The techniques are described outside the context of integrating the whole. They must not be used this way but only if properly indicated by that context. They can otherwise introduce disorder into the structure instead of order.
M. Obturator Internus in the Side Position
The m. obturator internus is often the key structure for the rotators(1). It originates from the inside of the membrana obturatoria and the bone encircling the foramen obturatorium and slants back and narrows towards the foramen ischiadicum minus, which is formed by the ramus ossis ischii anteriorly, the lig. sacrospinale cranially, and the lig. sacrotuberale caudally. There it exits the pelvis by turning around the ramus in back, and taking a lateral direction it inserts with a long tendon in the fossa trochanterica. Its extrapelvic portion is flanked by the two mm. gemelli. This trio together with the piriformis are the main external rotators for the femur.
Signs for a shortened obturatorius internus are: an externally rotated femur with genu valgum (X-legs), a flat gluteal region, a posteriorly tilted pelvis, and the posterior torsion side of the pelvis (ilium rotated back). These signs are typical for the external type (l).
In the side position with the lower leg extended and the upper leg flexed, the obturatorius internus of the lower side is reached from medial and below. After palpating for the angle between the ramus ossis ischii and the tendon of the semitendinosus just in front of the ischial tuberosity, the fingers slide over the ramus inside the pelvis to reach the muscle which is normally thick and flat. Going up and back in the direction of the corpus ossis ischii, the obturatorius internus is followed to the critical place where it crosses the ischium on the inside and turns out around the back of it. The shortened muscle is thin and rounded and lies more caudal in the foramen ischiadicum minus. It tends to be glued down to the bone, and the tissue can then not be moved easily.
Freeing the tissue from the bone and lengthening it is helped by two kinds of movement. Passively, the lower leg is taken back – the knee is now flexed – and rotated medially to prestretch the tissue. Releasing the leg and lifting the foot around the knee as the fulcrum rotates the leg externally and releases the tissue. Alternating between internal and external rotation eases the going in to the turning point of the obturator internus and helps with releasing the tissue with the other hand. Actively, the client alternates between going into an anterior pelvic tilt and tilting the pelvis back – aided by raising the knee of the upper leg more -, and the tilting back opens the area in a more general way.
With internal types, where the obturator internus and the other rotators are often overstretched and in secondary shortness, the tissue is made more resilient with the technique. There of course the primary objective is the tendon of the iliacus which can be reached in this position at its insertion at the lesser trochanter. The side position has some advantages over the usual prone position: the obturator internus is more superficial and available, the approach does not interfere with the n. ischiadicus, active and passive movements are easier, and the firm ground on which the hip rests provides stability for the area. So for the 70% of muscle mass that lie inside the pelvis this approach is a viable alternative.
Lengthening the Hamstrings with an Eye to Leg Movement
In our culture of thrones, chairs, car-seats, and even toilet seats, hamstrings tend to be chronically short except in people who consciously do stretching exercises. This shortness is due to the connective tissue of the muscles. The collagenous tissues develop their form according to the mechanical forces they are exposed to. In a tissue that hardly ever has to lengthen they will adapt to this reduced range of motion, grow short and thereafter seriously impair the normal range of motion. Thus hamstring work in our culture normally is lengthening. Beyond this well-known fact, how do hamstrings figure in our analysis of structure? I shall state some hypotheses.
1. In a balanced structure – if you look at it from the sides the rectus femoris and the hamstrings run nearly parallel to the central vertical line which coincides with the femur. As antagonists the two can neatly balance the os coxae.
2. In an external type, the pelvic block moves forward white the thoracic block bends back creating the familiar banana form. The weight of the structure is kept up against gravity by the muscles in front: amongst others the rectus femoris and the quadriceps creating an overextension in the knees. As a result the antagonist hamstring compartment slackens and its points of attachment at the ischial tuberosities and – around the epicondyles – to tibia and fibula are brought closer together. As the connective tissue adapts to this situation the already short hamstrings become even shorter in a passive rigidity which Hans Flury calls ?primary shortness? and which I suggest to describe as ?passive shortness?.
