In my last newsletter I described the side linear neuromyofascial pattern, one of the four neuromyofascial patterns I have identified in Myomemory Transformation Advantage (M.A.T.), an integrated, general systems, and functional approach to evaluating human posture and movement I utilize at my clinic. This approach was developed from my education and experiences as a physical therapist in over forty years of treating acute and chronic musculoskeletal pain and in my training and experiences in the winter sport of nordic ski jumping.
As I revealed in my last newsletter, M.A.T.’S side linear neuromyofascial pattern provides lateral stability for your structure in the frontal or coronal plane against the vertical forces of gravity and ground reaction force (GRF). Again, the frontal or coronal plane is perpendicular to the ground and divides the body in front and back portions. This newsletter, however, focuses on M.A.T.’S diagonal neuromyofascial pattern which has a functional interplay with the side linear neuromyofascial pattern in providing rotational stability and mobility in the frontal and transverse planes during the performance of many of your functional activities.
Again, the pinnacle of all human, functional movement is vertical, upright walking and during the gait cycle, the side linear and diagonal patterns are involved with the stance phase of your gait cycle. It begins when the foot first touches the ground and ends when that same foot leaves the ground making up approximately 60% of your gait cycle.
Normal functional, human motion including your gait is composed of mass movement or neuronal patterns setting the tone for your synergistic limb and trunk muscles. The brain generated and organized these neuronal patterns reflexively below your consciousness from the sensory input coming from your visual, vestibular, and proprioceptive systems regarding gravity and GRF. These patterns of movement generated by your brain are in a linear, diagonal, and spiral design and have a functional interplay or coordination during your posture and movement.
In the beginning of your neurodevelopment coming into this environment of gravity and GRF, the early positional and movement patterns you integrated within your central nervous system (CNS) were linear in nature. But as your nervous system matured and developed, it acquired diagonal and spiral patterns. Therefore your fascia, muscles, tendons, ligaments, and joints of your body produce a mechanical system allowing for linear, diagonal, and spiral positions and motions at its joints. In order for muscles to create diagonal and spiral positions and motions, they must be able to create and dampen the torque or rotatory forces in the transverse plane affecting a joint’s position and motion of axis as well as the integrated skeletal structure.
In reaction to GRF, rotational or torque muscle forces are created to effectively and efficiently accomplish and control any intended, functional task you chose during your activities of daily living. However as already mentioned, muscles can also generate linear muscle forces on the bones and joints by sliding the bones of a joint closer together or farther apart creating joint stability. Understanding these linear, diagonal, and spiral effects created by the muscles helps us understand how muscles can act as stabilizers and mobilizers on your skeletal structure and your joints during function.
Torque force is crucial for the performance of any functional, human movement you do because it is what creates the motion and power for a task at the joints in reaction to GRF. For torque to be acting at any joint it requires two forces or force couples that are equal in magnitude, but opposite in direction.
For example with glenohumeral (shoulder) abduction as in raising your arm out from your side, there is a force couple acting in different planes. In the frontal or coronal plane the deltoid and supraspinatus muscles function in the linear position and motion of the joint creating the stability while the rotator cuff tendons involving the subscapularis and infraspinatus act in creating the rotational position and motion in the transverse plane allowing for the shoulder abduction movement. Therefore, abduction of the shoulder involves the position and motion in the body’s medio-lateral axis created by the intersection of the frontal and transverse planes. In M.A.T., this shoulder abduction position and motion involves the side linear and diagonal neuromyofascial patterns.
Your body’s muscles because of proprioceptive sensory input not only are able to sense the torque produced in reaction to gravity and GRF, but can also use this information to orchestrate the proper combination of muscle contractions or neuronal patterning that provides the stability and mobility to successfully dampen and control the forces of torque in the execution of any desired functional movement such as just described.
As with M.A.T.’S side linear neuromyofascial pattern, the diagonal pattern involves descending neuromuscular reflexes from the brain and the vestibular system which functions to detect the position and motion of your head in space. It allows for the coordination of eye movements as with vestibular-ocular reflexes (VOS) to create your skeletal balance and equilibrium.
