Archive for the ‘rehabilitation’ category

The Scalenes, the Dynamic Duo +1

July 2, 2012

The Scalenes are an important neck muscle comprised of three parts, the anterior, the middle, and the posterior. The anterior and the middle will be the subject of this post because the posterior is mostly involved as a synergist for the upper trapezius. The brachial plexus passes through an opening between the anterior and middle scalenes, making it subject to dysfunction if the scalenes are hypertonic. The scalenes are also accessory muscles of respiration and can cause breathing imbalances if one is a chest breather. The scalenes are also involved in the kinetic chain of the arm as well as the front line and lateral line. We will examine all of these relationships to reveal just how dynamic these muscles truly are.

In cervical dysfunction the scalenes can be either facilitated or inhibited. If the sternocleidomastoid muscle is inhibited, the scalenes may compensate to stabilize neck flexion. In the case of whiplash, the scalenes may become inhibited by facilitated neck extensors. I find it very important to release the scalenes indirectly by stabilizing the first and second ribs while performing a myofascial stretch. I have found that working directly on the scalenes can cause them to rebound and tighten up even further. To strengthen the scalenes, resist at the forehead while nodding towards the ipsilateral shoulder. The scalenes also ipsilaterally flex the neck, and therefore can become inhibited by either the ipsilateral or contralateral upper trapezius. The scalenes produce ipsilateral rotation of the cervical spine, and can become facilitated by an inhibited contralateral sternocleidomastoid or an ipsilateral longus colli.

Because the brachial plexus passes through an opening between the anterior and middle scalenes, hypertonicity, whether caused by facilitation or inhibition, must be addressed. The extra pressure on the brachial plexus caused by hypertonic scalenes can result in Thoracic Outlet Syndrome. Symptoms include numbness and tingling in the arms and hands, as well as loss of strength in both the arms and hands. I have found the scalenes to be compensating for 13 different functions in the arm line with someone who had TOS. Reestablishing the proper relationship between the scalenes and these 13 different functions was crucial in the resolution of the TOS.

The scalenes are an important part of the front line kinetic chain. It is not unusual for the scalenes to be facilitated for an inhibited ipsilateral psoas and adductors. They may also be facilitated for an inhibited contralateral TFL and adductors. Even dysfunction of the extensor hallucis longus can be compensated for by the ipsilateral scalenes. In the lateral line, the scalenes oftentimes become facilitated in combination with the peroneals in cases of over pronation or ankle sprains. The most likely inhibited muscle in this scenario is the TFL. The scalenes can also be dynamically involved with the obliques and the quadratus lumborum.

The scalenes are also accessory muscles of respiration. They elevate the first and second ribs, and in chest breathers, they can become,along with the pectoralis minor, dominant muscles of respiration. In this situation they can become facilitated for inhibition of the muscles that depress the rib cage, such as the quadratus lumborum and the obliques. Resolution of these dynamic muscular relationships along with restoration of proper breathing patterns can go a long way to resolving this issue.

The scalenes are important to consider in cervical dysfunction, Thoracic Outlet Syndrome, problems with the arms and hands, dysfunction of the muscles of the front line, dysfunction of the muscles of the lateral line, and improper breathing patterns. Remember to treat these muscles with respect and they will reward you with outstanding therapeutic outcomes.

The Pectoralis Minor, King of Compensation

May 26, 2012

The pectoralis minor is a muscle that becomes easily shortened and tight due to many factors, including rounded shoulder posture, glenohumeral joint dysfunction,breathing dysfunction, and a variety of compensation patterns. It sits on top of the brachial plexus, and can therefore contribute to Thoracic Outlet Syndrome. The pectoralis minor is located in an area of the shoulder with many other muscles, including the pectoralis major, biceps, deltoids, coracobrachialis, subscapularis, serratus anterior, and the latissimus dorsi. I find that clusters of muscles like this often can become dysfunctional due to poor biomechanics. This can lead to adhesions, facilitation/inhibition, and synergistic dominance. The pectoralis minor is often the overactive muscle in these compensation patterns.

