Structural analysis

Can we usefully compare postural and structural relationships in terms of these myofascial meridians? Can this information be developed into unambiguous treatment strategies for unwinding and resolving body-wide patterns of compensation? Attempts at objective and inter-operator reliable visual analysis of overall postural patterns are fraught with difficulty, with few norms having been established scientifically.1,2 Yet, useful clinical information can be gleaned from an analysis of the standing client. This chapter puts forward one method for obtaining such information and putting it to use. In this chapter, we refer only to still photos of standing posture; in practice, such information would and should be corroborated with a carefully taken history, palpation, and gait or other movement assessment.

The Anatomy Trains map was first developed as a visual assessment tool for Structural Integration clients (see Appendix 2 on our Structural Integration method). This chapter describes the language and method of ‘bodyreading’ that we employ in our training seminars, where we systematically expand this introductory overview to standing assessment. Although this process is most easily assimilated when taught in person, attentive readers will be able to utilize this tool with their own clients, patients, or students, to apply various therapeutic protocols in a global and progressive manner. A ‘Visual Assessment’ DVD course based on these same principles is also available (DVD ref: BodyReading, 101).

This assessment tool rests on the concept of ‘tensegrity’ put forth at the end of Chapter 1. Practitioners seeking bio-mechanical alignment and other forms of movement efficiency, as well as kinesthetic literacy (an accurate sensing of where our body is in space and how it moves), or even psychosomatic ease, will do well to consider the unique properties tensegrity geometry shares with the human body. These include tensegrity’s unique ability to ‘relax into length’ as well as its distributive properties, accommodating local strain or trauma by dispersing it via small adjustments over the entire system (see Fig. 1.50, p. 47).

As clients resolve dysfunctional patterns, they more closely approach a ‘coordinated fascial tensegrity’ balance among the lines, creating a resilient and stable ‘neutral’ around which movement occurs. When accumulated strain is unwound into the desired efficiency and ease, the struts of the bones seem literally to float within a balanced array of tensile collagenous tissues, including the more closely adherent ligamentous bed, as well as the parietal myofascial system arranged in the longitudinal meridians that are the subject of this book.

The process of modeling the human frame in this way is just getting underway, but already a certain sophistication is available in the tensegrity models of Tom Flemons (www.intensiondesigns.com – Fig. 11.1). The relationship between the bones, myofasciae, and ligaments is more closely approximated when the common tensegrity icosahedron is modified to approach that of Figure 11.2, which is the same set of relationships, just shifted in their attachments: a process we can see happening to the connective tissue network in vivo in the films of Dr J-C. Guimberteau (Figs 1.70–1.72, pp. 58–60) (DVD ref: Interior Architectures).

Fig. 11.1 The wonderful and varying models of Tom Flemons (www.intensiondesigns.com) demonstrate clear similarities to human postural response and compensation patterns. With each iteration, these models get more sophisticated; more complex models appear on the website as they are developed.

Fig. 11.2 The tensegrity icosahedron shown in Figure 1.50A (p. 47) is commonly used by advocates of tensegrity as a simple demonstration model. Here we picture the same model, only with the end points of the dowels slid closer to each other so that the same construction shifts into a truncated tetrahedron. Our body works more like this still very simplified model. This results in (1) a more stable, less deformable structure, (2) the long part of the elastics parallel the dowels, just as most of our myofasciae parallel the bones, especially in the limbs, and (3) the short elastics that are tying the end of the bones together resemble the joint ligaments. Jolt one of the bones, as in an accident, and the strain is transferred strongly to these ligaments.

Fascial tensegrity implies evenness of tone – with allowances for differences of muscle fiber type and density variations from superficial to deep – along each line and among the lines. Anecdote and informal clinical observation suggest that inducing this even tone produces increased length, ease, generosity of movement, and adaptability for the client in both somatic and psychosomatic terms. To gain these heights for ourselves and our subjects, we must first have an accurate reading of where the skeleton literally stands in terms of its sometimes very small but telling aberrations from vertical symmetrical balance. This will allow us to accurately map the meridians and soft-tissue components necessary to improve the state of balance and support.

