue to both sides of the affected joint.

136 FASCIAL AND MEMBRANE TECHNIQUE Action The weight of the therapist’s forearms is sides, this process may take approximately two to transferred onto the treatment table in such a way three minutes. that the flexion musculature of the forearms is as relaxed as possible and the back of the patient’s Treatment of costal vertebral joints in the head is resting on it as if on two soft pillows. The mid-region of the thoracic spine therapist now positions the fingertips of both hands on both sides of the blocked joint slightly below Patient Sitting on a stool. the transverse processes of both vertebrae. If the therapist’s forearms are offset from one another on Therapist Standing at the patient’s side with one the treatment table, one hand will be able to reach foot on the seat of the stool in order to support the somewhat farther downward than the other. It is elbow of the hand applying the treatment on the crucial that the patient be relaxed, with the critical thigh. zone resting on the therapist’s fingertips. The ther- apist supports the region of the thoracic spine in Contact Precisely below the affected rib and such a way that the habitual curvature of this sec- slightly lateral of the costotransverse articulation. tion of the spine and back that is typical for every patient shows up. At the same time, the therapist Action The patient relaxes both hands and places uses “listening” to follow every movement, no them on the pectoral girdle without interlocking matter how small, that is sensed in the movement- them. The therapist holds both of the patient’s restricted joint. The therapist intensifies this move- elbows so as to be able to guide the patient’s upper ment tendency in the direction in which it can be body in passive rotation and lateral flexion. The felt most strongly and, in so doing, moves the joint therapist now examines how the tissue and the more into its restriction. In the brief moment of blocked joint in the area of fixation behave when this “wedging,” the tactile sense of the therapist’s the ribcage is rotated slightly to the left and right. fingertips concentrates on the pull of the soft tis- For this treatment, it is important to prevent rota- sue. The therapist gradually intensifies the contact tion to the side where the blockage is reflected. in a very precise manner with these tissue units, Instead, the therapist rotates the patient’s upper which may be quite small, until a countermotion body in the other direction while using the thumb can be felt that guides the joint out of its blockage. to maintain the pressure in the tissue below the rib. In the case of a genuine fixation of the joint on both It is important that the patient’s upper body not be overextended in this process. It is crucial that the Figure 5.1 Treatment of motion restrictions of vertebral joints in the thoracic spine.

SPECIAL JOINT TECHNIQUES 137 contact with the thumb remain very sensitive in order to sense precisely how the blockage changes with the lateral rotation. It is sometimes necessary to combine the lateral rotation with minimal lateral flexion of the thoracic spine. A similar treatment technique with the patient lying down is recommended for the lower three ribs. In the case of very increased tone in the muscu- lature of the pectoral girdle, this technique cannot be successfully applied to the two upper costal vertebral joints. In such a case, the mobilization of the posterior scalene fascia or a direct joint manip- ulation is advisable. Before applying this technique, it is advisable Figure 5.2 Treatment of costal vertebral joints in the to first examine and, if necessary, treat the middle region of the thoracic spine. connection of the ribs to the sternum in the anterior region (see section 4.1, Treatment of hands to the costal arch, and rotates the lower sec- the sternoclavicular connection). Under some tion of the chest cavity as a whole, first in one direc- circumstances, treatment should also extend to tion and then in the other. Below the fixated joint, global tension patterns of the myofascial layers the therapist’s thumb reaches into the tissue from that are located in the retrosternal region (see the lateral direction. While allowing this thumb section 4.1, Treatment of the sternum and the contact to act as a wedge, the therapist rotates both transversus thoracis). The transversus thoracis halves of the thorax opposite one another in a tiny and, for the lower ribs, the uppermost segment rotation, as if the body consisted of two self-con- of the transversus abdominis, which is directly tained cylinders in this area. It is important to per- adjacent to the transversus thoracis, are form the rotation of the two “cylinders” in such a particularly significant here. Because the way that the joint fixation of the ribs is reinforced rib–vertebra connection is a double joint—the until a countermovement manifests in the fixation, costotransverse articulation and the which the therapist uses to correct it. costovertebral articulation—and because tendons, ligaments, muscles, and membranes Treatment of motion restrictions in the are attached to this joint in a wide variety of upper lumbar spine directions, this technique requires precise knowledge of the joint mechanism. Patient Prone. Treatment of the lower three costal Therapist Sitting next to the treatment table at vertebral joints the level of the abdomen. Patient Supine, both legs extended. Therapist Standing at the level of the hips. Contact With both hands from the posterior direction in the region of the lower three ribs. Action The therapist surrounds the ribcage with both hands from the posterior direction, adapts the