Rounded shoulder posture and forward head posture will cause the pectoralis minor to shorten. This action is called protraction and is opposed by the muscles of retraction.  These include the middle trapezius and the rhomboids. Commonly the pectoralis minor becomes facilitated and the middle trapezius becomes inhibited. Release of the pectoralis minor followed by strengthening of the middle trapezius can be very effective in these cases. Because the pectoralis minor rounds the shoulder, it is opposed by the latissimus dorsi which moves the shoulder back and down. Again, release of the  pectoralis minor followed by strengthening of the latissimus dorsi can be very effective.

    The pectoralis minor is a downward rotator of the scapula and oftentimes involved in glenohumeral dysfunction.  If it is facilitated, it can inhibit the serratus anterior, which contributes to upward rotation of the scapula. This can lead to impingement syndrome and sometimes winging of the scapula. The resultant scapular instability greatly contributes to shoulder joint dysfunction.


The pectoralis minor is also an internal rotator of the humerus. When facilitated it can inhibit the external rotators of the humerus, including the long head of the biceps, the posterior deltoid, and the infraspinatus. A common  shoulder injury that occurs from this is that the long head of the biceps comes out of its groove and moves medially towards the short head of the biceps. Release of the pectoralis minor followed by relocation of the long head of the biceps tendon is very effective in these cases. http://youtu.be/vDUI4IR8OzY

The pectoralis minor also contributes to kinetic chain dysfunctions. For example, in the front line, the pectoralis minor often inhibits the psoas. In the diagonal line, it can inhibit the contralateral psoas. This is a factor in gait dysfunction. Also in gait it can inhibit the backward swing motion of the contralateral arm and the backward swing of the ipsilateral leg. Right thoracic rotation can be inhibited by the right pectoralis minor because of its contribution to internal rotation.

Lastly, the pectoralis minor can contribute to breathing pattern dysfunctions. People who are “chest breathers”, commonly have facilitated pectoralis minors and scalenes, which elevate the rib cage. These are opposed by the quadratus lumborum, which   depress the rib cage. If the QLs become inhibited, the possibility of lower back pain greatly increases. Release of the pectoralis minor followed by strengthening of the QL not only can relieve lower back pain, but also can help to repattern faulty     respiratory mechanics.

The pectoralis minor is a short and powerful muscle that can frequently become facilitated and contributed to a host of compensation patterns. Don’t forget this muscle when treating neck pain, shoulder pain, arm and hand pain, hip and leg pain, and breathing pattern dysfunctions.

The Popliteus, the Tiny Muscle of Knee Pain

April 22, 2012





5.Helps to withdraw the lateral meniscus during knee flexion.

I have heard it said that the popliteus can contract to up to 300% after knee surgeries such as meniscal repair, and ACL and PCL reconstruction. Inability to fully extend the knee after such surgeries may be a result of a hypertonic popliteus. Let’s now look at some of the  functions to see where and why an overactive popliteus can become such a problem.

It’s ability to initiate knee flexion makes it an antagonist for the quadriceps and a synergist for the hamstrings and gastrocnemius. Inhibition of the quadriceps, either of all four or one in particular, may cause facilitation of the popliteus. Inhibition of the vastus medialis is very common. Inhibition of the hamstring group, especially the biceps femoris, may also cause facilitation of the popliteus.



In the superficial back line, there is a chain from the bottom of the foot, through the calf muscles, to the popliteus, to the hamstrings, and the gluteus maximus. In the extension phase of gait, these muscles work together. Inhibition of one or more of these muscles may cause another muscle in this chain to become facilitated. The popliteus may become facilitated due to inhibition of the gluteus maximus. The popliteus can also become facilitated due to inhibition in the superficial front line. Inhibition of the extensor hallucis longus, rectus femoris, and psoas commonly cause facilitation of the popliteus. In internal rotation of the tibia, inhibition of the medial head of the gastrocnemius may cause facilitation of the popliteus. In external rotation of the femur, inhibition of the biceps femoris may cause facilitation of the popliteus. I have also seen compensation patterns involving the popliteus due to inhibition of the neck extensors, flexors, and rotators.