The first section of this chapter sets out the procedure to assess any given posture using the myofascial meridians, with emphasis on the accurate description of skeletal position. The main body of the chapter analyzes the standing posture of several ‘clients’ using this procedure to generate a single- or multi-session strategy. The final part of this chapter sketches in some of the more subjective elements of the ‘bodyreading’ or Anatomy Trains mapping process.

Global postural assessment method

Many forms of structurally oriented manipulation use an analysis of standing posture as a guide in forming a treatment strategy. Osteopaths, chiropractors, physiotherapists, soft-tissue practitioners, and movement educators such as Alexander and yoga teachers have used various grids, plumb lines, and charts to help assess the symmetry and alignment of the client.3–6 Our own approach and vocabulary emphasize the interrelationships within the person’s body, rather than their relation to anyone else or to a platonic ideal. For this reason, the photographs herein are devoid of such outside reference – except of course the line of gravity as represented in the orientation of the picture.

It is important to ‘expose’, not ‘impose’ proper body use. That there are benefits to an easy, upright alignment within the strong and shadowless gravitational field of the earth is a generally inescapable idea. The advisability, however, of in any way compelling left/right symmetry or even a ‘straight’ posture on a client is far more dubious. Alignment and balance are dynamic and neurologically adaptive, not static and biomechanically fixed. Postural reflexes and the emotional connection to muscle tension lie fairly deep in the brain’s movement structure. Efficient structural relationships must thus be exposed and resolved within the clients, not imposed upon them. The idea is to assist the client in the process of ‘growing out of the pattern’, not to box someone into a particular postural ideal. The former eases tension and leads to new discoveries; the latter piles more tension onto what is already there.

The goal of making such an analysis is to understand the pattern – the ‘story’, if you will – inherent in each person’s musculoskeletal arrangement, insofar as such a task is possible using any analytical method. The use of such an analysis merely to identify postural ‘faults’ for correction will severely limit the practitioner’s thinking and the client’s empowerment.

Once the underlying pattern of relationships is grasped, any (or several) treatment methods may be employed to resolve the pattern. Applying the Anatomy Trains myofascial meridians to standing posture is a vital step in this process of understanding structural patterns of collapse and shortness, but not the first step. The next section outlines a five-step method of structural analysis:

1. Describe the skeletal geometry (where is the skeleton in space, and what are the intra-skeletal relationships?);

2. Assess the soft-tissue pattern creating or maintaining that position (individual muscles, fasciae, or myofascial meridians);

3. Synthesize an integrating story that accounts for as much of the overall pattern as possible;

4. Strategize a short- or long-term strategy to resolve undesirable elements of the pattern;

5. Evaluate and revise the strategy in the light of observed results and palpatory findings.

Step 1: a positional vocabulary

‘Tilt’ is modified by the direction to which the top of the structure is tilted. Thus, in a left side tilt of the pelvic girdle, the client’s right hip bone would be higher than the left, and the top of the pelvis would point toward the client’s left (Fig. 11.5A). An anterior tilt of the pelvic girdle would involve the pubic bone going inferior relative to the posterior iliac spines, and a posterior tilt would imply the opposite (Fig. 11.5B). In a right side tilt of the head, the left ear would be higher than the right, and the planes of the face would tilt to the right (Fig. 11.5A). In a posterior tilt of the head, the eyes would look up, the back of the head approaches the spinous processes of the neck, and the top of the head moves posteriorly (Fig. 11.5B). In Figure 11.4C, the leg as a whole is anteriorly tilted, and the pelvis is posteriorly tilted relative to it. The head in this diagram is anteriorly tilted – looking down – which is an equivalent position to the pelvis in Figure 11.4B. Our terminology is thus applied consistently throughout the entire body.

