Pectoralis Minor on the left. Pectoralis Major on the right.
Almost a year ago I wrote about the pectoralis minor's referral pattern into the shoulder blade and shared a lovely release using a tennis ball (you can read about that here
). I am back at it again with another post highlighting the pectoralis minor and pectoralis major. Due to the location of their attachment sites on the skeleton, they can affect the function of the head, neck, shoulder and arm.
Pectoralis Minor attaches to the coracoid process of the scapula and to the outer surfaces of the third, fourth and fifth ribs. Restriction here can pull the shoulder blade forward (you will see the bottom/inferior portion of your shoulder blade lift away from your body wall), potentially bringing the entire arm with it).
Pectoralis Major is a big fan shaped muscle that is attached to the chest at the sternum (breast bone) and clavicle (collar bone) . The fan shaped fibers coverge at the arm and attach into the bicipital groove of the humerus. Restriction in this muscle will pull the arm in front of the body and rotate your arm into internal rotation (with your arms at rest at your sides, look in the mirror: where are your elbow creases facing? If they are turned toward your body, that is called internal rotation. In neutral, the arms should rest at the sides of the body with the elbow creases facing forward).
Just get it off your chest and feel more free!
Before you begin with the exercises, do a motion assessment first. Stand with your elbow creases and palms facing forward. Lift your arms up and see how far you can lift without arching your back or letting your lower ribs lift away from your body wall. Complete the movements as show below and then repeat the assessment. For the first exercise you can use a tennis ball, but I prefer the high grip rubber of the Yoga Tune Up massage balls.
Place the ball at the groove, just under the clavicle.
Lean into the wall. You can add more pressure by shifting your weight forward into a lunge. Find a tender spot and allow your muscles to release. Come down farther onto the ribs and find another spot. Work 2-3 minutes.
Lie down on your side. You may want to have a pillow under your head. Bend your hips and knees to 90 degrees, arms straight out from your shoulder.
Lie down on your side, bring your hip and knee to 90 degrees. Let your leg completely rest on the ground. Reach your left arm to the ceiling stretching your shoulder blades wide, then begin to reach toward your face/over your head. Then begin to sweep your arm in an arc of motion keeping your palm and elbow toward the ceiling from your head down to your side.
Keeping your knees stacked on top of each other, begin to open up your chest by reaching your top arm toward the floor. The driver of this movement is thoracic rotation. Try to increase the motion by using your breath to get deeper. Take a breath into your ribcage and on the exhale try to get your shoulder closer to the floor. Repeat on other side. Hold for 1-2 minutes or until tolerable.
Once your arm gets to your side, turn the palm down sweeping back up in an arc of motion toward your face. You will complete a full 360 degree circle. Repeat the process 5-10 times on each side.
Reassess your arm motion: Hopefully you have more freedom in your movement!
We have two psoas muscles on each side of our body: psoas major and psoas minor. This blog is specific to our psoas major.
This summer I took a very cool tele-class from Liz Koch, of Core Awareness
. In this 5 week series we explored the location and function of the psoas and its relationship to the nervous system and our "fight/flight/freeze" response, to our emotional well-being and to our skeletal support.
The psoas is centrally located: emerging from the midline at thoracic level 12, attaching to every lumbar vertebra and inserting into the inner thigh at the lesser trochanter.
The psoas allows the lower limb to move and swing a as a pendulum: multidirectional/orbital.
As a physical therapist I see many people with SI dysfunction, hip and back pain. In almost all cases, the psoas is the top priority to rehabilitate. On muscle testing the psoas is usually weak, and the flexibility test is usually tight. What I have come to understand through this tele-class, through my training as a Restorative Exercise Specialist™ and as an NKT™ practitioner, is that rather than manipulate the psoas through deep tissue work and stretching, the psoas needs to rehydrate and recover from over-exhaustion.
I have compiled my favorite top 10 ways to release, rehydrate and restore the psoas. It is helpful to perform a release before going onto the movement sequences. Some of these are from Liz Koch's book, "The Psoas Book" and some are from the Whole Body Alignment Program.
Position yourself on your back as shown. You can use a pillow for your head if you notice that your chin lifts to the ceiling. Begin to focus on your breathing. Tune your awareness to your hip sockets. Imagine that the head of your femur bone is centered in the socket of your pelvis. Breathe here for 5 minutes.