Whereas the side linear pattern involves the otoliths of the vestibular system and linear positions and motions of your body, the diagonal pattern involves the semi-circular canals and diagonal and spiral positions and motions. The semicircular canals are three tiny, fluid filled tubes in your inner ear that help you keep your skeletal balance and equilibrium in the rotational or transverse plane. When your head moves in the rotational or transverse plane, the liquid inside the semicircular canals called endolymph moves the tiny hairs that line each canal.
These hairs interpret the movement of the liquid into nerve messages that are sent to the brain to be processed and integrated causing the brain to react by telling a combination of muscles to work in order to keep your balance. If you spin around and then stop, the endolymph inside the semicircular canals moves a while longer and the hairs continue to send the message that you are spinning even though you’re not. That’s why you’re dizzy after carnival or amusement park rides.
Every visit I evaluate your posture to determine your overall body alignment looking for postural dysfunctional patterns involving M.A.T.’S deep anterior/posterior sagittal linear, superficial anterior/posterior sagittal linear, side linear, diagonal, and spiral patterns.
In order to understand a postural dysfunction identified, the concept of “ideal static alignment” needs to be defined. Ideal static alignment is a a body position where your body mass is evenly distributed between both sides of the body and balance is evenly maintained during sitting, standing, and walking. Simply, there is no postural asymmetry evident when comparing your R and L sides in all three planes indicating your center of gravity (COG) is located at its optimal position at the second sacral segment. In addition, your body mass is evenly distributed between your R and L sides in relation to gravity and GRF over a given base of support.
Since your brain and nervous system is designed to react to any shift in your body’s (COG) to maintain balance and homeostasis, if the normal function of any part of the mind/body system becomes overstressed due to a chronic postural distortion from a shift in your body’s COG, a vicious cycle of pain and dysfunction can occur.
These postural asymmetries, distortions may be at the root of your pain complaints and need to be addressed. Moving the body towards “ideal static alignment” is a realistic goal of M.A.T. Balancing the body by minimizing these asymmetries and distortions will optimize your body’s functional mechanics and may prevent stress, inflammation, and pain of your body’s soft tissues. Identifying these asymmetries will give you important clues in identifying and understanding your source of pain.
Each of us here on Earth is affected by the mysterious and potentially stressful force of gravity where gravity becomes a stress to the nervous system with the inability to achieve ideal static alignment. Postural lessons in creating structural homeostasis are learned very early by your CNS in human neurodevelopment as previously mentioned. Visual, vestibular, and proprioceptive sensory input is continuously supplied to your CNS as a toddler. The necessary information to cause the growth and development within your CNS with each year of life.
As you progress into adolescence, compressive forces on the spinal intervertebral discs and facet joints are still most likely balanced through fascial tension allowing minimal energy expenditure from your neuromuscular system. However during your life experiences, structural or functional body tension and stresses from your neuromuscular system, trauma, and genetics may begin to prevent you from achieving “ideal static alignment.” Dysfunctional postural asymmetries or distortions from physical occurrences such as a leg length discrepancies, cranial imbalances, and scoliosis alters your body’s COG which requires compensations by your CNS leading to neuromuscular, fascial, and skeletal adaptations.
If in compensation a joint’s position is altered from its ideal, neutral position only seen with ideal static alignment, your strength, flexibility, and range of motion at that joint suffers. The increase in mechanoreceptor stimulation from a chronically locked joint results in neuromuscular and myofascial changes in length and tension of your soft tissues not only at the isolated joint, but with the integrated body and its COG. Chronic activation of abnormal joint reflexes causes changes in the CNS and “myomemory” so the brain is unknowingly flooded with a constant stream of inappropriate proprioceptive information. The brain then comes to rely on this faulty information about where your body is in space and loses the ability to establish “ideal static alignment.” The brain just forgets where the ideal static alignment should be with your COG at S2.
Dysfunctional postural asymmetry or distortions involving M.A.T.’S diagonal pattern in the frontal and transverse planes involves primarily rotation of the head and neck, ribs, and pelvic girdle affecting how you sit, stand, and walk. The dysfunctional postural pattern usually seen with the diagonal pattern is neck and pelvic rotation to one side and contralateral rotation of the rib cage.