Fig. 11.5 In (A), the pelvis is tilted left, due to a short left leg. This has resulted in a compensatory right bend of the spine, right tilt of the shoulder girdle, and left shift of the rib cage relative to the pelvis. In (B), we see an anterior tilt of the pelvis, with a posterior bend of the lumbars and an anterior shift of the head due to an anterior bend in the upper thoracic spine. The neck is thus anteriorly tilted, and only by a sharp posterior bend in the upper cervicals can this fellow keep his eyes looking forward horizontally – compare to Figure 11.3B.

Tilt is commonly applied to the head, shoulder girdle, rib cage, pelvis, and tarsi of the feet. Tilt can be used broadly, such as ‘a right side tilt of the torso relative to gravity’, or very specifically, such as ‘an anterior tilt of the left scapula relative to the right’ or ‘a posterior tilt of the right innominate bone relative to the sacrum’ or ‘a medial tilt of the navicular relative to the talus’. Once again, for clarity in communication and accuracy in translating this language into soft-tissue strategy, it is very important to understand to what the term being used is related: an ‘anterior pelvic tilt relative to the femur’ is a useful observation, a simple ‘anterior pelvic tilt’ opens the door to confusion.

• Bend. A ‘bend’ is a series of tilts resulting in a curve, usually applied to the spine. If the lumbar spine is side bent, this could be described as a series of tilts between each of the lumbar vertebrae, which we usually summarize as a bend – either side, forward or back. In the right bend in Fig. 11.5A, the top of L1 faces more the client’s right than the top of L5.

The normal lumbar curve thus has a back bend, and the normal thoracic spine a forward bend. A lordotic spine could be generally described as an ‘excess posterior bend in the lower lumbars’, or could be specified in more detail. A low but strong lumbar curvature might parse out on investigation as: ‘the lumbars have a strong posterior bend from L5–S1 to about L3, but have an anterior bend from L3–T12.’

In the spine, the essential difference between a tilt and a bend is whether the deviation from ‘normal’ is a single-segment or multi-segment event. If the rib cage is tilted off to the right, we can presume that either the pelvis is likewise right tilted so the lumbars run straight, or more likely, as in Figure 11.5A, the lumbar spine has a right side bend. Further, spinal mechanics dictates that the left bend in the lumbars very likely involves the tendency toward a right rotation of some of those vertebrae. The spine can have one uncompensated bend, but commonly has two bends that compensate each other, and more complex spinal patterns, e.g. scoliosis, can have three or even four bends over the two dozen vertebral segments.

• Rotation. In standing posture, rotations usually occur around a vertical axis in the horizontal plane, and thus often apply to, for example, the femur, tibia, pelvis, spine, head, humerus, or rib cage. Rotations are named for the direction in which the front of the named structure is pointing. For instance, in a left rotation of the head (relative to the pelvis), the nose or chin would face to the left of the pubic bone (Fig. 11.6A). In Figure 11.6A, both the head and rib cage are right rotated relative to the pelvis. The head and the rib cage are neutral to each other, relative to rotation. Making this observation is crucial to strategy: attempting to de-rotate the head of this person via the neck muscles would fail; it is the structures between the ribs and pelvis that govern this rotational pattern.

Fig. 11.6 Rotations all take place in the horizontal plane around a vertical axis, and are therefore modified only with left or right (for axial structures – (A)) or medial and lateral (for paired structures – (C)). Rotations frequently counter each other from the ground up (A). One rotation in the middle, as in (B) (or mocked up in Fig. 11.3A), is not as simple as it looks to unwind.

Notice that, if the rib cage were left rotated relative to the pelvis, the head could be right rotated relative to the rib cage and still be neutral relative to the pelvis or feet (Fig. 11.6B). In this case, therapeutic strategy would need to consider the twist/rotational imbalance in both the cervical and lumbar tissues (as well as shoulder-to-axial structures) to resolve this more complex pattern.