Postion yourself on a bolster or rolled up exercise mat as shown in the picture. You want to find a bolster that is high enough so that the back of your thighs touch the floor. When you lie on the bolster, you want to make sure that your lower ribs are flush with your abdomen. Breathe here for 2-5 minutes.
Position a yoga block, rolled up yoga mat or thick book under your sacrum. You want to make sure that the block does not go higher than your pelvis (it should not be blocking your low back). Breathe here for 2-5 minutes.
After the block release, bring one leg toward your shoulder as shown in the picture. Let the other leg go out straight and begin to lower the leg down to the floor. Make sure to keep the knee straight. Hold for 3-5 breath cycles and then repeat on other side.
Come on to your hands and knees (or onto your forearms as shown in the picture). Kick one leg back with a straight leg. Make sure to keep your pelvis level. Move your leg toward the floor keeping your leg straight and then extend your hip back as far as you can go without moving or rotating your pelvis. Repeat 10 times, then switch sides.
Lie on your back as shown. In this movement you will keep your leg straight as you lift your leg up and down 10 times, then place your leg on the floor and slide your foot toward midline and then outwards 10 times. Repeat on other side.
Bend your knees and reach your arms toward the ceiling.
Begin to move your arms overhead as far as you can go without arching your back or lifting your ribcage, and then return to starting position. Repeat 10 times.
With your knees bent, bring one knee toward your chest. Take 3-5 breath cycles and then switch sides. Repeat 3 times each side.
With your opposite leg straight, bring one knee toward your chest. Take 3-5 breath cycles and then switch sides. Repeat 3 times each side.
The inner thigh (adductor group) is made up of five muscles:
- Adductor brevis
- Adductor longus
- Adductor magnus
When the foot is not planted on the ground, the adductors will bring the leg toward the midline, and flex the hip when the thigh is in an extended position as in the swing phase of the gait (walking) cycle.
The adductors play a significant role during walking and are active in all phases of the gait cycle. The adductors are a part of two important functional kinetic chains:
- Lateral Sling: comprised of the adductors, same side gluteus medius/minimus, opposite side quadratus lumborum. This chain is responsible for frontal plane stabilization of the lumbo/pelvic/hip complex during single leg stance (stance phase of gait), squatting and lunging.
- Anterior Oblique Sling: comprised of the adductors, same side internal oblique, opposite side external oblique and hip external rotators. This chain is responsible for transverse plane stabilization during trunk rotation in gait, throwing, swinging, twisting activities.
Dysfunction within the slings can result in overuse of the adductor group leading to over facilitation, increased tension and bound up connective tissue, and potentially pain. Here is a videoblog demonstrating how to release the adductors using a foam roller.
Tension in the piriformis
muscle can be a trigger for irritation of local surrounding tissues. The sciatic nerve
exits the pelvis just below the piriformis. When there is dysfunction in the lumbo/pelvic/hip complex, the piriformis often gets overworked, creating compression and friction in the small area which can wreak havoc on the sciatic nerve. Sciatica is defined as aching/burning/stinging pain along the distribution of the sciatic nerve: buttock, back of the thigh, lower leg and foot.
Stretching the piriformis can be a very effective way of diminishing the compression, and therefore irritation of the nerve. Pictured to the left is a very common stretch given as treatment to relieve sciatica.
Piriformis Stretch Refined
Using the wall and props can be an effective way of maintaining a neutral spine and pelvis. A traditional piriformis stretch, like the one shown above, is often done with a tucked pelvis and can irritate the nerve if pulled too aggressively. By staying in alignment, and by being able to adjust the load by gradually bending the knee to 90 degrees, the tissues will begin to yield and let go, rather than work to hold the body in position. Picture on the left: The half cylinder and block supports my shoulders and head to allow me to rest into neutral with my ribs down and in line with the level pelvis. Due to my tension, I also have to support my lumbar area with a rolled yoga mat so I can comfortably attain neutral pelvis (pubis and ASIS level). Middle picture: I place my left leg straight on the wall and cross my right leg over the left, making sure not to tilt the pelvis. Picture on the right: I begin to slide my heel down the wall and stop when I feel that I am at my resistance barrier, or my pelvis begins to shift. Hold at least one minute and repeat on the other side. If you can tolerate the stretch stay longer, up to 5 minutes each side.