The muscles of M.A.T.’S diagonal neuromyofascial pattern include the anterior scalene, piriformis, external intercostals, posterior gluteus medius and psoas major on the pronated side and the internal oblique, internal intercostals, anterior gluteus medius, and iliacus on the supinated side.
Remember, pronation here describes the position and motion of the lower extremity kinetic chain in reaction to GRF allowing for absorption of this external force whereas supination describes the position and motion of the lower extremity kinetic chain to overcome GRF.
In my description of M.A.T.’S side linear neuromyofascial pattern, I mentioned a dysfunctional pattern involving a muscle imbalance between the quadratus lumborum on either side causing pelvic obliquity and an iliosacral upslip because the position between the ilium and sacrum is no longer symmetrical. Again with a sacral upslip, the tissues of this joint joint between the sacrum and ilium of the pelvic girdle experience upward shear forces on the tilted side of the pelvic girdle resulting in elevation of the SI joint. With the constant and repetitive unbalanced loading caused by this muscle imbalance of the QL within the side linear pattern, compensation by the piriformis on the tilted side of the pelvic girdle and elevated sacrum occurs to maintain structural homeostasis.
Because of this sacral upslip caused in the sidelinear pattern, the piriformis of M.A.T.’S diagonal pattern becomes the site of a major muscle imbalance between the right and left sides. The piriformis becomes tight on the side of the tilted pelvic girdle and elevated sacrum which is the pronated side causing postural distortion and compensation in movement. Therefore, the piriformis plays a major role in the stability of your sacrum which again affects your COG. In fact, it is the primary stabilizer of the sacrum in the frontal and transverse planes.
To visualize this role, think of your spine as a long yardstick with the heavy head on top like an upside-down broom in the palm of your hand. In order to keep the broom up there, your hand will have to make precise little compensatory motions. The role of the piriformis is similar, though a little modified from this visual.
The spine sits into the sacroiliac joint (SI) and the piriformis inserts on the front of the sacrum just below the joint. No other muscle attaches to the sacrum like the piriformis and therefore it can counterbalance what is happening at the spine. For instance, if your spine leans more to the left, the tailbone and sacrum below the SI joint would want to move R. The left piriformis would reflexively increase its tone to prevent this from happening.
Besides balancing the spine, the piriformis also acts to approximate the bones of the sacrum and ilium forming the SI joint, locking them together while the hip is in the stance phase of your gait. So we expect the piriformis to alternate contractions from the R and L sides during the gait cycle, releasing on one side when the leg is swinging forward into flexion allowing the ilium to posteriorly tilt on the sacrum at the SI joint. It again contracts strongly at heel strike, holding the SI joint in solid apposition as the loaded femur swings back into extension.
However, the SI joint can get locked at one end or the other of this gait cycle causing dysfunction and pain because synergistically, the shorter fibers of the iliacus acting via lumbar vertebra 5, tend to take the sacrum in an anterior tilt or what is referred to as “sacral nutation” along with the anterior gluteus medius. The piriformis, on the other hand because of its location below the SI joint, along with the psoas major and posterior gluteus medius tends to take the sacrum into “counter-nutation” in a posterior tilt.
If the joint has increased mobility more than usual or locks into one end of its movement or the other during the gait cycle as just described, a neuromyofascial imbalance between these synergistic muscles will go into co-contraction to prevent the SI joint from hurting causing compensation in your posture and movement.
As just mentioned, the iliacus and psoas major play a major role in M.A.T.’S diagonal neuormyofascial pattern. The psoas minor also shown is involved with another M.A.T. neuromyofascial pattern and will be discussed later. These muscles are oftentimes joined together and called the “iliopsoas.” In fact though, this is false because they are two separate muscles located in two nearby, but separate locations with a common attachment point. Whenever muscles are really close to a joint as are the psoas major and iliacus is to the hip, you can expect them to act as stabilizers.