3. In internal types, the pelvic block moves backwards while the thoracic block collapses forward creating the characteristic deep lumbar lordosis. In such a structure the weight is kept up against gravity by the muscles in the back: amongst others the hamstring compartment. Now the hamstrings have to contract actively and keep the pelvis from going into an even more pronounced anterior tilt. If the tissue around the knees is weak, this constant tension in the hamstrings pushes the femoral epicondyles forward on the tibial condyles like a drawer of a chest. If the connective tissue around the knees is strong, the hamstrings are longer than in a balanced structure because the anterior tilt of the pelvis brings the ischial tuberosities up (cranial) and back. So – except in persons with chronically flexed knees coupled with a pronounced anterior pelvic tilt – the hamstring compartment will be long but rigid from holding, which increases the density of collagenous fibers and decreases the metabolic exchange of fluids in the interstitium. Hans Flury likes to call this active rigidity ?secondary shortness? although the fasciae may be longer than they should be. I prefer to call it what it is: ?active tightness?. If this tightness can be resolved by lengthening the already long compartment, this would allow the tibia and fibula to come forward under the pelvis, relax the passive shortness of the antagonist compartment, and contribute to a more horizontal pelvis and the first experience of lift because the structure is supported more evenly from below.
4. In a balanced structure, in bending or bicycling, the knees should be able to follow a straight course easily. The medial and lateral hamstrings share practically one origin at the ischial tuberosity, which permits relatively wide movements at the hip joint to have little influence on their tone. Their insertions are however farther apart, the line between them forming the base of a triangle with the tip at the tuberosity. Any one-sided shortness on the medial or lateral side of the triangle will definitively influence the position and function of the knee. As the knee moves towards the client’s chin, both sides have to lengthen in proportion to keep the knee on a straight course. If one side is short, the knee will describe an arc toward that short side. In extension and hyperextension, – i.e. in standing -, the axis of the knee joint is turned towards the shorter side: the knees look medial with shortness on the medial side and create bow legs, because they also move out, and they turn to front lateral with shortness in the biceps and create knock knees, because they also move together in hyperextension. Knock knees and bow legs can have other causes like a variance in the position of the ossa coxae or of the angle of the femoral neck. These have nothing to do with structural internal or external rotation of the femora. In these cases the knees can still track a straight course in bending, which they cannot if knock knees or bow legs are of structural origin.
5. But not only the knees are affected. If the whole hamstring compartment of one leg is shorter than that of the other, it will contribute to pelvic torsion by pulling the ischial tuberosity down, in (medial), and forward. The iliac crest will show a higher curve on that side. In the supine position, as the knees move towards the client’s chin, the ischial tuberosity of that shorter side will be lifted off and up earlier. Since this signifies clearly that the whole trunk will now go Into a curl, shortening and compressing the ?core?, hamstring work should be done in a way which avoids such compression.
I position myself on the table in such a way that the client’s foot rests against my chest, while she lies on her back. The other leg should be bent with the knee resting against the side of my body. This saves her the effort of keeping it from falling out, which would induce strain into the whole of the trunk. With clients with a posterior pelvic tilt or posterior or hypermobile lumbers, a shallow pillow should be placed under the lumbar spine for support. I now test the course the knee takes by moving the leg passively, bending the knee and bringing it towards the client’s chin until the ischial tuberosity starts to come up. I now take hold of the client’s knee with one hand to ensure its straight course in a sagittal plane, making certain that the axes of the foot, ankle, knee, and hip joints stay parallel, and bend them passively by bringing my chest and with it the knee toward the client’s head. With the other hand I lengthen the hamstrings, using knuckles or fist, taking hold of the tissue as it is stretched by my movements. The knee should never be taken up beyond the point where the ischial tuberosity starts to lift off the surface. The effect of lengthening can be measured by comparing how far up the knee goes now as opposed to before the intervention, using the lift-off of the tuberosity as the reference point.