Some people will try to get a deeper stretch by pressing the right knee down. Make sure that you don't drag your whole pelvis when you do that (as shown in the pic on the left). The purpose of this refinement is to maintain neutral, and that means a level pelvis (as shown on the right).
Even if you don't have sciatica, this is a wonderful stretch to open the hips, and allow more freedom to your pelvis! Enjoy!
The dot and arrow show pelvic posterior rotation.
Legs on the wall pose is a restorative position that should be a staple for every person that has a pelvis! Traditionally, the pose is taught by placing the butt close to the wall, and then bringing the legs up against the wall so the back of the legs touch, and the soles of the feet are facing the ceiling. A variation to the pose is to widen the legs into a "V" position to stretch the inner thighs and groin.
Recently I have rediscovered the beauty of this pose by modifying the position to be able to maintain neutral pelvis (pubis and ASIS in line) and rib alignment. The benefit of maintaining the alignment markers during this pose allows the connective tissue and muscles to fully release. When the alignment markers are not in place, there is more load to the tissues which can potentially maintain tension, and prevent a full yield ("letting go") of the muscles and fascia.
In order to do this pose in alignment, you may need to get out props. Due to the tightness of my psoas muscles
and the increased kyphosis
of my thoracic spine, I have used a thin yoga mat rolled up to maintain neutral pelvis: pubis and ASIS level, and a half cylinder & block to prop up my upper back to get my lower ribs down and flush with my abdomen. In order to get my pelvis level, I needed to scoot away from the wall, get the props set up, and then place my legs on the wall (see pics below).
Benefits to Legs on the Wall Pose:
- Gently stretches the back of the legs, inner thighs and low back to relieve aches and pains
- Improves lymphatic/venous return from the feet and legs
- Eases stress/anxiety
- Alleviates symptoms of menstrual cramps, PMS and menopause
- Helps testicular and ovarian problems
- Relieves swollen ankles and varicose veins
Legs on the Wall Pose in Alignment
Placing props to attain alignment: neutral pelvis and ribs lined up, prior to placing the legs on the wall.
The props allow the pelvis to remain neutral and the ribs are relaxed against the body wall. You can stay in the pose as you are able to tolerate: anywhere from 2-20 minutes.
Muscles that attach to the scapula: Left side of the pic you can see trapezius, deltoid. Right side of the pic you can see rhomboids, levator scapula, supraspinatus, infraspinatus, teres minor, teres major and serratus anterior.
Muscles that attach to the scapula: Pectoralis minor, bicep, subscularis, serratus anterior, teres major.
Movement of the arm requires joint mobility and muscular stability. Moving the arm requires appropriate muscle facilitation and mobility in the shoulder joint, the scapulo-thoracic joint (which is not a "true" joint, more of a physiological joint), the acromioclavicular joint (AC) and the sternoclavicular joint (this is the only joint connecting the arm to the axial skeleton).
Take a look at the pics on the left. There are a lot of muscles that can affect the movement of the arm, the scapula, the shoulder, and the clavicle. So... basically what I am pointing out here is that optimal muscle function of the shoulder girdle is key to a healthy pain free shoulder joint, neck and arm.
Muscle, bone and connective tissue adapt to how we use them. And typically during a day our arms are positioned out in front of the body: computing, driving, pushing a stroller/walker/cart. This positioning, along with all of our other daily habits of grasping, clenching and tensing can lead to shortened muscles, winged shoulder blades and internal rotation of the shoulder joint which can lead to impingement and eventual rotator cuff tendonitis/tear.
Hand Behind the Back Stretch
Before we get to the stretch, observe the position of your shoulder blades when your arms are down by your side. Notice the medial edge and the lower angle. Do they wing away from your back like mine? Ideally the scapulae should be positioned equidistant from each other with no visual boney edges. Winging of the scapulae is an indication of muscle imbalance.
Just for fun, see how you need to move your scapulae so you don't see your boney edges poking away from your thorax. In this pic you can see that I had to move my blades forward and elevated a little. Once the blades are in the ideal position you can really see some of the culprits driving this imbalance: can you say tight pectorals anyone?