But the psoas major, with its connection to the spine, works hard to keep the lumbar spine and hips stable while the iliacus, with its connection to the pelvis and hip, stabilizes the hip and SI joint. In addition when working bilaterally, these muscles will impact the iliosacral tilt of the pelvic girdle with the psoas major responsible for a posterior tilt and the iliacus an anterior tilt. This will be discussed in M.A.T.’S deep and superficial linear patterns.
Keep in mind that the QL of M.A.T.’S side linear pattern is continuous with the iliacus through the fascial system having their fiber direction nearly the same. The QL starts from the iliac crest, where the iliacus ends. In addition, the QL goes up to the 12th rib and lumbar transverse processes, which is not exactly where the fibers of the psoas end, but very nearly. So these two muscles, the QL and iliacus, form a quasi-psoas divided into two sections. The result is another major muscle imbalance within M.A.T.’S diagonal pattern between the iliacus and psoas major on opposite sides of the body with the iliacus being hypertonic on the supinated side and the psoas major on the pronated side.
The iliacus crosses the hip only and assists with the hip flexion function of the psoas while the QL spans the lumbar spine and assists the lateral flexion spinal function of the psoas. The other half of this major muscle imbalance in the diagonal neuromyofascial pattern involves the psoas major which is considered the major link between the upper and lower half of your structure providing stability. One of the biggest factors in chronic back and hip pain frequently involves the psoas. As a result, many have come to believe the psoas is one of the most important muscles in the body that is responsible for a number of health issues and forgets about it close relative, the iliacus.
Yet another muscle imbalance of the diagonal pattern involves the gluteus medius. The gluteus medius part of M.A.T.’S side linear neuromyofascial pattern is also part of the diagonal neuromyofascial pattern.
That is because the gluteus medius is divided in three portions similar to the deltoid of the shoulder with the posterior fibers passing forward and downward, the middle fibers passing downward, and the anterior fibers passing backward and downward. Middle fibers are primarily involved with abduction of the hip whereas the anterior fibers assist in flexion and anterior rotation of the hip, and the posterior fibers assist in extension and lateral rotation of the hip.
The anterior and posterior parts of the gluteus medius are seen as antagonists within M.A.T. and can create a muscle imbalance within its diagonal neuromyofascial pattern. The anterior gluteus medius is found to have increased tone on the supinated side with increased tone of the posterior gluteus medius on the pronated side. Again, the gluteus medius is a vital muscle for vertical, upright walking with it working during the stance phase of the gait cycle, preventing the opposite side of the pelvis dropping with the swing leg coming forward.
Another muscle imbalance of M.A.T.’S diagonal pattern involves the gracilis and sartorius which are primarily muscles of stability, but also transition into affecting your functional gait pattern. These two muscles are antagonists involving the position and motion of the hip and knee. Like most two joint muscles, they are primarily muscles of stability. The gracilis is considered a superficial muscle of your groin and inner thigh with its dominant action being adduction and internal rotation of the thigh. In addition, it serves to help the hamstrings flex your knees. Its name comes from the Latin term for “slender” which describes the gracilis to a tee. This slender muscle starts at your pubic ramus of the pelvic girdle near the pubic symphysis and runs down your inner thigh to insert on the medial or inner aspect of your tibia.
Its neighbors along its attachment to the tibia are the sartorius tendon which we will talk about below and the semitendinosus tendon of your hamstrings. All three of these tendons form what is called the “pes anserine” or goose foot insertion. There is a bursa that lies beneath the three tendons of the pes anserine, allowing them to glide and slide with minimal friction from the tibia. Often, a medial collateral ligament or medial cartilage tear are misdiagnosed when these tendons are the primary cause of a client’s knee pain.
It’s function during your gait is to stabilize the inner thigh and hip. It lightly contracts on the supinated side during the stance phase to keep your hip in an optimal position. As already mentioned, the gracilis assists the hamstrings and especially the biceps femoris longus in bending your knee during walking and running.