138 FASCIAL AND MEMBRANE TECHNIQUE Figure 5.3 Treatment technique for the lower three costovertebral joints. Contact With one hand on both sides next to the upper lumbar area in relation to the passively the sternum, in the region in which the fifth, sixth, induced movement. and seventh ribs are connected to the sternum; at the same time, with the other hand and extended If performed precisely, this technique has the forearm supporting the thighs from the anterior advantage that it includes prevertebral and posterior direction. layers in the treatment at the same time. If the fixa- tion of the upper lumbar vertebrae is more strongly Action The therapist first places both hands in pronounced on the left side, a variation of this tech- the initial position described above and then nique is advisable: with one hand, the therapist selects the contact in the region of the lower ster- grasps not the arch of the ribs and sternum, but num as the fixed point and uses the fingertips and rather the left section of the duodenum in the direc- heel of the hand to press in the direction of the tion of Treitz’s ligaments and uses a stretching xiphoid process. This pressure should act inward, impulse to guide it to its connection point on the that is to say, influence the tension of both cupulas upper lumbar spine and back again. of the diaphragm and their ligamentous connection to the stomach and liver. The arm and hand that Decompression technique for the transition the therapist is using to support the thighs now between the lower lumbar spine and sacrum perform a slight rotational motion to the left and right, which is then repeated several times in min- In the literature, there are numerous descriptions imal steps. This causes a spatial displacement of of techniques for treatment of the transition the insertion of the psoas on the lesser trochanter. between the lumbar spine and sacrum. The tech- By this repeated subtle movement, which covers nique described here is similar to techniques that only a few millimeters, an induction of the flexion are already known.1 and extension of the psoas muscle occurs. Finally, the therapist rotates the patient’s pelvis, which is Patient Supine, both legs extended. moved as one unit, and legs against the fixed tho- racolumbar transition. Therapist Standing at the level of the thigh. If the therapist now applies the diagnostic prin- 1 For example, cf. the detailed descriptions in Upledger and ciple of general “listening,” the therapist will be Vredevoogd (1983: 141–2). able to sense the behavior of the joint fixation in

SPECIAL JOINT TECHNIQUES 139 Figure 5.4 Treatment of motion restrictions in the upper lumbar spine. Contact With the palm of one hand supporting major muscle layers is only the precondition for the the sacrum, with the fingertips just reaching the actual treatment of the small muscular units and base of the sacrum, while the other hand creates a ligament and tendon units of this section of the contact with the tissue layers near the joint on both body. In this context, it is of interest to observe that sides of the lumbar spine at the level of the fourth the iliolumbar ligament is first constructed as a and fifth lumbar vertebrae. muscular structure and does not turn into a purely ligamentous structure until an advanced age, Action The therapist supports the sacrum with approximately around the thirtieth year of life. If one hand, trying to adapt the shape of the palm there is a compression between the fifth lumbar to the individual shape of the posterior surface of vertebra and the first sacral vertebra due to a gen- the sacrum as best as possible. With the other hand, eral, very strongly pronounced muscle tone, the the therapist creates contact on both sides of the therapist can, without reservation, use the finger- fourth and fifth lumbar vertebrae with the tissue tips to apply a massive pull on the part of the layers of the lower back. This action is a specifica- lumbar fascia that runs between the sacrum and tion of the technique that we have already learned subdermis instead of the subtle traction on the in the treatment of curvature of the lumbar spine in sacrum in the inferior direction. In this regard, the its transition to the sacrum (see section 4.1, technique is similar to Ida Rolf’s “pelvic lift.” 2 Treatment of lumbar lordosis at the transition to the pelvic cavity). First, the last lumbar vertebra Treatment of motion restrictions of the and sacrum are compressed and, in so doing, we lower cervical spine precisely trace any small rotation and lateral flex- ions movements that may occur between the bony Patient Supine, both legs bent. units on our hands. Only when the tissue layers involved no longer provide resistance to us is the Therapist Sitting to the side at the head of the sacrum moved in the inferior direction out of its treatment table. compression against the last lumbar vertebra. 2The term “pelvic lift” also occurs in Sutherland (1990: 281–2). Superficially regarded, this process first appears to be a simple relaxation technique. In reality, how- ever, the relaxation of the musculature and the