Now for the stretch. Bring the hand behind the back. Make sure to keep your elbow straight down from your shoulder (notice how this makes me wing even more. More than likely this will happen with you too). Begin to bend the elbow as if to reach for your opposite shoulder blade. Notice your elbow, did it start to go out wide? If it did, you went too far. Bring your arm back down so you can comfortably hold in position in a gentle stretch. Believe me, this can be intense, don't let it. Hold for up to a minute.
Now, let's refine the stretch. You will need to have a mirror for this so you can see the position of your shoulder blade.
Bring your hand behind your back. Move your scapula (usually forward and up) so that you do not see winging anymore. Make sure to watch your elbow. In this pic you can see that my elbow moved outward a little bit, and is not straight down from my shoulder. The requirement or alignment marker for this stretch is to keep the elbow in line with the shoulder. To correct that, I would need to lower my hand so the stretch isn't so intense. Notice in the pic that the lower angle is still lifted away a little bit. But because of my tension, I wasn't able to get completely flush with my thorax without moving my elbow.
Here is side view of me bringing the arm behind the back.
Here I am moving my shoulder blade forward so the shoulder blade doesn't wing.
This is what it looks like from the front. You can see how tight my pecs are. And I am smiling because I used to not be able to do this and now I can! Yeah!
Do you experience burning, stinging or rawness in your vulvar area? Maybe you feel itching, throbbing, or aching in the perineum and pelvis. You are not alone. These symptoms are typical of vulvodynia.
Vulvodynia is a pain condition of the female genitals: clitoris, vestibule (vaginal opening), labia, and perineum.
There are two main subtypes of vulvodynia:
- Generalized Vulvodynia is pain in different areas of the vulva. Pain occurs spontaneously and can be relatively constant. Activities that apply pressure to the vulva, such as prolonged sitting, wearing pants, riding a bicycle typically make the symptoms worse.
- Vulvar Vestibulitis Syndrome (Provoked Vestibulodynia) is pain in the entrance to the vagina, (vestibule). Often a burning sensation, this type of vulvar pain comes on only after touch or pressure, such as during intercourse or placing a tampon. This type is further classified as Primary: pain experienced with first attempt of vaginal penetration, or Secondary: woman has experienced pain free penetration prior to the development of pain.
Vulvar Vestibulitis Syndrome
Self Care Strategies
Self-care and treatments for vulvodynia can help bring relief and recovery. Unfortunately, there is not a "one size fits all" treatment. Working with a trained healthcare provider who understands vulvodynia is crucial to getting out of pain. Here are a few suggestions to alleviate symptoms:
Avoid Irritants to the vulvar tissue
- Use dermatologically approved detergent and don’t use fabric softener.
- Use unscented toilet paper that’s soft and white.
- Wear 100% white cotton underwear, menstrual pads, and tampons.
- Avoid getting shampoo on the vulvar area.
- Avoid perfumed creams or soaps (no Massengill or Summer's Eve cleaning products), pads or tampons, and contraceptive creams or spermicides.
- Avoid hot tubs or pools with lots of chlorine.
- Rinse the vulva with cool water after urination and intercourse.
- Avoid foods that make urine more irritating. This may include foods such as greens, beans, berries, chocolate, or nuts.
- Wear loose-fitting pants and skirts; don’t wear pantyhose.
- Keep the vulva clean and dry.
Relieve pain and ease pressure
- Use a water-soluble lubricant during sex. Olive and coconut oil can also be used as a lubricant.
- Avoid activities that put direct pressure on the vulva. This includes bicycling and horseback riding. Intense exercise that creates friction at the perineum.
- Learn how to sit with a neutral pelvis, this decreases pressure on the coccyx and tailbone. LImit sitting time to 20 minutes, then get up and move around.
- Soak in lukewarm or cool sitz baths.
- Apply heat, ice or a frozen gel pack wrapped inside a hand towel.
- Relaxation techniques and walking can improve blood flow, increase circulation and calm the nervous system.
Make an appointment with your local Pelvic Health Physical Therapist
Weak gluteal muscles can be blamed for many low back, hip and knee pain/injuries. Without the muscular support, the back, hip and knee are subject to increased loads and excessive motion leading to friction and wear and tear. The 3 gluteal muscles: maximus, medius and minimus assist in controlling the trunk and the leg as it is loaded during foot contact to the ground as in walking, running, jumping, going up/down stairs, as well as moving from a sit to a stand or bending.