The sartorius, its antagonist is the longest muscle of the body coursing from the anterior-superior iliac spine and crossing the front of the thigh where it finally inserts near the inner aspect of the knee along with gracilis and semitendinosus to form the pes anserine tendon. It also forms the borders to what is referred to as the “femoral triangle”, a superficial triangular space located in the anterior aspect of each thigh just inferior to the inguinal ligament.The boundaries of this triangular space are the lateral border is formed by the medial border of the sartorius, the medial border is formed by the adductor longus, and the base is formed by the inguinal ligament. Its significance is that from lateral to medial the contents of this triangle are the the femoral nerve, femoral artery, femoral vein, and deep inguinal ligaments.
The dominate open chain function of the sartorius is flexion of the hip and its closed chain function involves external rotation and abduction of the hip as well as bending your knee. It is referred to as as the “tailor’s muscle” because it helps to flex and rotate your hip and flex your knee as if your were to sit with one leg crossed over the other. This position was often used by tailors when doing their seams by hand.
During an optimal gait cycle, both the gracilis and sartorius contract throughout the stance phase with a burst of activity from the gracilis during the terminal stance phase whereas there is a burst of activity with the sartorius during the initial contact and throughout the stance phase
Another less known muscle imbalance muscle imbalance of M.A.T.’S diagonal pattern involves the internal and external intercostals of the ribs. There is nothing more boring and straightforward and inconsequential as the action of the intercostal muscles.
However, electromyography of the intercostals now indicate they are thought of as tertiary muscles of breathing, trailing behind the primary muscle, the diaphragm, and the secondary muscles, the scalene muscles and they have also been found to be involved with walking.
They live up to their name by covering the short distance between any two ribs from T1-T12. The intercostals and their fascia span the ribs and their associated cartilages from the sternum in front all the way around the trunk nearly to the transverse processes in the back. There are actually three layers of the intercostals including the external, internal, and innermost. These three layers correspond fascially speaking to the abdominal layers of the internal and external obliques and transversus abdominis. Because the innermost layer is irregular, and often follows the same line as the internal intercostals, the inner most layer will not be addressed.
The external intercostals span down and in similar to the external oblique. They extend from where the ribs meet the transverse processes all the way around the ribs to the front, but they end where the bones of the ribs end and the rib cartilages begin about an inch or so from the sternum.
The internal intercostals angle down and back, and fill in the area between the ribs or cartilage all the way from the sternum in front and around toward the back. They end around the angle of the ribs where the ribs can no longer be palpated or a few inches from the spine. Simply, the external intercostals are more in the back and the internal intercostals are more in the front, but overlap along the entire lateral aspect of ribs.
I am sure you are wondering what possibly could be the vital function of these intercostal muscles between the ribs? Well, they help keep you alive by assisting in your breathing, a foundational movement pattern as stressed by Dr. Karl Lewit’s quote, a neurologist, “If breathing is not normalized, no other movement can be.”
Now breathing in (inhalation) at its most basic level is designed to make the ribs often times described as a “box” around the lungs get bigger. The high domes of the diaphragm, the breathing muscle, drop moving the bottom of the box down and pulling air directly into the lungs.
The scalene muscles which I will discuss later hold the top of the box up, not allowing the box to go down with the action of the diaphragm, and additionally pulling air into the top of the lungs. Because the external intercostals are angled down, shortening them will pull the ribs up toward each other, lifting the sternum and the ribs as a whole during inhalation. Exhalation on the other hand, is supposed to be entirely passive with the the assistance of gravity and the elasticity of the lung tissue itself to be enough to bring the diaphragm back up and the ribs back down if we simply relax the breath out (exhalation). The internal intercostals using the reverse argument of the external intercostals could pull the ribs down and together, presumably only necessary in forced exhalation.
But the function of the intercostals does not stop with breathing as mentioned, they are also involved with walking. When walking, the right shoulder and arm goes forward to counterbalance the momentum of the left leg and hip in a “reciprocal pattern.”
As the right shoulder and arm swings forward the trunk between them must rotate to accommodate this contralateral motion of the extremities. This is due to the fact that while the soft tissue of the pelvic girdle and waist can create and accommodate this rotation, the lumbar spine cannot with the total allowable rotation through the lumbar spine being only about 5º total.