140 FASCIAL AND MEMBRANE TECHNIQUE Figure 5.5 Decompression technique for the transition between the lower lumbar spine and sacrum. Contact The therapist supports the back of one contact around the uppermost thoracic vertebra forearm and the back of the hand on the treatment remains very firm. table and places the four fingertips and tip of the thumb vertically around the spinous process of If the restriction of movement in the vertebral the first thoracic vertebra, supporting the occiput segments described above is the result of a spasm- with the other hand. like, lasting flexion of the scalene group, the con- tact should be made between the upper ribs to Action With the position of the fingers and thumb which the scalene musculature is attached instead around the upper thoracic vertebra described of around the first thoracic vertebra. above, the therapist forms five support points more or less in the shape of a circle in the region of Treatment of the atlanto-occipital the lower section of the nuchal ligament, which connection begins at that point to connect to the fascia of the trapezius muscle. With the other hand, the thera- There is such a variety of tissue layers in the short pist raises the patient’s head somewhat and section between the axis, the atlas, and the base of pushes it gently in the inferior direction, as if to the skull that it is not easy to decide where the push the entire cervical spine slightly into the force is originating that is ultimately causing a ribcage. The contact around the first thoracic ver- restriction of movement at the atlanto-occipital tebra is maintained throughout this process, as if joints and, under some circumstances, fixating it the therapist were trying to send all imaginable on a lasting basis. At the transitional zone between energy from the fingertips, through the patient’s the cervical spine and the head, quite literally all tissue, and in the direction of the ceiling. The ther- of the layers may be involved, beginning with the apist now begins to minimally move the head and surface of the galea aponeurotica, which contains neck alternately to the left and right in rotation motor and sensory nerves, through the suboccipi- and lateral flexion. Here, the therapist is gradually tal musculature, into the interior of the vertebral reducing the push in the inferior direction. In canal and cranium through the dura. In addition, other words, the therapist is no longer pushing the tension patterns from sections of the body located cervical spine and neck into the upper chest cavity, in the inferior direction can easily transfer onto the but rather is accompanying the neck in the oppo- atlanto-occipital connection. site, cranial direction. In so doing, the therapist allows every lateral movement of the neck, regard- Restraint is advisable in the case of unilateral joint less of how minimal, while the supporting contact fixations because they rarely have a local origin; at the base of the skull remains very light and the rather, they arise from the various compressional and tensional conditions in both halves of the body

SPECIAL JOINT TECHNIQUES 141 Figure 5.6 Treatment of motion restrictions of the lower cervical spine. below the neck. However, it is also true for bilateral, nuchal line. This small muscle, which appears to genuine joint fixations on the occipital condyle that have a fascial connection to the dura, is of central the dominant tensile forces can originate at a greater significance to treatment practice because it can distance from the joint, for example, at the joint cause a massive compression of the atlanto-cranial between the coccyx and sacrum. If the coccyx is joints due to its almost vertical course. chronically displaced in the anterior direction and is limited in its mobility relative to the sacrum, then However, in the case of chronic joint fixation, it is the dura comes under a large amount of tensional certainly not only the tone pattern of one individual forces over its entire course into the foramen mag- muscle or muscle group that plays a deciding role. num. It is possible that the tensional conditions are Rather, it is the cooperation of the various tissues also changing in the large anterior longitudinal liga- that changes the mobility of a joint on a lasting ment, which is directly connected to the atlanto- basis. Therefore, the following technique combines occipital membrane. In any event, it can be seen direct tissue contact with a type of positioning over and over in practice that a mobilization of the known from Jones 1981. coccyx leads to a direct and very long-lasting relief of the transition between the atlas and the base of Patient Supine, both legs bent. the skull. Then we must make only a minimal sub- sequent correction at the atlanto-occipital transition. Therapist Sitting at the head. If we apply our treatment directly to the region Contact With the fingertips of both hands on the of the joints at the head of the atlas, the relatively atlanto-occipital transition, if possible. small muscles that run in the posterior direction are important. Action It is fundamental for this technique that the therapist first exaggerate the joint position that is Here, it should be taken into account that the typical of the fixation. The therapist supports the obliquus capitis inferior, the rectus capitis major, patient’s occiput very gently, then reaches directly and the rectus capitis posterior minor all run diag- below the base of the skull toward the atlanto-occip- onally to the middle line of the neck at different ital membrane after having moved the joint laterally angles of incline. The angle of incline is most pro- and rotated it corresponding to its fixation. Now, the nounced in the rectus capitis posterior minor, therapist’s sternum pushes directly against the top which runs almost vertically between the posterior of the skull in such a way that the joint position is atlantic tubercule and the internal third of the reinforced. In so doing, the therapist pushes the foremost part of the fingertips of the index and