It is very important to consider the popliteus not only when dealing with knee pain, but also when dealing with complex kinetic chain compensations. Never underestimate this tiny but critical muscle.

Thanks to Chris Mallac for his excellent article. http://www.sportsinjurybulletin.com/archive/popliteus.html

The Often Overlooked Tensor Fascia Lata

March 15, 2012

The Tensor Fascia Lata (TFL) is a muscle with many different functions. It is an abductor, and internal rotator of the hip, and a hip flexor. Having so many functions, the TFL can be involved in many dysfunctional movement patterns throughout the body. We will explore its role in each of the aforementioned functions, assessing the resultant dysfunctions based on whether it is facilitated or inhibited. The TFL is most commonly associated with the IlioTibial Band, which unfortunately has led to its being treated as one unit. The usual treatment for this unit is myofascial release or foam rolling without assessing whether or not it is facilitated or inhibited. This can lead to further biomechanical complications and unnecessary pain and discomfort.

As an abductor, the TFL works in conjunction with the gluteus medius and the gluteus minimus. If one or two of these become inhibited, the other may become facilitated and overburdened. Often times inhibition of the gluteus medius is associated with a valgus knee and foot pronation. I find more often, using the manual muscle testing techniques from NeuroKinetic Therapy, that the TFL is inhibited in this situation. This can lead to ACL tears and other knee problems. http://ow.ly/9FUT2 . Here is an excerpt from an excellent article that references this very topic, “The more accurate description of the anatomy of the glutei and the new biomechanical theory that has been presented describe the abductor mechanism as a system in which the tensor fasciae latae has the primary function of balancing the weight of the body and the non-weight-bearing leg during walking. Gluteus medius with its three parts and phasic functions is responsible for the stabilisation of the hip joint in the initial phase of the gait cycle. It is important also in initiating the major gait determinant of pelvic rotation.Gluteus minimus functions as a primary hip stabiliser during the mid- and late phase of the gait cycle. This proves the importance of the TFL and the resultant dysfunctions when it is inhibited.” http://ow.ly/9FUwH . Inhibition of the TFL can also cause IT band syndrome, where the ITB is compensating for the TFL. In this scenario, rolling out the ITB without strengthening the TFL first, will prove fruitless.

The TFL is also involved in internal rotation of the hip along with the gluteus medius and minimus, adductors, and iliacus. If the TFL becomes inhibited, a greater burden is placed upon these other muscles. I often find facilitation of the adductor magnus and iliacus, which can lead to groin pain. Because internal rotation is opposed by external rotation, inhibition of the TFL can cause facilitation of the external rotators of the hip, especially the piriformis and the obturators. Facilitation of these can lead to an impingement of the hip joint.

The TFL is also a hip flexor working in conjunction with the psoas, iliacus, rectus femoris, adductors, and sartorius.  Inhibition of the TFL may result in a facilitation of any of these muscles. Not uncommonly, the psoas is inhibited and the TFL becomes facilitated. Facilitation of the TFL can result in inhibition of the opposing muscles such as the gluteus maximus, lumbar erectors, and hamstrings.

Trendelenburg’s sign is found in people with weak or paralyzed abductor muscles of the hip, namely gluteus mediusminimus, and TFL. The Trendelenburg sign is said to be positive if, when standing on one leg, the pelvis drops on the side opposite to the stance leg. The weakness is present on the side of the stance leg. The body is not able to maintain the center of gravity on the side of the stance leg. Normally, the body shifts the weight to the stance leg, allowing the shift of the center of gravity and consequently stabilizing or balancing the body. However, in this scenario, when the patient/person lifts the opposing leg, the shift is not created and the patient/person cannot maintain balance leading to instability. This can cause a shift in the trunk leading to a variety of compensations with the obliques, QLs, and head position.

Inhibition or facilitation of the TFL can cause numerous compensation and dysfunctional movement patterns to occur throughout the body. Please don’t ignore this very important structure!

The Piriformis is a Real Pain in the Ass

February 19, 2012





Temporomandibular Joint Dysfunction

January 21, 2012







Hip Joint Jam

December 22, 2011