When the gluteal muscles are weak, you will notice increased movement of the trunk toward the side of weakness, and the knee will cave in toward the midline. Are your glutes weak or strong?
Start to observe what you do when you go up/down stairs: do you turn your foot out to give yourself more support, does your knee drift to the midline, do you shift your torso over to the planted leg to make it easier to step up? If yes, then your glutes are weak
What happens when you bend down to pick something off of the floor or transition to get in and out of a chair: do your knees come together? If yes, then your glutes are weak.
Gluteal assessment: Step down from a stool.
Stand on a stool. Slowly begin to lower one leg down, tap the floor with your heel and then return back up. Repeat 5 times. Notice if your standing knee collapses toward midline, or if your torso leans to the side. If either or both happens, you need to strengthen your glutes!
Strengthen your glutes: standing progression
1. Start by standing on your left leg. Keep your thighs parallel and bend your other knee so your foot can tap down on the floor like a kick stand if you need it to balance. Check yourself in the mirror. Make sure that your pelvis does not rotate. Keep your ASIS facing forward (that is what I am pointing to). Ideally you want to have your pelvis level. Check your waistband: if the right side is elevated then you are using your back muscles to compensate, if it has dropped, then you are not activating your left glute! Work toward standing for 1 minute. Switch sides.
From a side view, try to maintain vertical alignment: midpoint of shoulders and hips over ankle bone (I am not quite there, helps if you have a mirror to look into). Keep the standing leg straight, and your quads in front of the thigh relaxed!
2. Next progression begin to bend your knee as far as you can and then return to start position. Perform 10 reps and then on the last one, keep it bent as you balance for the final minute. Again, make sure that the pelvis doesn't rotate or drop.
3. Stand on your left leg. This time your pelvis will elevate because you won't be bending your right knee. Keep your leg straight as you move it out to the side and in. Work toward 1 minute and then switch sides.
4. Side step with a light resistance band (if you have had a hip replacement do this without the band). Make sure to keep feet straight ahead and plant your foot with the outside edge straight.
Make sure not to bend your knees. Most people cheat by bending the knee because the glutes are weak. Don't do it!
Make sure to land your foot with the outside edge straight, this position engages your glut med and min. Return to normal hip width distance. Make sure to relax your quads between steps!
5. Now for the glute max finale! Standing on your left leg, extend your rlght leg behind you. Begin to lower your torso as you hinge at your hips bringing your hips behind your ankle, and then return.
Make sure the movement is coming from your hips, not your spine! Pelvis should stay level. This is challenging, mostly from a balance perspective. If this is hard for you, then get into position and hold.
Photo courtesy Wikipedia
In my practice I work with a lot of people who have low back pain, and sacroiliac (SI) pain. How we stand, how we sit, and how we move in our bodies over time, contributes to our dysfunctions and potential pain syndromes.
Being mindful of HOW we stand and sit are simple steps to begin to unravel the increased loading and compression on the spine and SI joints, as well as the tension and pull on corresponding ligaments and muscles.
Before going over standing and sitting, let’s look at the anatomy: The pelvic girdle is comprised of the 2 pelvic (inominate) bones and the sacrum. The inominate bones join in the front by a thick fibrocartilage disc similar to that of the vertebral discs. This area is called the pubis or pubic symphysis. In the back, the inominate bones attach to the sacrum, creating the sacroiliac joints.
The function of the pelvic girdle is to transfer the loads between the trunk and the lower extremities via the spine and hips (lumbopelvic-hip complex). There are 35 muscles that attach directly to the pelvic girdle. Therefore, the mobility and stability of the SI joints depends on the interaction of these muscles, ligaments, fascia and nerves that surround the pelvic girdle.
Photo courtesy: www.pt.ntu.edu.tw
In healthy movement, the sacrum moves relative to the inominate bones. When the sacral promontory moves forward into the pelvic bowl, the motion is called nutation; counternutation is the opposite motion. The optimal position for the sacrum in standing and sitting is slightly nutated between the inominates. This is the goldilocks position: not too tight and not too loose.
During sitting and standing, you can diminish stress on the SI joints by maintaining a neutral pelvis.
Learning how to stand
Look around you, most people stand with their pelvis out in front and their shoulder’s and ribcage back (as in the pic below).