142 FASCIAL AND MEMBRANE TECHNIQUE Figure 5.7 Deep muscles in the region of the posterior section of the neck. Smaller posterior rectus muscle of the head Semispinal Greater posterior rectus muscle of the head muscle of the head Superior oblique muscle of the head Splenius muscle of the head Posterior occipital membrane Inferior oblique muscle of the head middle fingers toward the more strongly fixated Treatment of the membrane connections side in the direction of the joint connection and between the axis, atlas, and occipital bone maintains a “melting contact” with the tissue there. The therapist pays the greatest attention to every Patient Supine, both legs extended. small change in tone at this point. As soon as the therapist’s fingertips are able to sense an increase in Therapist Sitting to the side at the level of the radiated heat or a reduction in tone of the small neck. muscular units, then the therapist slowly rotates the head and neck back into their normal position. Contact Supporting the tissue covering the pos- terior arch and transverse process of the atlas from Compared with direct joint manipulation, the the posterior direction with the thumb and index technique described above has the advantage finger; the other hand supports the occiput and its that it has a very gentle and protective effect on fingertips maintain contact just below the base of the tissue layers. Moreover, it is advantageous the skull. that the combination of positioning the joint and applying a direct effect on the tissue layers Action The primary weight of the head is trans- allows us to reach the myofascial units, ferred onto the supporting hand on the base of the membranes, tendons, and ligaments at the same skull; only part of the weight of the neck is resting time. If we omit the push against the roof of the on the contact point at the posterior arch of the atlas. skull and vary the hand position accordingly, The therapist gradually lifts the atlas slightly in the this technique can also be applied effectively in anterior direction, specifically in such a way that the the region of the middle cervical vertebral joints. vertebra moves minimally along the articular fascia. While doing so, we are guided by imagining that we are moving the anterior arch of the axis onto the anterior part of the pons of the occiput so that a relaxation occurs in the anterior portion of the

SPECIAL JOINT TECHNIQUES 143 Figure 5.8 Treatment of the atlanto- occipital connection. Occipital bone Cranial dura mater Figure 5.9 Medial section of the joints of the head. Anterior Cruciform ligament of the atlas: atlanto-occipital Longitudinal fasciculi membrane Transverse ligament Apical dental of the atlas ligament Longitudinal fasciculi Tooth of Spinal process Occipital the axis of the axis squama Dura mater of the spine Posterior atlanto- occipital membrane Tectorial membrane Posterior arch of the atlas 3rd cervical vertebra Cervical nerves, radices atlanto-occipital membrane. Once the therapist is For this purpose, it is necessary to twist the occiput able to sense the relaxation, the therapist first fol- and axis minimally opposite one another while “lis- lows only the atlas with “listening”—the occiput tening,” finally to guide them together and wait for remains a fixed point—then the therapist follows the shear effect that occurs in the small intermediate the occiput in any small movements that may occur. area between the occiput, atlas, and axis. As soon as these movements abate, the therapist changes the contact to the second cervical vertebra Treatment of the iliosacral joints using the while continuing to support the patient’s occiput. ligament and membrane connections of the The therapist now attempts to affect the tectorial pelvic cavity membrane and the short piece of the spinal dura mater that runs between the occiput and the axis. Patient Prone.