In paired structures, we use medial or lateral rotation (Fig. 11.6C). While this is in common use as regards femoral or humeral rotation, we extend this vocabulary to all structures. What is commonly called a ‘protracted’ scapula would, in our vocabulary, be a ‘medially rotated’ scapula, since the anterior surface of the scapula turns to face the midline. A medially rotated calcaneus often accompanies what is commonly called a ‘pronated’ foot (which we would call, and not just to be confusing, a ‘medially tilted’ foot).

• Shift. ‘Shift’ is a broader but still useful term for displacements of the center of gravity of a part (right–left, anterior–posterior, or superior–inferior). Balinese and Thai dance involves a lot of head shifting – side-to-side movement while the eyes stay horizontal. The rib cage likewise can shift to the back or side while still staying relatively vertical relative to the ground (Fig. 11.7A and B). Such shifts, of course, commonly involve tilts and bends, and often accompany rotations as well. We can use the terminology to specify these particular relationships when called for, but we have found that phrases such as ‘left lateral shift of the rib cage’ or ‘the head is shifted to the right relative to the pelvis’ are a useful shorthand when making an initial evaluation.

Fig. 11.7 In (A), there is an anterior tilt of the legs that results in the pelvis being anteriorly shifted relative to the feet, but the pelvis has a posterior tilt relative to the femurs. The rib cage in this diagram is posteriorly shifted relative to the pelvis, and the head is anteriorly shifted relative to the rib cage, in a pattern that is sadly commonplace in the Westernized world. Notice that the ribs are fairly neutral relative to the feet, and the head is fairly neutral relative to the pelvis. Undoing this pattern involves soft-tissue release in nearly every segment of the body. In (B), we see the pelvis neutral relative to the feet, but the ribs are right shifted relative to the pelvis, and the head left shifted relative to the ribs. The pelvis and head are thus relatively neutral, but as you begin to shift the rib cage on the pelvis via manipulation or training, the head will generally shift left relative to the pelvis, requiring work between the ribs and head.

The mobile scapula is commonly shifted in any of the six modifying directions. The pelvis is commonly described as being anteriorly (as in Fig. 11.7A) or posteriorly shifted relative to the malleoli, with the understanding that some tilts must occur along the way in the upper or lower leg for that to happen. A protracted shoulder involves a lateral shift of the scapula on the ribs, adding in a medial rotation as it slides around the rib cage. A wide stance could be described as a lateral shift of the feet relative to the hips. Genu varus involves a lateral shift (and probably a medial rotation as well) of the knees.

None of these terms are mutually exclusive. A rib cage can have its center of gravity shifted relative to the pelvis, with or without a tilt, and additionally with or without a rotation. Identifying one event does not preclude the others.

Yet more detail

This simple yet comprehensive vocabulary allows for a quick sketch or can be used to describe a series of relationships in minute detail. What might initially present as the easily seen ‘right tilted shoulder girdle’ in our quick sketch (as in Fig. 11.5A) could parse out, with more detailed examination, as ‘a right tilted shoulder girdle with an anterior tilt and a medial rotation in the right scapula, and a medially shifted left scapula’. This allows the practitioner to be as detailed or as general as necessary. The description can be noted down quickly, and accurately conveyed to another practitioner or mentor in a phone call or e-mail when seeking assistance or describing a successful strategy for others to follow.

In terms of this greater level of detail, it is worth focusing on the spine, shoulders, and feet to clarify how this vocabulary can be consistently applied. As noted, we could give a general description (e.g. ‘the spine in the torso is generally right rotated’), or we could fill it in to whatever level of detail is necessary (e.g. ‘the spine is left side tilted and right rotated from the sacrum through L3, right side tilted and left rotated from L3 through T10, and then right rotated from T10 through about T6, forward bent through the upper thoracics, and again left rotated in the cervicals to bring the head to face in the same direction as the pelvis’). The general sketch is quite helpful in getting a global handle on which myofascial meridians might be involved. The more detailed description aids in specific strategy for de-rotating vertebrae and getting specific to local muscle or even particular muscle slips in treatment plans.