The lumbar vertebrae are great at flexion and extension and adequate at lateral flexion, but they are not designed to twist. The thoracic vertebrae in contrast are designed to accommodate rotational twisting a total of 35º of an arc across the whole thoracic spine. Simply if the thoracic spine is twisting, the ribs have to twist with them. Therefore when you step forward with the left foot and the right shoulder comes forward as a counter-balance, the rib cage will rotate to the left, and as you step forward with the right foot and the left shoulder comes forward, the rib cage rotates to the right. To make it more clear when I am talking about left rotation of the trunk, it means the top of the sternum is more left facing than the bottom, and the sternum as a whole is more left facing than your navel. Therefore, the internal and external obliques as well as the intercostals are involved in this twisting motion of the rib cage. In this left rotation of the rib cage, the internal intercostals on the right and external intercostals on the left help create this movement while the right externals and left internals would be stretched. So as you can see, the intercostals are indeed muscles of walking helping to wind and unwind the rib cage providing the central spring in the reciprocal gait motion of humans.
As just mentioned, the abdominal muscles are also involved in your gait including the internal and external obliques. Whereas the external oblique is part of M.A.T.’S spiral neuromyofascial pattern, it is the internal oblique I will focus on with M.A.T’S diagonal pattern. Internal means inside and oblique comes from the Latin work “obliquus,” which means a slanting orientation. The slanting direction refers to the direction of internal oblique’s fibers where its direction is reaching across your body. As in, if you place your hand on the on your abdomen, your fingers represent the direction of the fibers.
The main function of the internal obliques is stabilization. They can function bilaterally when both sides contract causing flexion at the trunk. However, they can also work unilaterally on one side to laterally flex the trunk and rotate it to the same side. Therefore in the diagonal pattern if there is a muscle imbalance of tension from right to left, the trunk will be rotated more on one side. If the right internal oblique is tight, it will rotate the trunk left and vice versa if the left internal oblique is tight.
Finally another muscle imbalance I find with M.A.T.’S diagonal neuromyofascial pattern is between the anterior scalene on one side of the body and the posterior scalene on the opposite side. The scalene muscles are a group of muscles on either side of your neck. You have 60-70 muscles in your neck, head, and face area including the scalene muscles.
They are made up of three pairs including the anterior, posterior, and middle. Whereas the middle scalene is part of M.A.T.’s side linear pattern providing lateral stability, the anterior and posterior scalene muscles are part of the diagonal pattern. When the scalene muscles are healthy and working as they should in a balanced way, they help support your upright, vertical posture of your cervical spine.
The anterior scalene, located more to the front even though it is considered a side neck muscle, has more than one function. When acting together on both sides of the neck, they flex the cervical spine. However when acting unilaterally, the anterior scalene will laterally flex and rotate the spine to the opposite side. In addition, it lifts the first rib during inhalation and as a result is considered a an accessory breathing muscle.
The posterior scalene, on the other hand, occupies the farthest back position of all the scalene muscles. It does not contribute to the scalene triangle as mentioned with the side linear pattern which is an anatomical area formed by the anterior and middle scalene muscles and the first rib where the brachial plexus nerve complex and vascular structures passes through it.
The posterior scalene laterally flexes the cervical spine. It also raises the second rib and is considered an accessory breathing muscle during inhalation. In fact as already mentioned, all three scalene muscles are accessory breathing muscles that help you inhale. They contract when you take a breathe in, lifting the top of the rib cage opening the space for the lungs to expand. With respiratory issues such as with asthma, your scalene muscles work extra hard to allow you to breathe.
It is easy to see how the anterior and posterior scalene muscles, internal oblique, and intercostals are a synergistic group that can affect your posture, gait, and breathing. It goes to show you that the “things thought as little and insignificant can amount to big and important things.”
Well, there you have a description of M.A.T.’S diagonal pattern which has a functional interplay or coordination with M.A.T’S side linear pattern, the topic of the last newsletter. The next newsletter will be focusing on the M.A.T.’s spiral neuromyofascial pattern. Until then, “be well!”