The side of the compartment towards which the knee arcs must be lengthened until the arc disappears in passive as well as in active bending. This may not be possible completely since such arcs can also be the result of shortness of the psoas or the rotators. Therefore the procedure should be repeated frequently in subsequent sessions until the straight course of the knee is established.
In addition, I look and palpate with my free hand for places where the hamstrings don’t move freely over the tissue below (vastus lateralis and adductor magnus) but are glued down. I free these thick septa between the compartments of the thigh by activating the two meeting at a septum in opposite ways by extension /adduction and flexion/abduction (vastus lateralis) or extension/abduction and flexion/adduction (abductors). It is important to keep these movements tiny and soft in order to avoid inducing strain into the overall structure. Afterwards, the straight course of the knee should be tested again and established anew if necessary.
A Strain Position for the Fascia Lata
The fascia lata is approached and manipulated in many different fashions and with varying intention. It is sometimes extremely thick and hard from its function of containing the sideward thrust of the weight of the body and can ?overachieve? this goal, jamming the core at the pelvis from both sides. When it is intended to open the center from the inside, preliminary work on the fascia lata to make room for this may be indicated.
With the client on the back, the knee of one leg is lifted up and the lower leg is taken out, the thigh rotating internally. The leg rests on the medial side of the foot which is pronated passively, forming the distal support point. The leg and the ipsilateral side of the pelvis are suspended, with the middle or upper back and the contralateral hip providing the other support point. The knee should not cross the midline, and the lower leg should be bent back more than 90°. The knee sinks as far as it goes towards the table. Bearing down lightly on its lateral side – which points up in space – lifts up the pelvis a little more and permits to check that the client is completely relaxed.
The anterior side of the fascia lata is stretched maximally from the iliac crest to the tibia. Long and narrow strings of tightness become prominent in it and allow for specific lengthening. I work from the lateral epicondyle up to the crest, freeing the fascia from the femur and the tensor from the trochanter when it is glued down there besides lengthening the strings. Because in this position the client is very vulnerable, I only use fingers or the vola manus. The other hand pushes the knee slightly down, alternating with releasing it, so the body stays relaxed and the fascia moves a bit. This can be combined with a soft pull in the distal direction when the controlling hand reaches around the biceps tendon or those inserting as the pes anserinus.
Because of the extreme internal rotation and hyperextension at the hip and the relaxation of the body, all work must be considerate and with regard to the body suspended in balance. For the same reason, resolution of the position must be slow and careful by lifting up the knee slowly and holding it securely when the lower leg is taken forward. For internals, the position means taking the thigh far into the aberration, and the focus is naturally on the anterior part of the fascia. For externals, the position takes the thigh in the direction where it belongs but crosses over this point to its maximal range. The focus is then on the posterior side of the fascia which is a little less stretched especially proximally and so allows to go deeper behind the trochanter. It can be monitored by pulling and releasing the posterior margin of the fascia from behind or in front of the biceps tendon.
Due to the maximal passive tension, intention is solely on the most superficial layers. But some adjoining structures come also under consideration: the distal biceps, the lateral edge of the rectus, the vastus lateralis, and especially the septum intermusculare laterale. Except for very advanced clients the position must be considered as disorganizing, making it necessary to integrate the body some time afterwards.
Lower Back Technique in the Supine Position
The lower back is usually organized with the client on the side or sitting bent forward. The prone position, lying on the stomach, requires care with internals and is more apt for externals with a marked posterior pelvic tilt. The supine position, where the client lies on his back, makes for comfortable working using his weight. The variation proposed here renders this a little more stringent. It is designed exclusively for internals.
The substrate is the fascia thoracolumbalis, the lumbodorsal fascia, the right and left sides of which meet at the dorsal processes of the thoracic and lumbar vertebrae, to which it is fastened down. It also continues down the back of the sacrum. From there it bridges over to the iliac crest which it follows out and up about halfway. There it departs from the crest in the cranial direction forming something like a free edge along the lateral margin of the erectors which it envelops. It narrows with them medially towards the spine as it traverses the thoracic area. There it is attached to the angles of the ribs. At its beginning at the crest the free edge forms the medial border of the trigonum lumbale, whose base is the crest, whose lateral border is the posterior margin of the external oblique, and at whose floor lies the internal oblique. More cranially it also forms the medial border of the spatium tendineum lumbale, which is bordered cranially by the 12th rib, laterally by the posterior margin of the internal oblique, and which is covered by the latissimus on the outside and the m. transversus on the inside.