Shoulders

Though in a general sketch, the shoulder girdle might be described as a whole, e.g. left or right tilt, or superior shift, closely reasoned strategy requires far more detailed description of each clavicle, scapula, and humerus.

Scapulae are particularly interesting because of their great mobility. To simply describe a shoulder as ‘protracted’ or ‘retracted’ can easily, even necessarily, miss much of the detail that lies at the heart of soft-tissue specificity. Imagine a scapula described as follows: ‘the right scapula is medially rotated, anteriorly tilted, and posteriorly shifted’ (Fig. 11.8). The term ‘protracted’ might be applied to these scapulae, but would not distinguish the degree of medial rotation, or specify the anterior tilt, or how the shoulder was positioned in the A–P axis on the rib cage. All these characteristics, however, have significant implications for how the person’s use pattern is understood and thus for our working strategy. A laterally shifted shoulder would lead us directly to the serratus anterior or the subscapularis fascia or the upper slips of pectoralis minor. The anterior tilt element would send us to the lower pectoralis minor and the clavipectoral fascia. The posterior shift would lead us to strategize about the middle trapezius and to add work in the axilla. With this level of description, we approach our work with greatly increased precision. It also allows a discourse in the bodywork field where logical thinking can displace magical thinking.

Fig. 11.8 Here we see shoulders that are posteriorly shifted – relative to the rib cage – but then medially rotated to bring the glenum anterior to the vertebral border, thus bringing the anterior face of the scapula to face the midline more; hence, a ‘medial rotation’ of the scapula is an essential part of protraction.

Feet

The human plantigrade foot is complex enough to warrant special attention. When we use ‘rotation’ in describing the head or spine, we have a good intuitive sense of what is meant. The same is true for tilts of the pelvis and shoulder girdle, and rotations in the humerus and femur. When we get to the feet, however, the long axis of the metatarsals and of the foot itself is horizontal. Therefore, ‘lateral rotation’ of the foot will designate that the toes are more lateral than the heels – but then we need to say, ‘Relative to what?’ Does the rotation take place in the foot itself, at the ankle, within the knee, or at the hip?

If the top of the foot is farther lateral than the sole and the weight shifts to the outside (a supinated foot), we would say the foot is ‘laterally tilted’. Conversely, falling onto the inside of the foot would be ‘medially tilted’ (see Fig. 9.49, p. 207). In the extremes of these patterns, one can also have a ‘rotation’ within the foot, meaning that the metatarsals are pointing more lateral or medial than the heel. The person with bunions could be pedantically described as having a ‘laterally rotated hallux’ or ‘laterally rotated big toe’ (in other words, use the midline of the body, rather than the midline of the foot, as the reference).

Since the calcaneus is often the key to support of the back body and sacroiliac joint, a few examples of calcaneal description are also offered. For the person who has the top of the calcaneus more toward the body midline than the bottom we would say, ‘medially tilted calcaneus’. If a calcaneus has the lateral side farther forward than the medial side, so that the front of the bone faces more medially, it would be termed – consistently but a bit counter-intuitively – a ‘medially rotated calcaneus (relative to the tibia or the forefoot)’. Such medial rotation and/or medial tilt often accompany a so-called pronated foot, fallen arch pattern, but how much of each will guide your strategy. Shifting the Superficial Back Line ‘bridle’ around the calcaneus is vital to arch restoration, as well as lengthening the outside of the foot, along the lateral band of the plantar fascia.

This language requires only a few hours of practice to manage, and only a couple of weeks of regular use of the notation for reasonable facility with the process. Of course, more usual language such as ‘low arches’ or ‘pronated feet’ can be used when it meets the needs of the moment, but reversion to this terminology can be used for argument, or for simplicity and accuracy in the resolution of ambiguity. It also has a pleasing neutrality: ‘medially shifted knees with laterally rotated femurs’ may be a mouthful, but for the client it is less demeaning than ‘knock knees’ and less distancing than ‘genu valgus’ (see Fig. 11.6C).