144 FASCIAL AND MEMBRANE TECHNIQUE Figure 5.10 Treatment of the membrane connections between the axis, atlas, and occipital bone. Therapist Standing at the level of the hips. Mobilization of the inferior section of the iliosacral joint Contact With one hand on the sacrum and the other hand transverse to it from the anterior direc- Patient Supine, both legs extended. tion slightly below the navel. Therapist Standing at the level of the thighs. Action The therapist tests the mobility between the organs and the sacrum by exerting vertical pres- Contact One hand supports the region of the sure in the anterior direction precisely on the sec- upper lumbar spine from the posterior direction ond segment of the sacrum. The therapist observes and the other hand supports the sacrum, with the whether this pressure arrives at the anterior hand palm touching the lower part of the sacrum in placed on the abdomen. If this is not the case, it is a order to guarantee that the fingertips can be moved sign that strong tensions exist between the sacrum laterally. and the organs located anterior to it. In this case, the therapist uses the anterior hand to lift the entire Action The supporting hand in the region of the abdominal cavity in the posterior direction toward lumbar spine reinforces the lordotic curvature. the sacrum. During this movement, the contact with This causes a general reduction in tension in the the posterior hand on the sacrum is maintained. The major extensors of the back. We ensure that the therapist subsequently allows the abdominal cavity patient is not “holding” the position, but rather to sink back a few millimeters in the anterior direc- that the weight of the patient’s entire body is being tion and follows the movement with “listening.” If transferred into our hands. By reinforcing the lor- the therapist’s hand rotates in one direction, the dotic curvature, the pelvis is tilted slightly in the therapist follows this movement to its end in order anterior direction. We follow this movement with to exert posterior pressure in the direction of the the hand supporting the sacrum. We now observe sacrum. The contact with the other hand on the how the sacrum behaves with regard to the reduc- sacrum is maintained unabated during this process; tion in tone of the musculature in the region of its quality should be slightly elastic. In this manner, the lower lumbar spine. The pulling effect of the the ligamentous connection between the cervix ligaments will become far more tangible. Under and sacrum becomes more mobile. This in turn certain circumstances, the sacrum may tilt in a diag- improves the mobility of the neck of the uterus. The onal direction, rotate slightly, or move in a clockwise forces that may be fixating the sacrum from the or counterclockwise direction. We first register the anterior direction find an improved equilibrium. direction in which the sacrum is being pulled or pushed and use our hand to feel both lateral edges

SPECIAL JOINT TECHNIQUES 145 Figure 5.11 Treatment of the iliosacral joints using the ligament and membrane connections of the pelvic cavity. Rectouterine ligament Rectum Figure 5.12 Ligamentous connection Uterus between the bladder, neck of the Cardinal ligament uterus, and rectum. of the uterus Broad ligament of the uterus Round ligament of the uterus Vesicouterine Urinary bladder ligament Pubovesical ligament of the sacrum very precisely. We concentrate However, sometimes it is also the region of the ori- entirely on detecting whether we can feel one indi- gin of the anterior piriform muscle. Under certain vidual segment of the bone as conspicuously rigid. circumstances, we can feel a type of rigidity on the This is frequently the point at which a ligament posterior section of the lower joint connection itself, with a high concentration of fibers exercises pull. which I presume comes from the lasting tension of

146 FASCIAL AND MEMBRANE TECHNIQUE Figure 5.13 Mobilization of the inferior section of the iliosacral joint. the sacroiliac ligament, which is interwoven with of a drastic protrusion being visible on the MRI the lumbar fascia. Some skill is required to keep the image but no dysfunction being associated with it lumbar region in a lordosis to support the lower and the patient being free of discomfort. part of the sacrum with the palm and use one or two fingertips to produce contact on the connec- With this fact in mind, it is worthwhile to tion of the ligament or the tendinous insertion of a attempt to treat disk problems manually, even if it is muscle on the periosteum as if we wanted to make not entirely certain that the dysfunction is actually this connection “melt.” If this technique is per- originating from the intervertebral disk. Manual formed precisely, the sacrum “swims” into a nor- treatment should be applied only if we can rule out mal relationship to the two ilia. the danger of neurological damage—and even then under neurological supervision. In order to check the result of treatment, it is advisable to have the patient stand up and walk The techniques below are particularly suited for a few steps. Then the patient should lie supine application in the region of the lumbar and cervi- again, the therapist lifts the patient’s spine into an cal spine. It is fundamentally necessary for the increased lordosis, allows the sacrum to tilt slightly patient to be positioned such that compensatory in the anterior direction, and determines whether muscle spasms are reduced to the greatest extent the unfavorable pull effect of myofascial units and possible and the acute symptoms are alleviated for ligaments has been reduced. Ideally, the sacrum the moment. The therapist should avoid any will now exhibit an intensified tilt without escap- abrupt manual intervention and only conduct ing more to the side or making rotational motions. shear, rotational, and tilt movements slowly and in small degrees in order to avoid additional irrita- tion of the affected nerve. 5.2 TREATMENT OF INTERVERTEBRAL Treatment of intervertebral disk protrusions DISK PROTRUSIONS in the region of the lower lumbar spine In spite of great progress in imaging processes, it is This technique is suitable for the treatment of lat- not always easy to decide whether the protrusion eral protrusions. In most cases, it has been shown shown on an MRI image is actually responsible for in practice that the patient should be positioned on the discomfort the patient is suffering. From the unaffected side. This allows the intervertebral orthopedic practice, we know numerous examples disk to sink back somewhat into the intervertebral