Figure 4 – Before and after fascia lata (1)
and after lower back technique (2).
The lateral margin only appears to be a free edge, especially when the musculature of the back is overdeveloped. It is then often drawn in by the two layers that branch off from there medially. The middle layer or aponeurosis lumbalis passes in front of the erectors, which it ensheathes together with the superficial layer, and in back of the quadratus to reach the processus costarii of the lumbar vertebrae. The deep layer goes in front of the quadratus to the bases of the processus costarii, enveloping the quadratus together with the middle layer. It continues laterally as the fascia transversalis, covering the m. transversus on the inside, all the way to the linea alba where it connects to the fascia transversalis of the other side. Superficially the fascia of the latissimus dorsi also branches off laterally.
In internals with a deep anterior lumbar curve the short lumbodorsal fascia:
– maintains the lumbar lordosis as a string bends a bow,
– keeps the erectors medial and rounded, with their crowding the spine accentuating the lordosis further,
– pulls the back of the thorax down,
– and keeps up the iliac crest reinforcing the anterior pelvic tilt.
With the knee taken up, one hand, the working hand, goes under the back with varying intentions:
1. In the thoracic area the attachments to the ribs are freed by the fingers extending obliquely up and anterior.
2. The fascia of the erectors is spread and lengthened by going across it from the spinal groove to lateral.
3. The quadratus lumborum is affected by going under the erectors from lateral to medial in the direction of the middle and deep fascial layers or through the erectors directly.
4. The attachment to the iliac crest is lengthened by going deep and anterior above the crest.
5. The space between L4/L5 and iliac crest is widened.
The raised leg plays the more important role as it is manoeuvred to stretch and release the fascia. The contralateral leg is put up, and the knee should rather be allowed to sink in than fall out. The pelvis then lies back broadly on that side helping to keep the lower back open. With one hand I take up the knee of the ipsilateral leg towards the chest. My other hand is on the groin indicating that I don’t want the tuberosities to rise up but the hip to stay back and distal. I then take the knee between my arm and the side of my chest. With the hand of this arm I hold down below the anterior superior iliac spine, replacing the other which goes under the back.
Only when the most superficial layer should be stretched is the pelvis allowed to come up following the leg. The controlling hand then keeps the hip well distal to assure that the back and the front of the spine remain long. But usually the tuberosities stay on the table. The raised knee is rather pushed back vertically toward the table than pulled up more to the chest. This squeezes the pelvis out in the distal direction. The controlling hand may go to the abdomen to assist the working hand, in which case axial pressure on the femur into the table and caudally supports the pelvis staying back and distal. The knee can be moved over to the other side which leads the hip to rotate out, aided by the controlling hand, tensing the fascia in the transverse direction.
The general guideline for the technique is that the front of the spine, which is approximately along the psoas, should not shorten or be compressed but only the tissue in the back should be stretched. Structural change is less effected by an active working hand than by placing it in the relaxed tissue with the intended direction and then tensing the tissue over it by moving the leg. Not all bodies are suitable for working with the fingers in this way. But it should not be forgotten that it is an eminent technical principle that the back of the hand is allowed to be pushed into the mattress maximally by the weight of the client and that extension of the fingers from there is primarily by pressing the back of the hand more into it.
The technique gives maximal and complete control over the client’s body. It is experienced as comfortable rather that threatening and induces deep general relaxation. Any mistake is indicated promptly by muscle contraction. A well developed balance of the Rolfer’s body is an essential prerequisite for success.
1. Jan Sultan: Towards a Structural Logic, Notes on S.I. 86/1, and personal communication.