This posture causes the sacrum to fully nutate, meaning that this is the maximally closed position of the SI joints. This position can create low back and SI joint aching during prolonged standing.
Incorrect Alignment: Anterior Pelvic Sway
Correct your alignment by shifting your hips back, allowing your trunk to move forward so the line of gravity travels through your joints: shoulder, hip, knee and ankle. Now the pelvis is in neutral: the pubic bone and ASIS line up vertically, and the SI joints are in optimal position.
Neutral Pelvis: ASIS and pubic bone line up vertically.
Learning how to sit
Many people slump their spine and pelvis while sitting watching TV, or sitting slumped at the computer. In this posture, the weight of the body is positioned behind the SI joints. This places the SI ligaments under load, the sacrum is tucked (counternutated), and pressure is at the tailbone (coccyx).
Photo from www.physioadvisor.com.au
The stress of this position will stretch the ligaments of the SI joint, and can also create tailbone pain. Maybe you can relate to having pain while trying to walk after sitting like this for awhile. The initial steps are excruciating until you are able to walk it out as the ligaments regain their normal position.
Correct your alignment by sitting on your ischial tuberosities (SITS bones). The pelvis and spine should be in neutral.
Photo from www.posturereview.com
Trigger points in a muscle can be the culprit in many pain disorders. In this post, I provide a self care technique to assist with these potentially troublesome trigger points. The muscles that can refer pain into the hip area are the tensor fascia lata, iliacus, psoas and sartorious. If you are interested in learning more about what causes trigger points and how to treat them, I have listed some websites dedicated to trigger points and myofascial pain syndromes at the end of the blog. Click on the pictures below to enlarge the picture and to link you to triggerpoints.net, an amazing resource for trigger points and referred pain.
Tensor Fascia Lata (TFL) attaches to the iliac crest/ASIS and into the fascia lata that terminates at the lateral knee. The primary functional movement of this muscle is to stabilize the pelvis and the knee. Its action is hip abduction, flexion and medial rotation. Trigger points related to the TFL refer to the outside of the thigh.
Iliacus & Psoas = Iliopsoas
attaches to the iliac fossa and the Psoas
attaches to the transverse processes of L1-L5 and the lateral aspect of T12-L5. They share a common attachment point on the lesser trochanter of the femur. The iliopsoas flexes the hip and trunk.
Trigger points in the iliopsoas refer to the anterior thigh and low back.
Sartorious attaches to the ASIS on the pelvic crest and to the medial condyle of the femur. Its action is hip flexion, external rotation, abduction and knee flexion. Trigger points in the sartorious refer to the anterior and medial thigh.
If you are experiencing any of these pain patterns , try this:
Release tension in the psoas, and the surrounding hip musculature by performing a constructive rest position with a bolster. Allow yourself to breathe and relax for 5 minutes. For instructions on how to do this click here
Perform a release technique utilizing myofascial release balls such as Yoga Tune Up
Therapy Balls for Self Massage (that's what I have and I love them), Melt Method Products
, or good old tennis balls. There are a lot of different ways to get into the muscles. For this technique you will take two balls held together in a sock or bag. My finger is pointing to my ASIS on the iliac crest
. Place the balls horizontally just below the ASIS.
You will be working near a tender area due to the superficial exposure of the femoral vein, artery and nerve at the femoral triangle. If you start to feel tingling and nerve sensations, move to a different area. Just underneath the vessels and nerve lies the iliopsoas. The next muscle laterally (to the right in this pic) is the sartorious, and the muscle in red is the tensor fascia lata. Sandwiched in between the two is one of the quadricep muscles, the rectus femoris. This will get released as well.
The balls are placed as above on the left side here. With the right leg you can adjust how much body weight you put down into the balls. If it is more comfortable, you can prop up onto your elbows. If you are not able to get down onto the floor, you can place the balls at your hip, and lean into the wall or a door jam. Try to allow your muscles to relax and mold over the balls. If you find that the balls are too intense to start with, place a folded hand towel over them to disperse the pressure. If you are holding your breath and tensing your muscles to deal with the pain, this defeats the purpose. You should be able to feel the sensation and breathe into the area as the muscles release. Once you feel that the muscle has let go, move the balls into a new area. Spend 5 minutes on each side. Enjoy how you feel when you get up to walk. Feel the freedom in your hips!