SPECIAL JOINT TECHNIQUES 147 Figure 5.14 Treatment of intervertebral disk protrusions in the region of the lower lumbar spine. space under the weight of its gelatinous filling as intraperitoneal organs diagonally in the anterocra- soon as the pressure from the two adjacent verte- nial direction toward the diaphragm. This causes a brae has been reduced. slight release of pressure between the intra- and retroperitoneal space, while the positioning of the Patient Lying on one side, legs bent. patient reinforces the stricture in the critical inter- vertebral space. The therapist now attempts to use Therapist Standing at the level of the hips facing “listening” to precisely detect the behavior of the the patient’s back. vertebrae located above and below the herniation. I assume that, in so doing, we are able to influence Contact With one flat palm in the region of the the fiber pulls of the intervertebral disk ring in the lower lumbar spine at the transition to the sacrum; moment of an indirect release of pressure. the other hand surrounds both ankles from the anterior side. In addition to “listening,” we also need the per- manent feedback from the patient regarding the Action The therapist uses the palm to precisely pressure or release of pressure on the critically sense the motion behavior of the vertebrae in the affected nerve in order to regulate this technique. critical zone. With the other hand, the therapist The angle of pelvic tilt and extent of induced pelvic surrounds both of the patient’s ankles and gently rotation are crucial. pulls the patient’s bent legs in the posterior direction in order to change the kinked transition between If the application of this technique causes the the lower lumbar spine and the sacrum into a “soft” pain situation to spontaneously improve, it is help- curvature. ful to allow the patient to rest for a while longer in the treatment position. In the second treatment step, the therapist’s thigh is positioned for support below the patient’s This technique is also suitable for treating mul- lower leg in such a way that the tilt of the right tiple protrusions in the region of the lower lumbar side of the pelvis around the hip axis in the ante- spine. rior direction is somewhat more pronounced and the right side of the pelvis rotates slightly in the Treatment of lumbar intervertebral disk direction of the center line of the body. With the protrusions in the retromedial region other hand, the therapist maintains flat contact in according to Barral the lateral region of the lower ribs and pushes the Patient Prone.

148 FASCIAL AND MEMBRANE TECHNIQUE Therapist Standing, one knee bent on the treat- Action The therapist positions the patient prone ment table. carefully enough to avoid additional nerve irritation. The therapist then places one hand in the region of Contact The thigh of the therapist’s bent leg sup- the affected segment of the back. The contact ports the patient’s legs slightly in the cranial direc- should be loose enough to allow the most subtle tion above the knees and, at the same time, the “listening.” The goal of the position is to create a therapist reaches around both legs in this region. “soft” lordosis instead of the kink characterized by compression between the fifth lumbar vertebra and first sacral segment or between the fourth and fifth lumbar vertebrae. Care should be taken if a spondylolisthesis is present with a long-term positional displacement in the anterior direction. In this case, it is advisable to support the abdominal cavity from the anterior direction and slide the peritoneum, including the retroperitoneal layers, slightly toward the critical segments in the posterior direction. Figure 5.15 Fiber orientation of the fibrous ring of an The therapist now uses a slight rotational move- intervertebral disk in the region of the lumbar spine. ment of the thigh supporting the patient’s legs to lift the patient’s legs minimally and rotate the legs slightly to the left and to the right so that this move- ment is transmitted to the pelvis. The therapist accompanies this process with “listening” using the contact hand in the region of the critical lumbar Figure 5.16 Treatment of intervertebral disk protrusions in the region of the lower lumbar spine, second treatment step.