Once the skeletal geometry of the client’s standing resting posture has been described to the satisfaction of the practitioner, and noted down, either verbally or pictorially on such a form can be found in Appendix 2 for the reader’s use, we proceed to the second stage.

Step 2: an assessment of the soft tissues

The second step is to apply a model to the soft tissues to see how the client’s skeletal relationships, as described, might have been created or are maintained. The Anatomy Trains myofascial meridians is one such model, the one we will apply here, but single-muscle strategies or other available models could be employed as well.8–12

Step 2 begins with the question: ‘What soft tissues could be responsible for pulling or maintaining the skeleton in the position we described in Step 1?’ A second question, ‘What myofascial meridians do these myofascial units belong to, and how are they involved in the pattern?’ follows immediately.

For example, if it is determined that the pelvis has an anterior tilt (as in Fig. 11.4B), then we could look at the hip flexors for the soft-tissue holding – for example, the iliacus, pectineus, psoas, rectus femoris, or tensor fasciae latae myofasciae. Limitation in any of the first three would lead us toward the Deep Front Line; the rectus femoris might guide us to look at the Superficial Front Line; the sartorius (unlikely; it is too small and thin for postural maintenance) might lead us to the Ipsilateral Functional Line; and the tensor would suggest Spiral or Lateral Line involvement. Alternatively, the pelvis is being pulled up from behind by the erectors (Superficial Back Line) or the quadratus lumborum (Deep Front Line or Lateral Line).

If the shoulder on the right side lives farther away from the spinous processes than the one on the left, we could look to see whether the serratus anterior is locked short. If treatment of that single muscle results in a stable repositioning of the scapula, all well and good, but if not, we are guided toward assessment of the rest of the left Spiral Line: Are the right ribs closer to the left ASIS than vice versa, as in Figure 11.5A? Perhaps lengthening of the left internal and right external obliques and their accompanying fascia will allow the work on the serratus to hold and integrate.

Perhaps, however, we find that the scapula is not being pulled into a lateral and inferior shift by a short serratus, but rather that the scapula is medially rotated (which often involves some lateral shift). In this case, we might suspect the pectoralis minor (which pulls down and in on the coracoid process to create a medial rotation or anterior tilt or both). If treatment of the pectoralis minor and associated fascia does not solve the problem, we might be drawn into working on either the Superficial Front Line, the Deep Front Arm Line, or the Front Functional Line to see if ‘feeding’ the pectoralis minor from its lower trunk connections might help the local work be successfully absorbed.

It is important to keep in mind that portions of lines may be involved without affecting the entire meridian. It is equally important to keep the broad meridian view, since, in our teaching experience, practitioners from almost all schools tend to fall into the mechanist’s habit of trying to name the individual muscles responsible for any given position. This is, of course, not wrong, merely unnecessarily limited and ultimately frustrating, since it leaves out the fascia and effects over distance.

This ‘bodyreading’ process of Step 2 is modeled below using client photographs. Although many possible ways of analyzing soft-tissue distribution could be used at this point, we have an understandable prejudice toward employing the Anatomy Trains myofascial meridians schema here. This five-step process, however, can stand independently of any particular method.

By increasing familiarity with the system, it becomes a matter of a minute or two to analyze which lines might be involved in creating the pattern you have observed in Step 1. Trunk and leg rotations generally involve the Deep Front Line or Spiral Line, or both. Arm rotations involve either the Deep Front Arm Line or the Deep Back Arm Line. Side-to-side discrepancies often involve portions of the Lateral Line on the outside and Deep Front Line in the core. The balance between the Superficial Front and Back Line elements is always assessed and noted. If it appears that individual muscles are creating a pattern, we note in which lines this muscle is also involved. The relative positioning among the lines and their fascial planes is also important (e.g. the SFL is inferior relative to the SBL, the DFL has fallen relative to the more superficial lines, etc.).

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